Bioterrorism and Weapons of Mass Destruction John van der Steeg MD In peace the sons bury their fathers, but in war the fathers bury their sons. Croesus Naturally the common people don't want war; neither in Russia, nor in England, nor in America, nor in Germany. That is understood. But after all, it is the leaders of the country who determine policy, and it is always a simple matter to drag the people along, whether it is a democracy, or a fascist dictatorship, or a parliament, or a communist dictatorship. Voice or no voice, the people can always be brought to the bidding of the leaders. That is easy. All you have to do is to tell them they are being attacked, and denounce the pacifists for lack of patriotism and exposing the country to danger. It works the same in any country. Categories of Weapons of Mass Destruction B N I C E Biological Nuclear incendiary Chemical Explosives History of Biological Weapons 184 BC Hannibal ordered pots of venomous snakes thrown of decks of enemy ships. Tartar army catapulted bodies of plague victims into the city of Caffa in 1346 British army provided blankets to Delaware Indians in 1763…after they were used by smallpox patients. During WW II Japanese utilized Yersinia pestis containing rice and fleas spread by airplane against Chinese and Russian troops. America had prepared 5000 anthrax bombs at Camp Detrick, Maryland in 1942. (none used during the war) Aum Shinrikyo religious cult contaminated a Tokyo subway with Sarin gas in 1995. (5500 hospital visits and 5 deaths) Aum Shinrikyo make several unsuccessful attempts to release anthrax or botulinum toxin to other areas around Tokyo Anthrax laden envelopes sent via US mail in 2001, resulting in 11 cases of inhalational anthrax (including 5 deaths) and 12 cases of cutaneous anthrax. History of Biological Weapons Many countries agree to stop research and development of Biological weapons in 1972. Many smaller countries continue to develop biological warfare programs. A little perspective 200lbs of aerosolized anthrax spread over a city the size of Omaha on a clear breezy night could kill as many as 2.5 Million people. 200lbs of Botulinum toxin could kill as many as 40,000 people in an area the size of the Mall of America. 200lbs of VX gas sprayed over Disney land could kill 12500 people. Critical Biological Agents The CDC published a list of Critical Biological Agents in 2000. List is divided into categories A, B, and C. Category A agents are of the highest priority and Category C are of a lesser priority. Category A Pose a risk to national security. Spread easily by person to person contact. Cause a high death rate. Require special action for public health preparedness. – Bacillus anthracis (Anthrax) would be a category A biological agent. Category A Threats Anthrax Botulism Plague Small pox Tularemia Viral hemorrhagic fevers Category B Fairly easy to disseminate. Cause moderate illness and have a lower death rate than Category A agents. Require an enhanced diagnostic capacity and disease surveillance. – Coxiella burnetii (Q fever) is an example of a Category B biological agent. Category C Include new pathogens which could be engineered for mass dissemination in the future. Widely available. Easy to produce and dispense. Potential to cause high rate of death and sickness. – Nipah virus is an example of an Category C biological agent Dissemination Biologic agents designed to enter the body one of three ways. Inhalation – All category A agents may be aerosolized Ingestion – Contaminated food and water Skin contact Aerosolization Aerosols may be delivered in wet or dry forms. May be used in closed or open spaces Crop dusting planes, ventilation systems in buildings, fine powder that are easily aerosolized when disrupted Anthrax Not just the name of a speed metal band Discovered in 1877, may have been cause of plague described in Egypt 4000yrs. Ago. Also known as wool sorters of black bane dz Weaponized in 1950’s & 1960’s in the US 70 Russians died in 1979 after aerosol release by military facility in Svedlovsk Weaponized by Iran in 1995 Anthrax Caused by spore forming bacterium B. anthracis. Symptoms occur approximately 7 days post exposure. Most common form is cutaneous anthrax Symptoms of inhalational anthrax initially mimic common cold and progress rapidly to resp. distress and sepsis. Anthrax Direct person to person spread does not occur. Fatality Rate – Cutaneous :untreated 5-20%, treated 1% – Inhalational :untreated 100%, treated >80% if >48hrs after symptom onset Infective dose 2500-80,000 spores by inhalation Spore viability >40yrs in soil and resistant to sun light, heat and disinfectants Anthrax Treatment Ciprofloxacin 400mg iv q 12 hrs OR Doxycycline 100mg iv q12 hrs AND – One or two additional antimicrobials i.e. Rifampin, vancomycin, penicillin, ampicillin, clindamycin, clarithromycin, chloramphenicol Cutaneous Anthrax Inhalational Anthrax Botulism Botulism Botulism Researched by Iraq in 1991 Weaponized & deployed in 100 munitions in 1995 by Iraq Nerve toxin produced by Clostridium botulinum which produces a descending paralysis. The most potent and lethal substance known to man Botulism Gram + anaerobic bacillus which forms spores Block presynaptic ACh release Infective dose 0.001mcg/kg, lethal dose .09.15mcg/kg IV or .7 mcg IM Pt’s are alert, oriented and afebrile Pt can require vent. Support for 2-3 MONTHS due to resp. failure – Occurs in 20 – 60 % of cases Botulism Signs and symptoms can include nausea, dry mouth, blurred vision, dysphagia, fatigue, and dyspnea which may begin several hours to days after the exposure Botulism Treatment Not spread from person to person If diagnosed early food and wound botulism may be treated with antitoxin Recovery may take several weeks. Plague Used as a weapon in the 14th century (Infected corpses catapulted into enemy strongholds) One of the greatest engines of socioeconomic change Potential agent in 1950’s & 1960’s by USA Investigated by Japan in WWII (unit 731) Plague Plague Caused by Yersinia pestis, a gram negative bacteria found in rodents and their fleas. Bacteria may be grown in large amounts and aerosolized. Aerosolization allows for pneumonic form of disease with potential for secondary contamination. (resp. droplets are infectious until pt gets therapy for 72 hrs) Infective dose <100 organisms Plague Aerosol of bacillus viable for 1 hr at distances of 10 km Morality – Untreated bubonic plague: 50 – 60 % – Untreated pneumonic plague or septicemia: 100% – Treated pneumonic plague (<24hrs) 10 – 20 % Plague Pneumonic plague – incubation in 2 – 4 days – Rapid onset – High fevers, chills, hemoptysis, bloody sputum, dyspnea, stridor, cyanosis – Death from resp. failure, circulatory collapse and bleeding diathesis Plague Treatment Preferred choices – Streptomycin 30mg/kg div bid IM x 10d – Gentamycin 5mg/kg IM or IV QD x 10d Vaccine: effective against bubonic plague not against aerosol exposure – Not approved for peds < 18 y/o PEP: doxycycline 100 mg po bid x 7d OR – Ciprofloxacin 500 mg po bid x 7d Ricin Ricin Significant due to the wide availability of; 1 million tons of castor beans processed annually in production of castor oil. Used in assassination of Bulgarian exile Georgi Markov in London in 1978. Ricin Ricin is part of the waste “mash” produced when castor oil is made. May be produced in the form of a powder, mist, or a pellet or it can be dissolved in water or a weak acid. Depending on route of exposure, inhalation vs ingestion, it can take as little as 500 mcg to kill a person. (about the size of the head of a pin) Ricin respiratory exposure Results in pulmonary toxicity with sever resp. symptoms within 8 hrs. Followed by respiratory failure in 36 – 72 hrs. (marked by nonspecific findings such as weakness, fever, vomiting, cough, hypoxemia, hypothermia, and hypotension) Ricin gastrointestinal exposure Rapid onset of gastrointestinal symptoms such as nausea, vomiting, abdominal cramps, and severe diarrhea. Followed by vascular collapse and death. Ricin Treatment No antidote, vaccine or prophylactic antitoxin available Treatment aimed at avoiding exposure and eliminating toxin from the body as quickly as possible. Smallpox Smallpox Considered by Japan in WWII Global eradication program began in 1967 Declared eradicated in May 8, 1980 In 1996 WHO recommends all stockpiles be eradicated by 1999 Still exists in government labs of US and Russia Smallpox Variola virus which causes disease is very stable Infectious dose is very small (10-100 organisms) Virus spread from person to person via resp. droplets. (w/in 3 meters), their bedding or clothing Incubation 7 – 19 days Smallpox Signs and symptoms include high fever, fatigue, head and back aches. Followed w/in 2 – 3 days by smallpox rash and skin lesions. Mortality: – 3% vaccinated – 30% if unvaccinated – 50% if develop secondary bact. Pneumonia Smallpox At this time the government does not recommend prophylactic vaccination of healthcare workers or the general public Smallpox Treatment No proven treatment of smallpox. Patients affected with smallpox require supportive care and quarantine. Tularemia Tularemia Tularemia First found in Tulare County, California Found in Japan in 1800’s and Russia in 1926 Caused by Francisella tularensis, a gram negative bacterium found in animals, especially in rodents, rabbits and hares. Common in people who skin rabbits, rodents. Tularemia Highly infectious disease and some strains are resistant to antibiotics. Bacterium may be delivered by aerosol and infection by inhalation or from skin, mucus membrane, or gastrointestinal being exposed. Transmission of the disease from person to DOES NOT occur Tularemia Pulmonary form: – Most likely bioterrorism form – Aerosol exposure – Presents with fever, chills, headache, weight loss, non productive cough – Pneumonia in 30 – 80% Tularemia Inhalation – Sudden febrile illness – Pharyngitis, bronchiolitis, pneumonitis, pleuritis – Hilar lymphadenitis and/or sepsis Tularemia Treatment Streptomycin 1g IM bid x 10 D until afebrile for 5 – 7 days OR Gentamycin 5mg/kg/d IM or IV QD x 10d OR Cipro 400 mg IV BID OR Doxycycline 100 mg IV BID for 14d Tularemia Treatment PEP – Cipro 500 mg po BID for 14 d OR – Doxycycline 100 mg po BID for 14 d Viral Hemorrhagic Fevers (VHF) Viral Hemorrhagic Fevers (VHF) VHF group of illnesses caused by a distinct family of viruses which include arenaviruses, filoviruses, bunyaviruses, and flavaviruses. Most are highly infectious if spread by aerosolization, some can cause infection just by touching corpse at burial! Cause multisystem syndrome characterized by hemorrhagic disease. Viral Hemorrhagic Fevers (VHF) Signs and symptoms – Fever, fatigue, dizziness, muscle aches, loss of strength, exhaustion, bleeding from mucous membranes, internal organs, or from mouth, eyes, or ears. – Shock, renal failure, CNS dysfunction, coma, and seizures may develop as well Viral Hemorrhagic Fevers (VHF) Treatment Supportive quarantine Nuclear and Radiological Threats Nuclear and Radiological Threats Most likely scenario involving terrorist use of radioactive material would involve use of a Radiation Dispersion Device (RDD) also known as a Dirty bomb or Dirty nuke. Require little technical knowledge to build and deploy and do not require relatively difficult to obtain weapons-grade plutonium or uranium. Nuclear and Radiological Threats Main type of RDD combines an explosive with radioactive material. Extent of contamination would depend on a number of factors such as size of the explosive, amount and type of radioactive material used and weather conditions. Detonation of an RDD releases radioactive fallout which could cause radiation sickness, severe burns, and long term cancer fatalities. Nuclear and Radiological Threats In most cases the conventional explosive will cause more deaths than the exposure to the radioactive material. Nuclear and Radiological Threats Principles of time, distance, and shielding should be used for personal protection and the protection of others – Limit time at scene – Increase distance from scene – Shield self with appropriate personal protective equipment, geography, or structural materials whenever possible. Nuclear and Radiological Threats Rad (radiation absorbed dose): – Special unit of absorbed dose Rem (roetgen equivalent man): – Biologic effect of radiation – Unit of radiation dose equivalent – Equal to absorbed dose in rads x relative biological effectiveness of radiation in question Nuclear and Radiological Threats Exposure levels – – – – – – – – – Sleeping next to a human 0.1 mR Flying in an aircraft 0.5 mR 3 mile island accident 1.5 mR Nuclear weapon fallout 4.5 mR Single Cxr 12 -17 mR Cosmic rays & terrestrial sources 25 mR/yr Radon 200 mR/yr Smoking 280 mR/pack yr Cancer Rx 5000R Nuclear and Radiological Threats Symptoms by Dose (whole body dose in rem) 5 – 100 asymptomatic-decr leuks/plat, chromosomal aberrations 100 – 200 n/v, anorexia, decr lympocytes w/i 48 hrs 200 – 400 n/v for 2 – 4 days, skin erythema, epilation 400 – 600 n/v/d, 50% mortality w/i 30d, 600 – 1000 acute radiation syndrome, n/v/d, GI hemorrhage, incr. mortality w/i 14 d >1000 rapid onset GI symptoms, cns, cvs complications, 100% mortality w/i 72 hrs Nuclear and Radiological Threats Exposure risks 1 R over a few mins: incr risk of CA btwn 1 in 2000 and 1 in 100,000 10 R: incr. risk of genetic abn. btwn 1 in 300 to 1 in 20,000; can cause prenatal death 15 R: decrease in sperm count Nuclear and Radiological Threats Treatment No symptoms 6hr post exposure: exposure < 50 rems Symptoms 2 – 6 hrs post exposure: exposure 200 rems Symptoms <2 hrs: exposure > 400 rems, acute radiation syndrome Follows abc’s stabilize pt, Potassium iodide may protect thyroid Containment and monitoring of radioactive fallout, evacuation, and decontamination. Incendiary threats Range of device from the simple molotov cocktail to larger more sophisticated devices The main use in terrorism is to generate panic (weapon of mass disruption) Primary concerns include: – Possible large number of injured victims and fatality – Overwhelming of local resources – Public fear Incendiary threats Management Dependent on nature of attack First responders should not approach until scene is safe. High probability of second device designed to injure/kill emergency response personnel. Biological, chemical or nuclear materials may have been used in the explosion. Chemical Threats Chemical Threats Chemical Threats Developed in pre WWII Germany US stockpiles contain nerve agents Sarin (GB) and VX Matsumato GB attack in 1994 Tokyo subway GB attack in 1995 Chemical Threats Most toxic and rapidly acting of the known warfare chemical agents Nerve agents work similarly to organophosphates in terms of how they work and what kind of harmful effects they cause. (inhibit effect of acetylcholinesterase, leads to cholinergic overdrive) Chemical Threats Sarin (BG) clear, colorless, and tasteless w/o odor; can evaporate into a vapor rapidly and mixes easily with water. Anyway you can contact this stuff, it can kill you. Symptoms start w/in min. to hours dep on dose: headache, salivation, chest pain, abdominal cramps, fasiculations, sz, resp. failure and death Chemical Threats Soman (GD) and Tabun (GA) Similar to Sarin except GD has odor similar to Vicks vapor rub or a rotting fruit odor. GA has a faint fruity odor. Effects similar to Sarin Chemical Threats VX thick amber colored odorless liquid. Most potent of all nerve agents – Considered much more toxic than other agents when absorbed thru the skin and somewhat more toxic when inhaled than the other agents Symptoms appear w/i seconds after to exposure to vapor and w/i min. to hrs after exposure to the liquid form Chemical Threats Treatment Rapid decontamination, clothing can release agent for about 30 min. after exposure Atropine and pralidoxime chloride are antidotes. (available in auto injector kits ie. Mark I) Large and repeated doses of these drugs may be required Chemical Threats Lethal dermal dose for 70 kg adult – – – – Sarin 1.7 g Tabun 1 g Soman 100 mg VX 1 mg Persistence in environment – – – – Sarin 5 d Tabun 1 – 2 d Soman 1 – 2 d VX 6d Chemical Threats (poisonous gases) Popular weapons in WWI Produced in large quantities worldwide for use by the industrial sector Chemical Threats (poisonous gases) Chlorine gas- yellow green gas, odor of pineapple and pepper. Shipped as a liquid under pressure, quickly aerosolizes when released Exposure thru skin, inhalation, or eye contact May also be released in water as well Chemical Threats (poisonous gases) Exposure: – – – – – – 1 – 3 ppm: mild mucous memb. Irritation after 1 hr 5 – 15 ppm: mod. Irritation of upper resp. tract 30 ppm: immediate chest pain, vomiting and coughing 40 – 60 ppm: toxic pneumonitis & pulmonary edema 430 ppm: lethal after 30 min. 1000 ppm: fatal w/i a few mins. Chemical Threats (poisonous gases) Phosgene (CG) – Gray/white cloud and smells of freshly mown hay – Shipped as a liquid under pressure but changes to vapor when released – Stays close to the ground and spreads rapidly – Can be mixed with water as well Chemical Threats (poisonous gases) Both chlorine and phosgene gas produce similar symptoms: – Chest pain – Burning sensation in nose, eyes, or throat – GI distress, dermal burns – Sob/dyspnea, pulmonary edema – Phosgene also causes hypotension and heart failure Chemical Threats (poisonous gases) Treatment – No specific treatment – Remove from exposure – Do not induce vomiting – O2 and bronchodilators for bronchospasm – Steroids of no proven benefit – Treat pulm. Edema with cpap or peep Explosive Threats classification Unconventional: conventional object used in an unconventional way…think 9/11 Vehicle bomb Pipe bomb Satchel charge: old military term for explosives carried in a canvas satchel, now any backpack/daypack bomb Package or letter bomb Explosive Threats Same warnings from incendiary bombs apply Hermann Goering