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Bio/chemical - terrorism: Threats,Responses and Impact an the Practice of
Occupational (?) /military MedicineSummary Presentations Bioterroism, San Antonio, USA,1999
modified W.Gaber 2001
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Bioterrorism
The premeditated, unlawful use or threat ofuse of microorganisms or toxins derived fromliving organisms to produce death or disease
in human, animals, or plants which is intendedto create fear and / or intimidate governmentsor societies in the pursuit of political, religous,
or ideological [email protected]
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1925 Geneva Protocol
1972 Biological Weapons Convention:Parties agree never to produce stockpile,acquire or retain any bilogical agent forother than peaceful purposes
International Agreement
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* 1984 Oregon, Salmonella* 1991 Minnesota, Ricin toxin* 1994 Tokyo, Sarin and bilogical attacks* 1995 Indiana, bubonic plague* 1997 Washington DC, Anthrax hoax* 1998 Nevada, nonlethal strain of B. anthracis* 1998 Numerous Anthrax hoaxes
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Salmonellosis Caused by InternationalContamination----------------------------------------------------------------------------------* The Dalles, Oregon in Fall of 1984
* 751 cases of Salmonella Typhimirium
* Eating at salad bars in 10 restaurants
* Criminal investigation identified perpetrators as followers of Bhagwan Shree Rajneesh
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� Aerosol
� Food
� Water
� Medicine / devices / blood
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� can disseminate at great distance� agent clouds invisible� detection quite difficult� first sign is illness� overwhelms medical capabilities� simple threat creates panic� perpetrators escape before effects� ideal terrorist weapon ?
Advantages of BW:Are Biologicals the Ultimate Weapon ?
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Special Features� Potential for mass casualties
� Short window for effective intervention
� Use of rare or unusual organisms:> Variola major,> genetically manipulated organisms> antibiotic - resistant organism
� Requires different agency coordination and integration
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BW Proliferation and the ChangingWorld
� Increasing number of countries developing BWcapability at least 5-6 countries are implicated assponsors of international terrorism
� Regional aggressors and terrorist groups
� Groups or individuals who seek revenge against thegovernment or society, extremist groups, religousfanaticism
� State Sponsored vs. non-State [email protected]
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International Biological Weapons Programs
Known Probable PossibleIraq China CubaRussia Iran Egypt
North- IsraelKoreaLibyaSyriaTaiwan
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Strategic* Cover large populations / geographic areas* May be directed vs. crops, livestock-resulting in famine, economicdisruption
Tactical* Limitations due to incubation times* Possibly effective vs. fixed positions
Terrorist* Easy to deliver, difficult to detect
Biological Warfare Agents as Threats
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� Availability� Ease of Production� Lethal or Incapacitating� Stability in storage� Infectivity / Toxicity� Stable / deliverable in aerosol
What Makes A Good BioWeaponCandidate ?
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Cost ComparsionCost per square km (USA,1999)
Agents Costs ($$)
BW Agents 1
Nerve Agents 600
Nuclear Weapons 800
Conventional Weapons 2000
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Examples of Warfare Agents
� Bacillus anthracis (ANTHRAX)� Yersinia pestis (PLAGUE)� Francisella tularensis (TULAREMIA)� Brucella species (BRUCELLOSIS)� Variola major (SMALLPOX)� Viral Encephalitis Viruses� Hemorrhagic Fever Viruses� Botulinum Toxis� Ricin� Staphylococcal Enterotoxins� Saxitoxin� Tricothecene Mycotoxins
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� Smallpox� Plague� Anthrax� Botulinus� Tularemia� Q-Fever� Marburg� Influenza� Melioidosis� Typhus
Former Soviet BW Priorities
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Illnesses Potentially Resulting fromBioterrorism
* Critical agentsPapulopustular RashHemorrhagic PneumoniaDescending ParalysisHemorrhagic FeverRespiratory Distess
* Unexplained illnesses / death
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Hypothetical Dissemination by Airplaneof 50 kg Agent Along a 2 km Line Upwind
of a Population Center Of 500,000 *
Agent Downwind Reach (km) Dead Incapacitated
Rift Valley Fever 1 400 35,000Tick-Borne Enceph. 1 9,500 35,000Typhus 5 19,000 85,000Brucellosis 10 500 100,000Q Fever >20 150 125,000Tularemia >20 30,000 125,000Anthrax >>20 95,000 125,000
* Health Aspects Auf Chemical and Biological Weapons, WHO, 1970
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� Inhalation of Aerosols:
� Limited, air-delivery in enclosed space
� Oral: Contamination of food or water
� Dermal: Mucous membranes or abrasions
� Percutaneous: Intentional or [email protected]
Routes of Exposure
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Highest Threat
� Dispersed in aerosol� Highly lethal� Production capability / knowledge� available� Lack of treatment or vaccine� Communicable� Mere threat of use creates panic
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�Recognition of bioterrorist attack and differentation from natural outbreak of disease�Awareness of health care experts of unusual outbreaks�Local dignostic, therapeutic, and preventivecapabilities to respond immediatly to an incident�Public health issues, quarantine requirements, and communicability�Disease / illness surveillance requirements
Health Care Issues
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�Economic or corporate impact�Clustering of susceptible individuals in the workplace:potential target of terrorism�Specific working enviroments and levels of ventilationconducive to airborne transmission�Zoonotic disease outbreaks with secondary cases inhumans�Foreign vs. domestic terrorism: may be different risksand conditions�Threat vs. actual use of biowarfare agent
Occupational Setting Issues
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Preparedness and Response
� Security concerns� Training and education� Medical emergency response plan� Use of chemical and biological agents� Crowd control of mass hysteria� Definition of responsibilities
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Biological TerrorismWhat´s Important to the Nation ?* Awareness of the Risk
The real threat ... Not just the popular threat* Education
What we don´t know can hurt us !* Readiness for the Unexpected Drugs and Vaccines, Diagnostics, Planning, Exercises* A strong Public Health Infrastructure and Tech Base
The consequences of lack of preparedness are unacceptable
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CDC has been designated by DHHS tocoordinate and lead the overall
planning effortto upgrade national public health
capabilities torespond to bioterrorism.
(www.cdc.gov)
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Clues to Possible Bioterrorism - I� Single case caused by an uncommon agent� Large number of ill persons with similar disease,syndrome,� or death� Large number of unexplained disease, syndrome, or death� Unusual illness in a population� Higher morbidity & mortaility than expected with a common� disease or syndrome� Multiple disease / coexisting in the same patient� Disease with an unusual geographic or seasonaldistribution
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Clues to Possible Bioterrorism - II� Multiple atypical presentations of disease agents� Similar genetic type of agent from distinct sources� Unusual,,, atypical, genetically engineered, or antiquated� strain� Endemic disease with unexplained increased incidence� Simultaneous clusters of similar illness in con-contiguous� areas� Atypical aerosol, food, or water transmission� Ill persons presenting during the same time� Concurrent animal disease
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Bioterrorism: Response Needs
� Computerized questionnaire capability forinvestigation
� Ability to rapidly „geocode“ cases to definepopulation at risk
� Rapid integration of data from multiple sources foranalysis
� (standards of data transfer)
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Public Health Response toBioterrorism
� Detecion & surveillance
� Rapid laboratory dignosis
� Epidemiologic investigations
� Implementation of control measures
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Available Countermeasures* Anthrax
Vaccine, Antibiotics* Smallpox
Vaccine, ? , Quarantine* Botulinum Toxin
Antitoxin, Intubation / Ventilatory Assistance* Other Bacterial Agents
Antibiotics* Viral Hemorrhagic Fevers
Intesive supportive care
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PreventionVaccinations
ExposureTherapy
Person Enviroment / Agent
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Contact Information
For additional on the CDC BioterrorismPreparedness and Response Program, please
contact 404-639-0385 (USA)www.cdc.gov
Germany: San. Akademie 24 Hours Service089-3168-88 Physician on Duty (Studien und
Wissenschaft)(Director 089-3168-2701,fax 3829)
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Chemische Kampfstoffe
Nerven-Kampfstoffe
Haut-Kampfstoffe
Lungen- Kampfstoffe
Blut- Kampfstoffe
Psycho- Kampstoffe
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Nerven - KampfstoffeWeiterentwicklung E605
z.B. Tabun (GA), Sarin (GB),Soman(GD),VX
Wirkungsmechanismus:Hemmung Cholinesterase, Anreicherung Acetylcholin........Folge: Krämpfe, motorische und zentrale Lähmung.....TOD
Symptome:extreme Übererregung wie ..Pupillen (klein),Speichelfluss,Nasenlaufen,RRAbfall,Pulsverlangsamung, Atemnot,überschiessendeDrüsentätigkeit (Magensäure,Schweissdrüsen),vermehrteDarmbewegung und Bauchkrämpfe,Urin- und Stuhlabgang
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Nerven - Kampfstoffe
Resorption :
Haut, Speisewege, Bindehaut, Augen, Atemwege
Schnellstmögliche Giftwirkung:
Einatmen des Nervenkampfstoffes
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Nerven - Kampfstoffe
Therapie:�vollständige Dekontamination�Kleidung entfernen�Haut entgiften�Atropin 2-10mg i.v.; Kinder 0,1mg/kg/KG�danach nach Pulsfrequenz und Schweissneigung�nicht nach Pupillendifferenz (Iran/Iraq!!!)�Schutz der Helfer !!!�Weitere Therapie siehe Kat.med.ISBN3-00-007967x
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Haut - KampfstoffeS-Lost(Senfgas,Gelbkreuz,Yperit)
N-Lost, Lewisit
Symptome:symptomfreies Intervall 30 Min. - 3 Std.; Zellgift ,Eiweißstrukturenund Zellkerne werden geschädigt;Haut-Schleimhauttoxisch,Lungentoxisch,Schwere BlutbildungsstörungHaut:Rötung,Juckreiz,Blasenbildung, bernsteinfarbener Inhalt(keinKampfstoff nachweisbar),Schädigung vorwiegend feuchte Haut(Achsel etc.)Respirationstrakt:Bei 10 Grad C fest; verdampft ab 200mg/m3 krtisch
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Haut - Kampfstoffe
Therapie:CAVE: durchdringt Handschuhe binnen 10 Min.!!!(Helfer)Dekontamination,EIGENSCHUTZ,Abtupfen,Spülen (kaltesWasser),0,2% Chloramin T Lösung frühzeitig einsetzen(oxidiert Lost),NATRIUMTHIOSULFAT Dosis500mg/kg/KG i.v. binnen der ersten 20 Min. , AntibiotikaMilitärische Bedeutsamkeit:gute Mischbarkeit mit anderen Kampfstoffen. In taktischenGemischen dienen sie der Schmelzpunkterniedrigung undTarnung anderer Kampfstoffe.
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Lungen - KampfstoffePhosgen, Diphosgen, Chlorpikrin
Lungenkampfstoffe werden ausschliesslich über Atemwegeaufgenommen; höchste Konzentrationen können binnenSEKUNDEN durch Bronchialkrämpfe zum Tod führen; mässigeKonzentrationen ---- Schutzreflexe (Husten,Niesen...----HEIMTÜCKISCHE Latenzzeiten bis 18 Stunden !!!Körperliche Anstrengung in dieser Zeit untersagt !Symptome:Brustschmerzen, Beklemmungsgefühl, Atemnot
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Lungen - Kampfstoffe
Therapie:
Inhalation von z.B. Auxilloson
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Blut - KampfstoffeBlausäure , Chlorcyan
Resorption:Atemwege, Magen-Darmtrakt, Hautgasf. besonders leicht von feuchter Haut resorbiert;Blockade Atmungsferment(Cytochromoxydase)...Erstickungstod der ZellenSymptome: Krämpfe, AtemnotDD.: Nervenkampfstoff (enge Pupillen),starkePUPILLENERWEITERUNG; typ. BittermandelgeruchClorcyan: starke Reizwirkung auf Atemwege und Augen(Tränenfluss)
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Blut - Kampfstoffe
Arsenwasserstoff:farbloses Gas; Knoblauchgeruch (geringe Konzentrationen)Wirkung:schwere Hämolyse; Latenzzeit 4-6 Std.Symptome:Kältegefühl, Empfindungsstörungen, Bauchkrämpfe,Übelkeit,Erbrechen,Urin weinrot dann schwarz(Hämoglobin)
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Blut - Kampfstoffe
Therapie:Sauerstoff 9-10 l/min.,ABC Schutzmaske, DMAP AntidotSchutz der Helfer beachten
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Psycho - Kampfstoffe
LSD;Mescalin, Psiloybin,Benzilate, Cannabiole, u.a.m.
z.Zt. In Überarbeitung
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Resumee:�ein Anschlag mit chem. Und biol. Kampfstoffen ist nicht nurdenkbar; er ist auch praktisch möglich�Anti Bio/chem. Terrorismus Programme sind erforderlich�Die epidem. Überwachung von Infektionskrankheiten mussverbessert werden�Mindestmengen an Impfstoffen und Medikamenten müssenbevorratet werden�Wissenschaft und Forschung müssen gefördert werden (sieheUSA;CDC)�Früherkennungssysteme müssen vorgehalten werden�bei Anschlägen ist primär das öffentliche Gesundheitswesengefordert, Personalabbau ist nicht tolerabel�Aus- und Weiterbildung muss Pflicht sein�enge Kooperation Bundeswehr,Krankenhäuser LNA´s ..... Istnotwendig
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Literatur, Infos:� www.cdc.gov (bzw. www.bt.cdc.gov)�San. Akademie Tel.: 089-3168-88�Krüger,Dermatosen 39,Nr. 5,S143 (1991)�Workshop „Kehren die Seuchen zurück?“ 02.2000Akademie für Notfallplanung ,Bad NeuenahrTagungsband I und II, 2.2000,5.2001�RKI Prof. Fock Tel.: 030-4547-3700�Chem. Kampfstoffe, WWD Nr. 140,Appler,Lohs�Franke, Lehrbuch der Militärchemie,Militärverlagder DDR,Berlin 1977�Literatur und Internet hat keinen Anspruch aufVolständigkeit
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Impact of BW on the Medical CareSystem
� Terror in affected population and the medical caresystem
� Overwhelming numbers, special medication needs� Need for protection of personnel in medical care
areas
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Where Are We Going ?
� Flexibility to deal with a wide range of threats
� Expand emergency public health capacities
� Increase public health infrastructure
� Multi - agency linkage
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Bioterrorism: Surveillance
* Detection of high & low frequenzy eventsEarly, rapid recognition of unusual clinical syndromes
or deathEarly, rapid recognition of increase above „expected
levels“ of common syndromes, diseases, or death* Confirm the ethiologic diagnosis
* Monitor the response
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Bioterrorism: Surveillance Needs
� Ability to rapidly / definitively / distinguish true cases from� „worried - well“� Rapid electronic syndrome surveillance capability� integrated communication & surveillance systems� Develop algorithms to review health utilization &� surveillance data� Evaluate new surveillance systems
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� Preparedness planning & prevention research
� Detection & surveillance
� Communications & training
� Diagnosis & characterization of critical agents
� Response
