11/1/200611/1/2006

BIOTERRORISMBIOTERRORISM--How possible is it?..How possible is it?..And, what are we And, what are we

doing about it?doing about it?Vincent A. Fulginiti, M.D.Vincent A. Fulginiti, M.D.

Professor EmeritusProfessor EmeritusUniversity of Arizona & University of ColoradoUniversity of Arizona & University of Colorado

Departments of Pediatrics, Chancellor & Departments of Pediatrics, Chancellor & DeanDean’’s Officess Offices

Tucson AZ and Denver COTucson AZ and Denver CO

What is it?What is it?

• Deliberate insertion of an infectious or biologic agent into a given population

• Can be by a variety of delivery systems• Goal is to terrorize, to do so in a manner to

delay diagnosis and treatment and to inflict greatest harm in shortest period of time

WHY ARE WE CONCERNED?WHY ARE WE CONCERNED?1. HISTORY FROM ANCIENT TIMES SUGGESTS THAT MAN HAS

ALWAYS SOUGHT TO USE BIOTERRORISM IN WARFARE 2. CURRENT EVENTS WORRISOME

Terrorist attacks of 9/11 and prior experienceAnthrax episode in 2001 in USKnown production of materials in several countriesMultiple terrorist episodes in Spain, England, Iraq, Israel etc

HOWEVER, SOME SCEPTICISM:No credible evidence of biologic materials in Iraq

Difficulty in delivery for some agentsClaims of politicalization of issueScientific worry about use of scarce research $$

for biodefense in lieu of more urgent health issuesIntelligence failures revealed post-Iraqui invasion

•

9/11 CHANGED OUR 9/11 CHANGED OUR PERSPECTIVE FOREVERPERSPECTIVE FOREVER

BRIEF HISTORY OF BIOTERRORISMBRIEF HISTORY OF BIOTERRORISMAssyrians poisoned wells with ergot – 6th Century B.C.Weapons dipped in pus-since ancient timesCadavers catapulted into Kaffa by Tartars in 1346,

? caused Black Plague in Europe via trade routesPizzaro used smallpox clothing in 15th century British give Infected blankets to Indians in 1754Germans infected allied horses with glanders Plague fleas into China in 1937 WW2-”Unit 731”

(Many more bioterrorist atrocities by Japanese)Anthrax bacilli obtained by mail in US 1998US and USSR prepare bioweaponsOther countries produce biological weapons????

FROM KAFFA TO THE PLAGUEFROM KAFFA TO THE PLAGUE

Kaffa

BIOHAZARDBIOHAZARD--Ken AlibekKen Alibek

OTHER EVENTSOTHER EVENTS

• Rajneeshi sect in Northwest U.S. seeded salmonella in salad bars-many infected

• Shigella was used to infect donuts in Texas• Aum Shinrikyo in Japan tried anthrax spray and

botox but were unsuccessful; but then released sarin, a potent toxin, killing and maiming many in a subway in Tokyo.

• Bulgarians used ricin for assasinations-notorious instance in London of contamination of sharp end of umbrella used to murder diplomat

Background Background -- USUS

• In 1995 US declared that 17 countries had bioweapons programs: Iran, Iraq,Libya,Syria, North Korea, Taiwan, Israel, Egypt, Vietnam, Laos, Cuba, Bulgaria, India, South Korea, South Africa, China and Russia

Is it possible? 1Is it possible? 1

• Techniques for preparing organisms and delivery systems well known; agents available. Anthrax was obtained via mail in U.S

• Use of “rare” agents (anthrax, smallpox) would delay diagnosis as most unfamiliar with symptoms

Is it possible Is it possible -- 22

• Terrorist groups can easily infiltrate • “martyrs” can carry infectious agents

during the incubation period; no symptoms • Political, religious, economic factors may

initiate global bioterrorism• Selective targeting can inflict widespread

damage, chaos and panic with disruption of everyday life

MARTYRDOM MAKES ANYTHING POSSIBLE

THE BIOLOGIC THREATSTHE BIOLOGIC THREATSCATEGORY A AGENTS

Smallpox (variola virus) Anthrax bacilliPlague bacilliBotulinum toxinViral hemorrhagic fevers

CATEGORY B AGENTSQ feverBrucella bacilliEncephalomyelitis virusesGlandersToxins-ricin, sarin, clostridia (gas gangrene)Food and waterborne pathogens

CATEGORY C AGENTSNipah virusHantavirusesTickborne diseasesYellow feverTb, multidrug resistant

A = high riskHigh mortalityMajor public health impactPublic panic & disruptionRequire special action

B = moderate riskEasy to disseminateModerate morbidityLow mortalityHigh surveillance needed

C = Emerging pathogens? Engineered for bioterrorEasy availabilityEasy productionEasy disseminationPotenially high morbidity

and mortality

SMALLPOXSMALLPOXPossible scenarios:

1. Infected individual(s) in incubation period enter country and scatter2. Aerosol spread (no evidence for this)3. Altered virus with high virulence, resistance to vaccine and/or drugs

Some factors: 1. Difficulty in recognition2. Mis- or late diagnosis leads to wide spread3. Mass hysteria, panic, disruption?4. How easy (or difficult) to control?5. Logistical problems: care, housing,quarantine,etc.

SMALLPOXSMALLPOX

SMALLPOXSMALLPOX

SMALLPOX SMALLPOX -- CONTINUEDCONTINUED• Knowledge of vaccine is limited • Public health units underfunded &

fragmented - improving• With ring vaccination concept, can

control, once disease known, vaccine available, and its use understood, but time delay critical; antivirals????

• Affects gatherings, travel, social intercourse, effective management

““RINGRING”” VACCINATIONVACCINATIONVACCINATE TWO LAYERS OF CONTACTS OF THE SMALLPOX PATIENTVACCINATE TWO LAYERS OF CONTACTS OF THE SMALLPOX PATIENT

CONTACT CONTACT

CONTACT

SMALLPOXPATIENT

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ANOTHER SCENARIOANOTHER SCENARIO

• ANTHRAXEffective agent for production,

delivery by aerosolHigh virulence, death rateConfused with other causes of

sepsis, meningitisDelayed diagnosisVaccine available in military only

ANTHRAXANTHRAXBacilli In lung

Sverdlovsk, Russia Sverdlovsk, Russia -- 19791979• Over 7 wk period (April-May) 250

persons infected and 100 died• Russia: claim infected beef cause• US: accidental release of spores from

biological weapons facilityAutopsy findings consistentNarrow band of exposure S.E. of the facilityConsistent with prevailing windIn same pattern, cattle infected

• Conclusion: Accidental release 4/2

Anthrax in United StatesAnthrax in United States--20012001--22• Weaponized anthrax, i.e. very pure, powdered

so spread facilitated• Letters sent to prominent politicians and

newspersons• 25 cases; 5 deaths; both pneumonic and

bubonic forms seen• Considerable national confusion; re risk, re

treatment, re licensing requirements• Considerable effort required to identify

contamination, decontaminate• Much disruption, some panic, confusion, and

fear

From EMed site: Demetres Velendzas, MD, Susan Dufel, MD, FACEP,

PLAGUEPLAGUE--YersiniaYersinia pestispestis• Rodent infestation to fleas to humans• Aerosol transmission• 1-6 day incubation• Pneumonic>bubonic; transmission possible

human – human with plague pneumonia• Treatable within 24 hours symptoms; with

tetracyclines (e.g. doxycycline) ,or fluoroquinolones (e.g. Ciprofloxacin)

• Preventable: antibiotics a.s.a.p after exposure• No vaccine available; research underway

BOTULINUM TOXINBOTULINUM TOXIN• Clostridium botulinum/ C2 toxinADP-

• From JAMA, Botulinum Toxin as a Biological Weapon Medical and Public Health Management

• Stephen S. Arnon, MD; et al JAMA. 2001;285:1059-1070.

• “An aerosolized or foodborne botulinum toxin weapon would cause acute symmetric, descending flaccid paralysis with prominent bulbar palsies such as diplopia, dysarthria, dysphonia, and dysphagia that would typically present 12 to 72 hours after exposure. Effective response to a deliberate release of botulinumtoxin will depend on timely clinical diagnosis, case reporting, and epidemiological investigation. Persons potentially exposed to botulinum toxin should be closely observed, and those with signs of botulism require prompt treatment with antitoxin and supportive care that may include assisted ventilation for weeks or months. Treatment with antitoxin should not be delayed for microbiological testing. “

•

VIRAL HEMORRHAGIC FEVERSVIRAL HEMORRHAGIC FEVERS--EBOLA, MARBURG,ETC.EBOLA, MARBURG,ETC.

THE VIRAL HEMORRHAGIC THE VIRAL HEMORRHAGIC FEVERSFEVERS

Brief Report: Outbreak of Marburg Virus Hemorrhagic Fever --- Angola,

October 1, 2004--March 29, 2005 On March 23, 2005, the World Health Organization (WHO)

confirmed Marburg virus (family Filoviridae, which includes Ebola

virus) as the causative agent of an outbreak of viral hemorrhagic fever (VHF) in Uige Province in northern

Angola.

Marburg virus outbreak in AngolaMarburg virus outbreak in Angola2005: 374 cases;329 deaths2005: 374 cases;329 deaths

BODY FLUIDS ARE INFECTIOUS; SPREAD IS DEVASTATING

RICINRICIN• In 1978 Ricin used to kill Georgi Markov, a Bulgarian

journalist (pellet fired from an umbrella in London)• Believed to have been used in Iran/Iraq war in 1980’s• In Feb. 2003, 6 Algerian men arrested in London

because of traces of ricin and a makeshift lab found in their apartment

• On Oct 22nd, 2003 a letter in South Carolina contained a metal capsule containing ricin and a message indicating that it was inside, and referencing an extortion threat against the government related to trucking legislation in Congress

• Episode repeated in 2004 with shipment of ricin to legislative offices of Senator Frisk

What have we learned?What have we learned?• Specific episodes abroad, and in the US in the past, plus the

known manufacture of anthrax, botulinum toxin etc by Iraq (and others?) indicate that the threat is not exaggerated, but immeasurable

• 9/11 and the anthrax episode made it REAL for the U.S.; not a fantasy

• The US government has put in place an extensive plan to counter bioterrorism- will it be effective?

• Denver and other “exercises” exposed lack of adequate cross-communication and integration of professionals and activities- major effort underway to improve coordination

• Response is slowly evolving; many changes as the systems evolve; more and more coordination of responses and improvement in communication among those needed in response.

PREPARATORY RESPONSES PREPARATORY RESPONSES TO THREAT OF BIOTERRORISMTO THREAT OF BIOTERRORISM

Professionals should cooperate with community efforts to establish response plans

• Assist in developing protocols for offices and local health care facilities;

• Create disaster system, procurement of protective gear, creation of separate ventilation & decontamination areas

• Local, county, state Public Health authorities responsible for developing plans. CDC, DHHS, HOMELAND SECURITY COORDINATE.

• Civilians can join volunteer efforts to assist in surveillance and response to a bioterrorism attack if that ever occurs.

NATIONAL PREPARATIONNATIONAL PREPARATION--11• Development of coordinated response

plan-in progress• Development of sentinel personnel and

laboratories- well developed• Provision of adequate equipment &

facilities: stockpiles available now• Development of “Unexplained Death

Project” by CDC• Development and deployment of

modern diagnostic methods

NATIONAL STOCKPILESNATIONAL STOCKPILES

MANY DRILLS UNDERWAYMANY DRILLS UNDERWAY

Example of a drill in Tucson last year to prepare teamsfor ability to find, identify,disseminate to a given area,and then to distribute toindividuals in an emergentsituation

APRIL 4, 2005APRIL 4, 2005• Anti-terror drills focus on patient care• By WAYNE PARRY

Associated Press Writer•

• UNION, N.J. (AP) -- The focus of the nation's largest-ever anti-terrorism drill shifted to hospitals Tuesday as fake victims streamed in from a mock biological attack in New Jersey and a simulated chemical-weapons explosion in Connecticut.

• Four large, inflatable decontamination tents were set up in the parking lot of Union Hospital to treat the dozens of "patients" who had arrived by 9 a.m. from New Jersey's mock pneumonic plague attack.

• Doctors, nurses and the actors all wore white face masks, and each patient was given a colored toe tag to signify the severity of their condition. Five of the 64 patients wore black tags, indicating they were "dead."

• The $16 million, weeklong exercise is meant to find weak spots in the nation's emergency planning.

•

LRN LABORATORY NETLRN LABORATORY NET

BIOSAFETY LABSBIOSAFETY LABS

NATIONAL PREPARATIONNATIONAL PREPARATION--22

• Support of local & state health departments in preparations

• Education of health professionals• Support needed research• Ensure adequate vaccine and other

biologic/antimicrobial supplies• Ensure distribution system for information,

equipment, supplies, biologicals

RECENT ACTIVITYRECENT ACTIVITY• Smallpox vaccination program->ALL HAZARDS• Bioterrorism preparedness plans-each state

coordinated by CDC at present• Several hundred millions for various activities• Establishment and operation of Department of

Homeland Security• Established civilian and professional volunteer

groups to permit response to bioterrorism, e.gMedical Reserve Corps of Southern Arizona –health professionals to serve as surge capacity

Recent disasters have had SUV’s (spontaneous unaffiliated volunteers) show up). These are untrained and unfamiliar with disaster protocol or behavior. Most are either turned away or do not do what they are trained for as a result.

• The MRC program provides proper training for health care professionals and is a national system of local, community-based volunteer teams of medical and public health professionals and others interested in public health who are identified, credentialed, trained, and prepared in advance of an emergency

MEDICAL RESERVE CORPS OF MEDICAL RESERVE CORPS OF SOUTHERN ARIZONASOUTHERN ARIZONA

• ADVISORY BOARD: Dr. John Schaefer, Don Shropshire, Les Caid, Dennis Douglas, Michelle McDonald,Scott Ingram, Alethea Caldwell Munsinger, others being recruited

• CO-CHAIRS: Dr. Bill Carrell, Vince Fulginiti• TASK FORCES: Medical (Ron Spark),

Pharmacy (Ted Tong), Allied Health (Bill Howe), Jim Justice (Public Health/Environmental.

• Recruiting for Nursing

KATRINA/RITA AFTERMATHKATRINA/RITA AFTERMATH

• Are we truly prepared in the U.S.?• Mass casualties could overwhelm system• Panic, looting, despair could lead to civil

disorder• Can we coordinate multiple agencies,

multiple governments, multiple egos, multiple interests?

• Communication remains a major problem

CIVILIAN PREPAREDNESSCIVILIAN PREPAREDNESS

• www.ready.gov• This is a Homeland Security site, currently

recommended by the CDC as one area for the lay public to learn about personal measures that prepare them for a possible bioterrorist attack

• There is a commercial site, www.ready.comwhich has some businesses that are involved in selling gear for biopreparedness, some of which appear excessive or unnecessary to experts.