Bioterrorism

1. Bioterrorism Monmouth-Ocean County Dental Society April 12, 2005

2. What is Bioterrorism? • FBI definition • The unlawful use of violence against persons or property to intimidate or coerce a government, the civilian population, or any segment of it in furtherance of political or social objectives.”

3. What is Bioterrorism? • The intentional use of micro-organisms or toxins derived from living organisms to produce death or disease in humans, animals, or plants • The goal of bioterrorism is to produce fear in the population with subsequent disruption of society

4. What is Bioterrorism? Potential • An overt attack that is announced • Resembles the traditional HAZMAT event Response to explosives and chemical exposures • First responders are likely to be traditional first responders • Fire, police, HAZMAT

5. What is Bioterrorism? Definite • A covert attack is unannounced • Thought to be the most likely scenario in bioterrorism • First responders • Healthcare providers • Emergency departments • Primary care physicians • Hospitals

6. History • Biological warfare has been employed as far back as the 6th century BS • Examples • 14th Century: During the siege of Kaffa, the Tartar army hurls its plague-ridden dead over the walls of the city; defenders are forced to surrender. • 15th Century: Pizarro gives smallpox laden blankets to Native South Americans, aids in his conquest of South America

7. History • 18th Century: During the French and Indian War, the English general, Sir Jeffrey Amherst, gives blankets laced with smallpox to Indians loyal to the French. The epidemic decimates the tribes, arguably, resulting in a successful British attack on Ft. Carillon. • 20th Century: Japan’s Unit 731 dropped plague-infected flees over Manchuria and China

8. History • 1942 • Gruinard Island, Britain • Anthrax test ground • Test was sanctioned amid fears of a German attack the UK with biological or chemical weapons • To test the killing powers of anthrax against a flock of sheep • Anthrax is most deadly and proves fatal in 95% of cases, even with medical treatment • Experts of biological weapons suggested that 100 kg of anthrax sprayed on a major city could kill more than 3 million people http://news.bbc.co.uk/1/hi/scotland/1457035.stm

9. History • Gruinard Island, Britain • WW II report suggested that anthrax could remain viable for generations • 1986 attempt to decontaminate the island • Soak ground with 280 tons of formaldehyde diluted in seawater • Topsoil was removed • 1990 island declared safe by British government • Questions still remain about the island’s safety

10. History: Recent Examples • The US Bioweapons Program • November 25, 1969 Nixon ends US research into bioweapons “The US shall renounce the use of lethal biological agents and weapons, and all other methods of biological warfare. The US will confine its biological research to defensive measures. The human race already carries in its hands too many of the seeds of its own destruction.”

11. History: Recent Examples • 1979 • Sverdlovsk Anthrax release • Explosion in April and May of 1979 at a secret military installation near Sverdlovsk that released a large amount of anthrax spores into the air • Soviet officials attributed it to consumption of contaminated meat • Affected 94 people and killed at least 64 • First victim died after four days; the last one died six weeks later. • Thirteen years later - 1992- President Boris Yeltsin admitted, without going into details, that the anthrax outbreak was the result of military activity at the facility http://www.emedicine.com/EMERG/topic864.htm

12. Sverdlovsk: Aerial View

13. History: Recent Examples • 1984 • On August 29, Indian religious Rajneeshee cultists give water laced with Salmonella to two county commissioners. • Both get sick, 1 hospitalized. • In September, the Rajneeshee cult contaminates salad bars of The Dalles, OR and Wasco County, OR with Salmonella. • Over 750 are poisoned and 40 hospitalized. • The purpose is to influence the outcome of a local election. It is only discovered a year later when members of the cult turned informants.

14. History: Recent Examples • 1995 • Aum Shinrikyo, a Japanese religious cult obsessed with the apocalypse • Released deadly Sarin nerve gas into the Tokyo subway system • Killing 12 people and sending more than 5,000 others to hospitals. • Attack came at the peak of the Monday morning rush hour in one of the busiest commuter systems in the world. • Witnesses said that subway entrances resembled battlefields as injured commuters lay gasping on the ground with blood gushing from their noses or mouths. http://cfrterrorism.org/groups/aumshinrikyo.html

15. History: Recent Examples • 2001 • Anthrax-laced letters sent through the mail killing 5 people. • Seventeen others developed symptoms, but recovered. • Most of the cases are linked to mail passing through NJ, NY, or Washington, D.C. • Estimated 10,000 people were placed on antibiotics. • Attorney General John Ashcroft released the text from the anthrax letters sent to Daschle, Brokaw, and the NY Post. • The letters dated September 11 contain the phrases • "Take penacilin (sic) now“ • "Death to America“ • "Death to Israel“ • "Allah is Great“

16. For less than $5.00 in mailing costs • Our government was shut down • There were 11 cases of pulmonary anthrax with 5 deaths • There were 5 cases of cutaneous anthrax • Thousands of people received an unnecessary 60 days of prophylactic antibiotic treatment • Caused billions in response costs • Caused fear and panic among the general population

17. http://www.freeinfosociety.com/science/physiology/diseasesanddisorders/anthrax2.jpghttp://www.freeinfosociety.com/science/physiology/diseasesanddisorders/anthrax2.jpg

18. http://barney.gonzaga.edu/~ghammerq/chstxray.jpg http://www.freeinfosociety.com/science/physiology/diseasesanddisorders/anthrax3.jpg

19. History of Bioterrorism • State sponsored bioweapons research • 1972 Biological Weapons Convention • Treaty prohibiting stockpiling and research onto biological agents • Ratified by >140 countries • Not adhered to in some countries • Former Soviet Union • United States Bioweapons program • Offensive program 1943-1969 • Defensive program 1953- today at the US Army Medical research Institute of Infectious Diseases (USAMRIID) http://www.usamriid.army.mil/

20. Category ‘A’ Agents of Concern • May be easily spread person-to-person • Cause high mortality with potential for major public health impact • Could cause public panic/social disruption • Require special action for public health preparedness

21. BT Category A List • Bacillus anthracis (Anthrax) • Variola virus (Smallpox) • Yersinia pestis (Plague) • Francisella tularensis (Tularemia) • Clostridium botulinum toxin (Botulism) • Viral hemorrhagic fever agents • Ebola, Marburg, Lassa, and others

22. Why Biologics as Weapons? • Easy to obtain • Inexpensive to produce • Potential for dissemination over large geographic area • Creates panic • Can overwhelm medical services • Perpetrators escape easily

23. Bioterrorism: A Legitimate Threat • Dissemination may cover large area • Difficult to detect release • Symptoms occur days or weeks later • Some have secondary spread • Use can cause panic • Users able to protect selves • Users can escape before effect

24. Bioterrorism: A Legitimate Threat • Former Soviet scientists successfully weaponized many agents • Active research was undertaken to engineer more virulent strains • With the collapse of the Soviet Union, microbe stock & technology has possibly landed in hands of terrorists

26. NOTIFICATION What to do when you observe, diagnose or suspect a threat to the public’s health, whether natural or man-made.

27. Interim Recommended Notification Procedures for Local and State Public Health Department Leaders in the Event of a Bioterrorist Incident Local Health Officer is informed of a BT incident or threat. Next: Notify FBI. Notify local law enforcement. Next: Notify and involve State DOH and other response partners, per a pre-established notification list. State DOH notifies CDC. CDC. Sept. 30, 2004

28. Yes No Interim Recommended Notification Procedures for Local and State Public Health Department Leaders in the Event of a Bioterrorist Incident Local Health Officer suspects that cases of illness may be due to a BT incident. Next: Inform and involve state DOH. DOH notifies CDC. Conduct investigation. Is BT incident confirmed or thought to be probable? Notify FBI. Notify other pre-determinedresponse partners. Continue investigation. CDC. Sept. 30, 2004

29. In Case of an Event • Assess environmental hazards. • Use self-protection. • Assess patients. • Notify – chain of command in practice setting (know your role in your organization’s emergency plan). • Notify – public health, first responders, law enforcement, etc. (know and post important contacts and phone numbers). • Stabilize patients, diagnose and treat, or refer as appropriate.

30. What the Dental Practitioner should Know? • Dentists may be called on to play a role in education • Knowledge of scientifically based information about disease agents that may be used in bioterrorism • Educate patients and correct misinformation that may be circulating throughout the general public • Dental workers are well-versed in infection control procedures • Apply knowledge in reducing the spread of infections

31. What the Dental Practitioner should Know? • Many diseases caused by bioterrorism actions will initially present with non-specific symptoms • Our responsibility is to be informed regarding biowarfare threats and to weigh this information along with clinical and epidemiological data • In diagnosis, surveillance, referral, and treatment, dental workers can detect characteristic intraoral or cutaneous lesions if they are present and report them to public health authorities

32. What the Dental Practitioner should Know? • Dentists can • Refer suspicious cases to the appropriate specialists • Collect salivary and/or nasal swabs for laboratory testing • Prescribe or dispense chemotherapeutic or chemoprophylactic medications for the public • Many dentists may be able to augment and assist medical and surgical personnel in providing treatment for victims of bioterrorist attacks • Who have hospital experience may be especially well-suited to provide services that require a close working relationship with physicians

33. What the Dental Practitioner should Know? • In the event that rapid inoculation or vaccination of the public is required to prevent the spread of infection by a biological agent, dentists may be recruited to assist in a mass inoculation program • Smallpox • Anthrax • Local dental societies are encouraged to develop a dental response plan that can be integrated into each community's mass disaster response plan

34. What the Dental Practitioner should Know? • In a major bioterrorist attack, traditional medical resources will be overwhelmed • ADA predicts that it will fall to non-physicians to provide many services ordinarily supplied by physicians • Triage • Dispensing medications • Providing general medical support

35. What the Dental Practitioner should Know? • As hospitals become filled, alternate sites for the provision of health care may be required • Dental office are located throughout the community • Equipped with many resources that hospitals have • Sterilization equipment • Air and gas lines, suction equipment • Radiology capabilities • Instruments and needle

36. What the Dental Practitioner should Know? • Dental offices may be called on to serve as local "mini-hospitals" when local hospital facilities become overwhelmed or when the concentration of patients is to be avoided, as in attacks involving contagious agents

37. What the Dental Practitioner should Know? • Dental practitioners should be familiar with the signs and symptoms of mass-destruction biological agents because some have oral-facial manifestations. • The role of dental practitioners includes recognizing bioterrorist disease signs.

38. What the Dental Practitioner should Know? • It is essential that oral health and other professionals know about the various diseases, and the systemic oral-dental manifestations of naturally occurring and bio-engineered infectious agents. • If the unthinkable should occur, oral health providers could play a key role in the early identification and subsequent control of a bioterrorist attack.

39. 10 Steps for Terrorism Preparedness • Finding out what can happen is the first step. Determine what the possible threats are and discuss them with your family, household, and office staff. 2. Create an emergency communications plan. Be sure to include your out-of-town contact to check on each other if local telephones are jammed or out of service. http://www.cert-la.com/education/Terrorism-Preparedness-10-Steps.pdf

40. 10 Steps for Terrorism Preparedness 3. Assemble disaster supplies kits, in easy-to-carry containers, for home, for work and your car. Include a three-day supply of water, non-perishable food, a first aid kit and book, flashlights, battery-powered radio, extra batteries, fire extinguisher, tools, prescription medications, copies of important documents, duct tape, plastic sheeting, and towels to seal door cracks. 4. Learn basic first aid and CPR. The American Red Cross provides training. http://www.cert-la.com/education/Terrorism-Preparedness-10-Steps.pdf

41. 10 Steps for Terrorism Preparedness 5. Be aware of your surroundings and report any suspicious activities to local authorities. 6. Know where the emergency exits, staircases, and fire extinguishers are at home, at the office or when traveling, and practice emergency evacuation procedures. http://www.cert-la.com/education/Terrorism-Preparedness-10-Steps.pdf

42. 10 Steps for Terrorism Preparedness 7. Check on the school and day care emergency plans for your school-age children. 8. Learn what to do if asked by officials to “Shelter in Place” (remain indoors or in your car) or to “Evacuate” (leave the hazard area). http://www.cert-la.com/education/Terrorism-Preparedness-10-Steps.pdf

43. 10 Steps for Terrorism Preparedness 9. Be prepared to do without services you normally depend on, such as electricity, telephone, natural gas, gasoline pumps, ATM machines, and Internet transactions. 10. If there is an attack or strong warnings of an attack, remain calm and follow the advice of local emergency officials. Listen to the radio or television for news and instructions. http://www.cert-la.com/education/Terrorism-Preparedness-10-Steps.pdf

44. Websites for Governmental Offices and Other Resources • Federal • Department of Homeland Security www.dhs.gov/dhspublic/index.jsp • Federal Emergency Management www.fema.gov • Federal Response Plan www.fema.gov/rrr.frp • State of New Jersey • NJ Department of Homeland Security http://www.njhomelandsecurity.com • NJ Domestic Security Preparedness Task Force http://www.state.nj.us/lps/dsptf/dsptfhome.html • Department of Law and Public Safety Office of Counter-Terrorism: http://www.state.nj.us/lps/oct

45. Websites for Governmental Offices and Other Resources • State of New Jersey (cont.) • NJ State Police: Office of Emergency Management: http://www.state.nj.us/lps/oct • NJ Department of Health and Senior Services http://www.state.nj.us/health/er/index/html • DHSS Terrorism and Public Health emergency Preparedness and Response Plan http://www.nj.gov/health/er/erplan.pdf • NJ Local Information Network and Communication System www.state.nj.us/health/lh/lincs/index.html

46. Websites for Governmental Offices and Other Resources • Education and Training • Cook College Office of Continuing Professional Education http://aesop.rutgers.edu/~ocpe/programs/public_health.html • New Jersey Hospital Association www.njha.com/ep/ • NJ Distance Learning Network http://www.njdistancelearningnetwork.org • UMDNJ School of Public Health, Center for Biodefense http://biodefense.umdnj.edu/training.asp • UMDNJ School of Public Health, NJ Center for Public Health Preparedness http://www.njcphp.org

48. Thank you!

49. New Jersey Preparedness Training Consortium Continuing Education for New Jersey’s Healthcare Professionals 185 S. Orange Ave MSB F607 Newark, NJ 07101-1709 www.nj-ptc.org

50. Teri E. Lassiter, MPHUMDNJ-NJDSOffice of Infection Control and Environmental SafetyPhone: 973-972-3635FAX: 973-972-8736E-mail: lassiter@umdnj.edu