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The History of Bioterrorism. Fred T Muwanga MD Msc. Definition of bioterrorism .
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The History of Bioterrorism Fred T Muwanga MD Msc
Definition of bioterrorism • Bioterrosim is the threat or use of biological agents by individuals or groups motivated by political, religious, ecological, social or for other ideological objectives to inculcate fear or cause illness or death in order to achieve their objective. (Carus 1998*).
World war II - Polish resistance organizations used biological agents against German forces 1952 - Mau Mau, an independence movement in Kenya , used a plant toxin to poison livestock. 1966 - Dr.Mitsuru Suzuki a Japanese physician, infected healthcare providers and patients with Salmonella typhi 1981 - Dark harvest group got anthrax contaminated soil from Gruinard Island and damped it on Porton Down. 1984 - Rajneeshees in Portland, Oregon(USA)used Salmonella typhimurium to contaminate restaurant salad bars. 1995 - AUM Shinrikyo used sarin nerve gas in the Tokyo subway in Japan 2001 - Anthrax contaminated s mail sent to various people in USA. Reported Cases of Bioterrorism
Casualties Incident Number of Cases Number of deaths Polish Resistance Not reported 200 Germans Mau Mau Not reported 33 head of cattle Dark Harvest None None Rajneeshes 751 no deaths (45 hospitalised) AUM Shrinkyo 5500 ( 641 seen at 106 hospitalised at SLIH* on day 1 & SLIH. 12 deaths (2 349 following week) at SLIH) Dr.Suzuki 200 4 deaths Anthrax(USA) 22 4 deaths
Motive for bioterrorism Incident Motive Polish resistance Resistance against foreign occupation Mau Mau Resistance against colonialism Dark Harvest Send a political message Rajneeshes Win a local election by incapacitating the non- Rajneeshee voters AUM Shrinkyo Seize control of Japan through mass murder, causing fear and apprehension Dr.Suzuki Revenge for unfair treatment he received at the medical training Anthrax (USA) Inculcate fear
The Polish Resistance • One official from the Polish resistance organization claimed to have killed 200 Germans by using biological agents during the second World war. No details of the planning and execution are available. • There has been no official confirmation of this report.
The Mau Mau • The Mau Mau was an African independence movement in Kenya. It comprised of soldiers from most of the eastern Africa countries. It fought for independence from the British. The toxin that was used to poison the cattle was derived from an African milk bush . They also attempted to use arsenic. The intended to cause a direct economic loss and create terror among the rural population. This would result in loss of public faith thereby motivating people to wage war against the British colonialists.
Dr. Suzuki • Dr.Suzuki was a Japanese physician and bacteriologist . He had extensive experience in laboratory science. • He injected patient and healthcare providers with salmonella typhi. • 200 people developed typhoid and dysentery, killing four. • The motive was revenge - he was angry about the treatment he was receiving as a resident in his medical training. • However, there are suggestions that he wanted to create clinical cases for his academic research into salmonella typhi.
The Dark Harvest • The Dark Harvest protested against the testing of an anthrax bomb on Gruinard Island by the British during World war II and the continued anthrax contamination. The group collected anthrax contaminated soil from the Island and discarded it on the grounds of Britain’s biological and chemical weapons research center in Porton Down.
The Rajneeshes • The Rajneeshes used a home made brew of poisonous salmonella typhimurium and sprinkled it secretly on the fruits and vegetables in salad bars, poured in the blue cheese dressing and on table-top coffee creamers in ten restaurants in The Dalles in Oregon(USA). They purchased the seed stock of salmonella from a medical supply company.
The Rajneeshes(contd) The Rajneeshes - a sex and religion cult, originated from Poona, India. Their leader - Bhagwan Shree Rajneesh fled India because of tax fraud. In 1984 they had taken over the city council of Antelope and created an intimidating police force and had set their eyes on winning the Wasco County elections. They had two strategies. They planned to bring in homeless people to vote for Rajneesh and secondly, to contaminate the water supply to incapacitate non-Rajneesh voters. The salad bar-spiking was just a test run. Most patients presented within 2-3 days with food symptoms suggestive of food poisoning. Some of the hospitalized had perforations of the colon and colon abscesses.
AUM Shrinkyo (Japan). • The AUM Shrinkyo was a “Supreme Truth doomsday cult” of 40 members led by Shoko Asahara. The membership included skilled scientists and technicians with training in microbiology. They attempted to develop weapons using B.anthracis, botulinum toxin, C.burnetii and Ebola. It is reported that they tried nine times to disseminate biological agents without success. Their main aim was to take over Japan through mass murder and causing fear and apprehension among the Japanese citizenry. They used sarin an organophosphate nerve gas. • The Tokyo subway attack was carried out by five two man teams who planted toxic sarin gas at several stations.
AUM Shrinkyo(contd) • Reports of toxic fumes in a subway station began at approximately 08.17am (Tokyo time) and symptoms began immediately. The nerve gas was concealed in lunch boxes and soft drink containers and placed on subway train floors. It was released as the terrorists punctured the containers with umbrellas before leaving the trains. the incident was timed to coincide with rush hour, when trains were packed with commuters. Over 5,500 people were injured in the attack. • On day one, 641 victims were seen at St.Luke’s International Hospital. 5 arrived with cardiopulmonary or respiratory arrest with marked miosis and extremely low serum cholinesterase(6IU/L), 2 died and 3 recovered. 349 were treated at SLIH in the following week. • SLIH treated the largest reported patient population exposed to the gas.
Hospitalized patients (AUM Shrinkyo) 106 patients were hospitalized*. The major signs and symptoms were: • miosis, headache, blurred vision or visual darkness - shown by almost all patients • dyspnea, nausea, ocular pain, vomiting, muscle weakness and agitation. • post-traumatic stress disorder(PTSD) - whereas other symptoms disappeared within weeks.PTSD persisted longer • Secondary contamination of house staff occurred in 23% of cases. They presented with ocular pain, headache, sorethroat, dyspnea, nausea, dizziness, nose pain
Diagnosis (AUM Shrinkyo) Diagnosis was based on signs and symptoms that were indicative of organophosphate poisoning which included: • Miosis and miosis related symptoms such as visual darkness, ocular pain, headache related with near vision. • Respiratory symptoms - rhinorrhea, cough, dyspnea and respiratory failure due to nicotinic effect on respiratory muscles or muscarinic effect on smooth muscle and secretory glands of the airway leading to bronchoconstriction and excess bronchial secretion. • Convulsive seizures in two patients.
Laboratory diagnosis (AUM Shrinkyo) Blood samples taken a few hours after sarin exposure in 451 patients showed the following: • a shift to the left • 50% had decreased ChE levels, and all severely ill patients showed markedly decreased ChE levels • 67% showed a respiratory alkalosis • 60% had increased white blood cell count • 11% had increased creatinine phoshokinase
Management • The five acute cases had cardiopulmonary resuscitation. • All patients were given Intravenous atropine sulfate(2mg) and 2g or more of pralidoxime iodide(PAM), dose depending on severity of symptoms. Those who received higher doses of PAM(>3g) tended to have faster improvement in their serum ChE levels. • Intravenous Diazepam(5-20mg) was used to control those that presented with seizures. • Psychiatric management of PTSD. 60% had PTSD and percentage remained the same over a period of 6 months.
Anthrax (USA) • The latest use of biological agents for terrorism involved sending mail contaminated with anthrax spores. The actual perpetrators not known yet • The first case was reportedin Florida - 63 year old male resident of Palm beach County who presented with fever and altered mental status. he died and autopsy revealed inhalational anthrax as the cause of death. • The second patient was a 73 year old co-worker of the index patient, admitted for a pneumonia. A nasal swab yielded positive culture for B.anthracis; PCT test for B.anthracis on pleural fluid was positive .
There was enhanced case finding by initiating retrospective and prospectivesurveillance systems. Environmental assessments and sampling were done at the index patient’s home, work site, travel site, mail or package delivery. questionnaires were administered at the index patient’s work site Center for Disease Control (CDC) developed a case definition for a confirmed case and for a suspect case of anthrax. post exposure prophylaxis with ciprofloxacin or doxycycline was given to prevent inhalational anthrax after a confirmed or suspected exposure. Case finding and diagnosis
Confirmed case - Clinically compatible case of cutaneous, inhalational or gastrointestinal illness that is laboratory confirmed by isolation of B.anthracis from an affected tissue or site OR - Other laboratory evidence of B.anthracis infection based on 2 supportive laboratory tests Suspect case - Clinically compatible case of illness without isolation of B.anthracis and no alternative diagnosis, but with laboratory evidence of B.anthracis by one supportive laboratory test. OR - Clinically compatible case of anthrax epidemiologically linked to a confirmed environmental exposure, but without corroborative laboratory evidence of B.anthracis infection CDC case definition of anthrax
Motives for bioterrorism vary and could include: - murder(Aum Shrinkyo) - gaining political mileage (Mau Mau and Dark harvest) - desire for revenge (Dr.Suzuki) - Cause fear (Anthrax cases) - Incapacitation (Rajneeshes) - anti-agriculture (Mau Mau) Terrorists do not usually announce their intent secondary contamination can occur (SLIH workers) There are various methods of dissemination: Direct application (Dr.Suzuki) Food or water contamination (Rajneeshes) Aerosol contamination (Aum Shrinkyo and anthrax cases) The effects of bioterrorismcan be immediate(illness and death) or long term (Post-stress disorder) Lessons learnt
Response involves: emergency measures to save lives active case finding through surveillance establish diagnostic criteria(case definition) and case management prevention and management of secondary contamination Accurate laboratory work Prevention measures Strategy formulation that stress deterrence as well as crisis and consequence management. Do a threat analysis so as to define the requirements contingency planning with clear definition of roles global surveillance of disease outbreaks to create more understanding on emerging threats Response and prevention of bioterrorism
With largely theoretical knowledge on bioterrorism, how best can we understand the problem we are faced with ? What ability and/or capacity does the world have to respond to the challenges of bioterrorism? What is the dividing line between bioterrorism and criminal activity ? Questions for reflection
