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BIOLOGICAL TERRORISM

BIOLOGICAL TERRORISM. Edward L. Goodman, MD, Chief of Infectious Diseases Presbyterian Hospital of Dallas December 14, 2005. Biological Terrorism. Use of biological agents to intentionally produce disease or intoxication in susceptible populations to meet terrorist aims

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BIOLOGICAL TERRORISM

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  1. BIOLOGICAL TERRORISM Edward L. Goodman, MD, Chief of Infectious Diseases Presbyterian Hospital of Dallas December 14, 2005

  2. Biological Terrorism • Use of biological agents to intentionally produce disease or intoxication in susceptible populations to meet terrorist aims • Has been done in the past on a limited scale • U.S. must be prepared to respond to this threat

  3. History of Biological Warfare • In 1346, Tartar army hurled corpses of plague victims over the walls of Caffa, a seaport on the Crimean coast • In 1718, Russians used same tactic against Sweden • During the Pontiac Rebellion in 1763, the British army provided the Delaware Indians with blankets and handkerchiefs from the “Smallpox Hospital”

  4. History of Biological Warfare (cont.) • German program in WWI • Japanese program in WWII • In 1943, the U.S. began research into the offensive use of biological agents: Program stopped by President Nixon in 1969

  5. History of Biological Warfare (cont.) • In 1972, U.S. and many other countries signed the Biological Weapons Convention • Former Soviet Union program began massive effort in 1970s • Today, term “warfare” is outdated…terrorism of civilian populations major risk: Anthrax in 12 persons 2001

  6. Why There was a Belief Bioterrorism in the U.S. Would Not Happen • Biologic weapons seldom used • Their use is morally repugnant to most • Technologically difficult? • Concept of “nuclear winter” was “unthinkable” and thus dismissed until suicide hijackers and anthrax appeared

  7. The “Coming of Age” and Bioterrorism • Perpetrators • Availability of biological agents • Methods of dissemination

  8. The Spectrum of Terrorists • State-sponsored • Insurgent/rebel • Doomsday/cult-type group • Non-aligned terrorists • Splinter groups • Lone offenders

  9. Sources of Agents for Terrorism Use • World Directory of Collections of Cultures and Microorganisms • 453 worldwide repositories in 67 nations • 54 ship/sell anthrax • 18 ship/sell plague • International black-market sales associated with governmental programs

  10. Methods of Dissemination of Biologic Agents • Postal service: never previously reported • Aerosol • Enclosed areas • Community-wide • Ingestion • Mass produced food • Water supplies

  11. “You have to be lucky all the time. We have to be lucky just once!” – Irish Republican Army

  12. “The only difference between reality and fiction is that fiction has to make sense.” – Tom Clancy

  13. Syndromes Suggesting BT • Encephalitis • Hemorrhagic mediastinitis • Pneumonia with abnormal liver function • Papulopustular rash • Hemorrhagic fever • Descending paralysis • Nausea, vomiting +/- diarrhea

  14. Biological Terrorism: Likely Agents • Bacterial: Anthrax Q fever Brucellosis Tularemia Plague • Viral: Smallpox Viral encephalitides Viral hemorrhagic fever • Toxin: Botulism Ricin Staph, Enterotoxin B

  15. Ideal Characteristics for Potential Biological Terrorism Agent • Inexpensive and easy to produce • Can be aerosolized (1-10µm) • Survives sunlight, drying, heat • Cause lethal or disabling disease • Person-to-person transmission • No effective treatment or prophylaxis

  16. Anthrax • Caused by Bacillus anthracis, a rod shaped, sporulating organism • Is a zoonotic disease in cattle, sheep, and horses • Transmission through scratches or abrasions of skin, wounds, eating insufficiently cooked infected meat, or inhalation of spores

  17. Pathophysiology of Anthrax Dixon, T. C. et al. N Engl J Med 1999;341:815-826

  18. Cutaneous Anthrax Infection of the Hand and Cheek Dixon, T. C. et al. N Engl J Med 1999;341:815-826

  19. Anthrax (cont.) • Case fatality in untreated inhalational disease is almost 100% • In recent 2001 occurrence, “only” 3/6 died • Incubation 1 – 45 days, most within 21 days • Initial flu-like symptoms are often followed by abrupt development of severe respiratory distress, shock, and death within 24 hours

  20. Anteroposterior Chest Radiograph Obtained on Admission, Showing the Widened Mediastinum That Is Characteristic of Anthrax Bush, L. M. et al. N Engl J Med 2001;345:1607-1610

  21. Cerebrospinal Fluid Specimen Containing Many Polymorphonuclear White Cells and Gram-Positive Bacilli (Gram's Stain, x1000) Bush, L. M. et al. N Engl J Med 2001;345:1607-1610

  22. Differential Diagnosis of Clinical Manifestations of Anthrax Dixon, T. C. et al. N Engl J Med 1999;341:815-826

  23. Anthrax (cont.) • Medical management must be reserved for those with early symptoms or no symptoms • Use of antibiotics for treatment (penicillin, ciprofloxacin, or IV doxycycline) and prophylaxis and vaccination • No secondary transmission

  24. Recommendations for Postexposure Prophylaxis Swartz, M. N. N Engl J Med 2001;345:1621-1626

  25. Recommendations for Antimicrobial Therapy of Clinical Inhalational Anthrax Swartz, M. N. N Engl J Med 2001;345:1621-1626

  26. Anthrax (cont.) • Weaponized by the U.S. in 1950s and 60s • Major emphasis of USSR program • Can be delivered as aerosol

  27. Inhalational AnthraxSverdlovsk, USSR, 1979 Days to Death 4.5 2.5 3.0 4.5 3.5 Incubation-Days 0-6 7-13 14-20 21-27 28-44 Cases* 6 28 9 6 11 Died 6 25 7 6 5 * 15 additional cases without an exact date of onset; all died.

  28. Shopping Mall Scenario - Denver • Anthrax aerosolized into shopping mall ventilation system; 10,000 people are present and 9,000 people are exposed; terrorist announces attack at 24 hours. • 90% of exposed started on antibiotics by end of day 2, 10% cannot be found initially • Total number hospitalized: 4,950; total requiring ICU care: 2,925; total deaths: 855; total ventilators required: 2601

  29. Shopping Mall Scenario – Denver (cont.) • The 13,000 military beds deployed for the Persian Gulf War would STILL not provide enough ICU beds (approximately 1,300) • Even a small biological terrorism event completely overwhelms a city’s medical care resources

  30. Smallpox An even worse scenario

  31. Smallpox • Killed more than 500 million persons in the 20th century despite being eradicated in 1978 • Mortality of 30% in susceptible population • Incubation period of 8 to 16 days

  32. Smallpox (cont.) • Clinical manifestations begin acutely with fever, rigors, vomiting, headache and backache • Approximately 10% of light-skinned patients exhibit erythematous rash during early phase • Two to three days later, an enanthem appears on face, hands, and forearms

  33. Smallpox (cont.) • Transmission begins with rash and lasts throughout convalescence • Ongoing transmission is critical factor • Most in the world are no longer protected by vaccination • Currently vaccine and treatment limited

  34. Date of Onset of Smallpox Cases by Two-Day IntervalsMeschede Hospital, 1970 4 3 2 1 Hospital Stay Case 1 Cases 13 15 17 19 21 23 25 27 29 31 2 4 6 8 10 12 14 16 18 January February

  35. Plague Not as likely but of concern

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