Bioterrorism: Practical Aspects

1. Bioterrorism:Practical Aspects Keith S. Kaye, MD, MPH

2. Overview • History and Overview of Bioterrorism • Smallpox • Update on Anthrax • What to expect in event of a Bioterrorism threat • What can you do to help?

3. Bioterrorism: History • 1346, Kaffa: Attacking Mongols catapulted cadavers of plague victims into city • 1710: Russians used plague victims against Swedes • 1767: French and Indian War: Blankets from smallpox hospital provided to Native Americans – resulted in epidemic of smallpox • World War I: Germany sent infected horses and mules into Allied lines • World War II: Japanese military unit 731 killed thousands of Chinese in Ping Fan, Manchuria, with various agents, including Anthrax • 2 incidents in US over past 20 years involving intentional bacterial contamination of food

4. United States Bioweaons Program • 1942 established at Camp Detrick, MD • 1950 biological simulant sprayed over San Francisco • 1966 biological simulant sprayed in New York City subway system • 1969 President Nixon suspends offensive program • 1972 U.S, U.K., Soviet Union sign Biological Weapons Convention

5. Soviet Union Bioweapons Program • Massive program • Many details known through defection of high-ranking scientist • Weaponized numerous biological agents • Much of offensive research took place after signing biological weapons treaty • After dissolution of Soviet Union leaks/dissmination of scientists (known) and bioterrorism agents (suspected)

6. Difficulties in Cultivating Biological Weapons • General difficulties in weaponizing a biologic agent • Ability to procure a virulent strain (e.g., anthrax, tularemia) • Ability to culture large amounts of the agent • Ability to process agent into a suitable form (e.g., anthrax spores) • Ability to safetly handle and store the agent (may be difficult for hemmorhagic fever viruses)

7. Why Biological Weapons? • Although challenging to develop, still easier and cheaper to obtain than nuclear weapons • Soviet scientists with expertise defected to rogue nations • Potential to cause destruction and hysteria

8. Smallpox • Virus with person-to-person transmission; rash similar to chicken pox, but can be easily differentiated • Naturally occurring disease eradicated in 1977 • Routine immunization in US stopped in 1972 • US and Russia known to have smallpox stocks; but concerns that other countries have Smallpox as well

9. Smallpox (cont) • Vaccine exists and is effective • More vaccine is being made • No imminent bioterrorism threat for smallpox, but we want to be prepared • Routine vaccination will probably not be reinstated unless new cases emerge • Stores of vaccine would be made available for control of outbreaks (bioterrorism)

11. Anthrax • Prior to 2001, no successful bioterrorist attacks • Known to be stockpiled by Iraq and possibly by former Soviet states • Outbreak due to accidental release, Sverdlovsk (Ekaterinberg, USSR 1979) • Increase in hoaxes in US, late 1990s

12. Antrhax: Clinical Diseases • Cutaneous • Spores enter through cuts/abrasions • Inhalational • Spores inhaled • NO PERSON-PERSON SPREAD!!! • Gastrointestinal • Infected meat ingested • Incubation period generally 1-12 days

13. Cutaneous Anthrax • Inoculation of spores into cut/abrasion • Lesions typically on hand/arm or face • Small pruritic papule  ulcer surrounded by vesicles (24-48h)  black eschar • Patients typically have local edema, +/- lymphadenopathy, fever and will feel ill • Antibiotic treatment extremely effective

14. First stage: insidious onset (1-4 d) Malaise Fatigue Myalgia Nonproductive cough Precordial pressure Fever Second stage: rapid deterioration (24 h) Acute dyspnea Cyanosis Stridor Fever Mediastinal hemorrhage CxR: Mediastinal widening Meningismus Septic Shock Coma Inhalation Anthrax: Manifestations

15. US Anthrax Cases as of November 9, 2001 • Inhalational-10 • Florida: 2 (1 fatality) • Washington DC: 5 (2 fatalities) • New Jersey: 2 • New York: 1 (1 fatality) • Cutaneous-12 • New York: 7 • New Jersey: 5

16. Clinical Symptoms of 10 Inhalational Anthrax Cases, U.S., 2001 • Almost all had links to contaminated mail (postal workers and press) • Median age 56 yrs (range 43-73) • All presented with fever, chills, malaise 10/10 • Cough (often dry) 9/10 • Nausea and vomiting 8/10 • Paucity of cold symptoms, sore throat • All 10 patients had abnormal CxR findings • All not receiving antibiotics had + blood cultures • 6/10 survived

17. US Anthrax Cases to Date November 9, 2001 • Source of exposure known for almost all cases (mail) • ~32,000 people in US were started on antibiotics for prophylaxis in past several weeks and in 5000 persons a full 60 day antibiotic course was advised. • 95/490 patients (~20%) receiving prophylaxis reported one or more side effect in one survey

18. Inhalation Anthrax: Summary Points • Almost all patients had clear epidemiologic links to anthrax source (investigations ongoing) • All patients had prodromal illness with fever • Cold symptoms, sore throat usually absent • Anthrax will readily grow in cultures • Anthrax is much more treatable than previously thought • Anthrax is NOT communicable, person to person • Currently NO anthrax cases in NC • Harmful effects of unnecessary antibiotics are common

19. GUIDELINES FOR MANAGEMENT OF POTENTIALLY THREATENING LETTERS • Do not open suspicious letter/package • Do not shake/empty • Do not show to others (don’t sniff, touch etc) • Place package on stable surface and alert others in the area • Leave area, close doors, prevent others from entering, shut off ventilation system • Wash hands/change clothes • Contact supervisor, local law enforcement via 911 • If possible, create list of persons in room (give to public health personnel) • www.bt.cdc.gov

20. Recommendations for Mail Handlers • New recommendations • Major focus is use of gloves for workers handling mail • Respiratory protection (N95 mask) for workers with mail sorting machinery • Follow news for further updates

21. What to expect in the event of a Bioterrorism Threat • Hospitals have plans, but CDC, State will organize response • Patients might be triaged at locations outside of local emergency rooms • Dispensing of antibiotics and vaccines will be organized through CDC/State, but will utilize local hospitals for support • Potential restriction of travel, movement; lock down of hospitals (Smallpox)

22. How Can You Help ? • Don’t crowd emergency rooms if you are not acutely ill • Talk with your primary care physician • Antibiotics not helpful unless there is a clear indication • No role for nasal swabs as diagnostic tool! • Have a high index of suspicion for atypical skin lesions, clusters of cases among friends, co-workers

23. How Can You Help ? (2) • Report suspicious letters/packages/powders to police/FBI, HAZMAT teams (911) • Report suspicious illnesses/clusters to your physician and county or State Health Department • Infection Control within the hospital • Follow the news: web sites for reliable, helpful information: • www.bt.cdc.gov • http://www.usps.com/

24. How can you help (3) • Increased level of awareness, but . . . • Remain calm • No cases in North Carolina (and in most states) • There are effective ways to prevent and treat anthrax once a threat has been recognized • Flu season is upon us • Let your doctor know if you develop flu symptoms • No reason to suspect anthrax, with no anthrax in NC • If you are ill, and feel you might have had an exposure, let your physician know • Even if you have had flu shot or a negative flu test, you can still might get the flu, or an illness like the flu!