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BIOTERRORISM
Dr. E. McNamaraPublic Health Lab. HSE, Dublin.St. James’s Hospital.
‘9/11 – Changes’
Move to high risk Biological Threat, specialist public
arena Newsworthy Rare/eradicated infections Low clinical experience
‘Autumn 2001 – USA’
5 letters, finely milled anthrax spores
11 pulmonary anthrax (5 died) 7 cutaneous anthrax All sent from Trenton, New Jersey, 1
person American origin, B. anthracis Criminal Act : Terrorist
‘Lessons Learned’
No one prepared Easy to produce contagious material Easy to spread, (except aerosolization) Small numbers affected, major concern Copy cat phenomenon – ‘Hoaxes’ Lab. techniques for diagnosis Major disruption Use of prophylactic antibiotics
Benefits Co-operation internationally
WHO CDC EU
National preparedness Plans Multidisciplinary
Government Admininstrative Emergency services Medical Scientific
History – Biological Warfare
Water wells contaminated with corpses
Siege Caffa, Crimea 1346, used plague corpses
British, gave Smallpox contaminated blankets as presents to Native Americans
Modern History – Biological Warfare
Germany WWI sold anthrax infected horses
WWI-II Many countries started biological programme
WWII – Not Used UK 5 million anthrax ‘cattle-cakes’ USA Botulinum Canada Plague Germany Salmonella Japan POW/Chinese trials
Post WWII USA
3400 people 1969, BTWC Allegation
Korean War Cuba
Misinformation, FBI to Soviets Soviets
1920 – 1969, BTWC signed 1975 Enlarged, Biopreparat
60,000 people40-50 facilities50 agents
Post WWII contd.
1979 Sverdlovks, Anthrax, 69 died 1980 – 1990 Defections 1990 Yelsin – cessation? Iraq 1974?, S. Africa 1980-1993 10 – 12 trying to acquire, evidence?
Preparing for Biological Attacks Enhance surveillance Resource laboratories Communication systems Bioterrorism education Stockpile vaccines and drugs Molecular surveillance microbial strains Support development diagnostic tests Support research Rx. and vaccines
CDC April 2000
Biological Agents
Category A Easily dessiminated High mortality Public panic Require special preparedness
Category B Moderately easy to dessiminate Low mortality Need enhanced Dx./surveillance
Category C Emerging pathogens
Anthrax, B. anthracis Zoonotic, spore forming rod Soil reservoir, years Affects large domestic and wild herbivoires Worldwide Humans
Contact with infected animals/products Skin – cutaneous GIT/resp. – inhalation
2000 cases, cutaneous / year 5 cases USA, 1 case UK No cases Ireland for 25 years
Anthrax contd. Bioterrorist threat – inhalation spores No person – person spread ! (cutaneous?) Cutaneous
Skin inoculation Painless swelling Papular – vescle – ulcer Black eschar Toxaemia Mortality with Rx., < 1%.
GIT Ingest contaminated meat Pain, diarrhoea, haematemesis, septicaemia Mortality > 50%
Anthrax contd.
Dx. (Confirm reference laboratory) Hazard Group 3 – CL3 Non motile, GPB, Aerobic Central / Terminal spores Non–haemolytic Sensitivity tests
Rx. – Penicillin / Ciprofloxacin Post exposure prophylaxis = Ciprofloxacin Infection Contol – standard precautions
Biological Agents
Category A Easily dessiminated High mortality Public panic Require special preparedness
Category B Moderately easy to dessiminate Low mortality Need enhanced Dx./surveillance
Category C Emerging pathogens
Anthrax, B. anthracis Zoonotic, spore forming rod Soil reservoir, years Affects large domestic and wild herbivoires Worldwide Humans
Contact with infected animals/products Skin – cutaneous GIT/resp. – inhalation
2000 cases, cutaneous / year 5 cases USA, 1 case UK No cases Ireland for 25 years
Anthrax contd. Bioterrorist threat – inhalation spores No person – person spread ! (cutaneous?) Cutaneous
Skin inoculation Painless swelling Papular – vescle – ulcer Black eschar Toxaemia Mortality with Rx., < 1%.
GIT Ingest contaminated meat Pain, diarrhoea, haematemesis, septicaemia Mortality > 50%
Anthrax contd.
Dx. (Confirm reference laboratory) Hazard Group 3 – CL3 Non motile, GPB, Aerobic Central / Terminal spores Non–haemolytic Sensitivity tests
Rx. – Penicillin / Ciprofloxacin Post exposure prophylaxis = Ciprofloxacin Infection Contol – standard precautions
Inhalation Anthrax Bioterrorist agent Mortality 90% Incubation 1 – 60 days Initial Phase (hrs – days)
Non-specific symptoms Non-specific clincial signs + Dx. test Recover / Progress to fulminant
Fulminant Phase Septicaemia / Toxaemia Dyspnoea with CXR mediastenal widening 50% haemorrhagic menigitis and death Mortality increased with short incubation
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Small Pox
Human, DNA variola virus 2 Forms
Variola major, mortality 30% (3% vaccinated)
Variola minor, mortality 1% Airborne spread, contact Secondary attack rate 50%
(unvaccinated) Last death – 1978 UK. WHO 1980, eradicated.
Small Pox contd.
Incubation 12-14 days, rash further 2-4 days
Fever, headache, myalgia, abdominal pain and vomiting
Delirium 15% Rash, centrifugal, face and extremities Copious virus on mucosal lesions Secondary bacterial pneumonia (mortality
> 50%) Haemorrhagic Small Pox (95% mortality) Differental = Chicken Pox.
Small Pox contd. Dx.
Hazard Group 4 EM (Herpes : Pox) - CL3 PCR (differentites Pox viruses) – CL4 Culture – CL4
Public Health Emergency – International Case: Standard, contact and airborne precautions
Isolate: negative pressure, HEPA extract PPE. Decontamination protocol Immune HCW (vaccinated) Rx. = supportive
Contact/Exposed Quarantine for 18 days - monitor temperature
Infectious form onset of fever
Small Pox Vaccine Face – face contacts HCW (core, prepardness) Designated emergency personnel Vaccine
Live vaccinia virus (not variola) Vaccine site, infectious until scab heals Newer vaccine development
S/E Efficancy
Small Pox Vaccine contd. CI – atopic dermatitis, pregnant,
immunocompromised S/E
Fever headache, rigors, vastles Generalised vaccinia (GV) Eczema vaccinatum (EV) Progressive vaccinia (PV) Post vaccinial CNS (PVE)
Incident 1968 Life threatening = 52 / million Deaths = 1.5 / million
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Cl. Botulinum
Botulinum neurotoxin – most potent Contaminated food, canned products Wound botulism, contaminated soil,
IVDA Bioterrorism agent
Aerosolisation – inhalation Contaminate food – ingestion Large numbers with acute flaccid
paralysis
Cl. Botulinum contd. Incubation
2hrs – 8 days, Foodborne 1hr – 5 days, Aerosol
Foodborne V+D, diplopia, dysarthria, weakness Ptosis, facial palsy, ↓gag Hypotonic
Inhalation Dysplagia, nystagmins, ↓speech, ↓gait
Terminal Progressive muscular paralysis Mortality 5% (with Rx.)
Cl. Botulinum contd.
Differential Dx. Guillain-Barré Myastheria gravis Stoke CNS despressants
Cl. Botulinum contd.
Dx.: Detect botulinum toxin Culture
Rx.: Antitoxin Supportive
Infection Control – standard precautions
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Plague Yersinia pestis – HG3
GNCB, 02
Aerosol, flea vector, person-person 3 Forms
Bubonic – 90% Septicaemic – 10% Pneumonic – 1%
Bioterrorist agent Aerosol – pneumonic Fleas – bubonic, septicaemic
Bubonic Plague
Incubation 1-8 days Fever, rigors, headache Buboes – painful lymph nodes 15% develop pneumonic plague Mortality = 12%
Septicaemic Plague
Primary, or secondary to bubonic Rigors, abdominal pain, V+D Purpura, DIC, necrosis Mortality = 30%
Pneumonic Plague
Highest bioterrorism risk Primary or secondary from
haematogenous Incubation 1-3 days Pneumonic symptoms Respiratory failure and shock Mortality - ↓with rx. = 8%
Plague Dx.:
Culture Rx.:
Gentamicin, Streptomycin IV Ciprofloxacin, Doxycycline P.O.
Infection Control: Standard and droplet, single room, surgical mask
Contacts: Prophylaxis – Ciprofloxacin – 72 hrs.
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Tularaemia F. tularensis
Non-motile, aerobic, GNCB, zoonosis, rabbits, deerfly HG3 Worldwide Low inoculum – 10 CFU
Ulceroglandular Typhoidal
Mortality 35-60% (untreated) Inhalation
Infection Control – standard (no person-person) Rx. Gentamicin/Streptomycin – 10 days Contacts : prophylaxis
Tularaemia
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Tularaemia
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