Terror Is Real !
Terrorism: Are We Ready?
Barbara Russell, RN,MPH,CIC,ACRN
Biological and Chemical
Terrorism:
How Real is the Threat?
What is Terrorism?
 No
single definition
 FBI: “The unlawful use of force or violence
against persons or property to intimidate or coerce
a government, the civilian population, or any
segment thereof, in furtherance of political or
social objectives.”
“Kill 1, Frighten 10,000”
Sun Tzu
Anthrax 2001
 22 confirmed or suspected cases
 11 inhalation (confirmed)
 11 cutaneous (7 confirmed, 4 suspected)
Inhalation Anthrax (11)
9 confirmed - exposed to mail
(other 2 possible)
55% (6) survived
Types of Terrorism
 Biological
 Nuclear
 Incendiary
 Chemical
 Explosive
 B-NICE
Target Selection
SSymbolic
target to audience or terrorist
Economic, political, social or religious value
Highly visible and photogenic
Random: To create confusion
Diversionary
Asymmetrical attack
Timing
 Anniversary of significant historical event
 Highly visible event in the area
 Increase in international tensions
Chemical & Biological Terrorism
1984:
1991:
1994:
1995:
1995:
1997:
1998:
1998:
The Dalles, Oregon, Salmonella (salad bar)
Minnesota, ricin toxin (hoax)
Tokyo, Sarin and attack
Arkansas, ricin toxin (hoax)
Ohio, Yersinia pestis (sent in mail)
Washington DC, “Anthrax” (hoax)
Nevada , non-lethal strain of B. anthracis
Multiple “Anthrax” hoaxes
Chemical Warfare Agents
Tokyo Subway Attack
•Odon March 20, 1995, terrorists released sarin, an organophosphate (OP) nerve gas at
several points in the Tokyo subway system, killing 11 and injuring more than 5,500
people.
Concealed in lunch boxes and soft-drink containers and placed on subway train
floors. It was released as terrorists punctured the containers with umbrellas before
leaving the trains.
•.On April 19th, 1995 repeat attack in subway which the same terrorist group killed
seven and injured more than 200 people.
Chemical Warfare Agents (CWA)
 Lethal
CWA’s
 Nerve
gas (Sarin, Tabun, soman, and VX)
 Organophosphates- anticholinesterase
 Colorless, odorless, tasteless
 Cyanides
 Vesicants (=blistering ) agents –
mustard gas
Nerve Gas Agents
 All nerve agents belong chemically to the group of
organo-phosphorus compounds.
 Stable and easily dispersed, highly toxic and have
rapid effects both when absorbed through the skin
and via respiration.
 Nerve agents can be manufactured by means of fairly
simple chemical techniques. The raw materials are
inexpensive and generally readily available.
Chemical
 Chemical
agents are toxic, but…
- They can be detected
- You can protect yourself
- Victims can be decontaminated
 Can be inhaled, absorbed through the skin or
injected
Nerve Agent Symptoms
Salivation
 Lacrimination
 Urination
 Defecation
 Gastrointestinal pain
 Emesis


SLUDGE
Decontamination
 Removes the agent from the patient
 Reduces the chance of secondary spread
 Helps the victim psychologically
Nerve Gas Poisoning


Eyes: excessive lacrimation
and pain.

Symptoms: minutes to 2 hours

Treatment: Atropine, 2-PAM
(pralidoxime-2-chloride)

Decontamination: Soap &
Water, Chlorox
Skin: excessive sweating

Muscles: involuntary
twitching

Respiratory: Mucous
secretion, dyspnea

Digestive: excessive
salivation, abdominal pain
Sulfur Mustard Poisoning


Eyes: reddening, congestion,
pain 1/2 -12 hours
Skin: itching, burning,
erythema, large blisters (1-12
hours)

Respiratory: burning throat,
cough, dsypnea. (2-12 hours)

Digestive: abdominal pain,
nausea, blood stained vomiting
and diarrhea

Treatment: none

Decontamination: Soap &
Water, Chlorox

Care: watch for leukopenia,
debride bullae
“I’m confident that we can defend
against chemical warfare. The one that
really scares me to death is biological”
Colin Powell - 1993
Potential Biological Weapon
Agents
Characteristics of a Biological Attack:










Civilian Targets Likely.
Possibility of Large Numbers of Casualties.
Symptoms May Not Appear For Days.
Initial Symptoms Likely to be Non-Specific.
Diagnoses Will Depend Heavily Upon Laboratory Tests.
Complex Epidemiology.
Ongoing Need to Care for Large Numbers of Patients
Concerns About Availability of Drugs, Supplies, Staff Members.
Legal Considerations.
Coordination with Local, State, and Federal Authorities.
Potential Bioterrorism Agents

Bacterial Agents
Anthrax
 Brucellosis
 Cholera
 Plague, Pneumonic
 Tularemia

Smallpox
 VEE
 VHF

Source: U.S.A.M.R.I.I.D.
Viruses


Biological Toxins
Botulinum
 Staph Entero-B
 Ricin
 T-2 Mycotoxins

Biological Agents of Highest Concern
 Variola
major (Smallpox)
 Bacillus anthracis (Anthrax)
 Yersinia pestis (Plague)
 Francisella tularensis (Tularemia)
 Botulinum toxin (Botulism)
 Filoviruses and Arenaviruses (Viral hemorrhagic
fevers)
 ALL suspected or confirmed cases should be
reported to health authorities immediately
Anthrax - The Weapon
 Bacillus
anthracis (coal = anthrakis) because of
black coal like lesions
 Aerobic, gram-positive, spore forming, non-motile
bacillus species.
 Inhalation Anthrax:
 Most
morbidity and mortality as aerosolized biological
weapon.
 Disease occurs 2 to 43 days after exposure.
Anthrax - The Disease
 Inhalation
anthrax:
Hemorrhagic thoracic lymphadenitis
 Hemorrhagic mediastinitis
 Hemorrhagic meningitis

 Two
Stages
1. Fever, cough, dyspnea, headache, vomiting, chills, weakness
 2. Sudden fever spikes, dyspnea, shock, cyanosis, hypotension

 Mortality:
89%!!!!
Anthrax:
Diagnosis, Prevention, Treatment
 CXR:
widened mediastinum
 Blood culture shows growth after 2-6 hours
 Vaccine: Licensed since 1970, 88% effective, not
available!
 Treatment: PNC, Doxycycline, Ciprofloxacin, first
generation cephalosporin, vacomycin, clindamycin
Anthrax
Cause
Bacillus anthracis
Incubation
1-60 days, average 7 days
Mortality (without
treatment)
Cutaneous: 20%
Intestinal: 25%-60%
Inhalation: Usually fatal
Varied; 8,000-50,000
spores (inhalation)
Yes; antibiotics and
supportive care
No
Infectious Dose
Treatable?
Human to Human
Transmission?
Anthrax (bacillus anthracis)
What is smallpox?
 Serious,
contagious, viral disease that causes
a fever and distinctive rash
 Treatment: supportive
 Historically, 30% of smallpox patients died,
many developed scars especially on face,
some became blind
 Prevented by smallpox vaccine (>95%
effective)
How is smallpox spread?
 By
direct, prolonged face-to-face contact
 Less commonly, indirectly by
contaminated bedding or clothing
 Rarely spread by air
 Transmission prevented by using airborne
and contact precautions in health care
settings
What is the risk of smallpox?
1972: routine smallpox vaccination discontinued in
U.S.
 1977: last naturally-acquired case in world
 Deliberate release is possible but risk is unknown
 Health care workers at higher risk due to exposure
to most severely ill patients
 In Europe from 1950-71, 50% of smallpox
transmission was in hospitals

How the skin looks with
successful vaccine “take”
Smallpox
Cause
Variola major
Incubation
7-17 days, average 12-14
days
30%
Mortality (without
treatment)
Infectious Dose
Treatable?
Human to Human
Transmission?
Small
Supportive care; vaccine
after exposure
Yes - Airborne
Smallpox vs. Chickenpox
Smallpox
Distribution of
pox
Stage of pox
development
Unique
presentation
Chickenpox
Centrifugal
distribution (face,
arms, legs)
All at same stage
of development
More covered parts
of body, trunk
Pox found on
palms and soles of
feet
Uncommon to find
pox on palms and
soles of feet
Various stages of
development
Smallpox (variola major)
Treatment
 Treatment
of smallpox is limited to supportive
therapy and antibiotics as required for treating
secondary bacterial infections.
 There
are no proven antiviral agents effective in
treating smallpox.
Plague
 Found
in rodents and their fleas in many parts of
the world
 Bites from an infected flea
 Bubonic, septicemic, pneumonic
 Seen in rural areas (US: 10-15 cases per year)
 Two recent human cases of primary pneumonic
plague contracted from cats
Plague (cont)
 US:
390 cases from 1947-1996
- 84% bubonic (standard precautions)
- 13% septicemic (standard precautions)
- 2% pneumonic (droplet precautions)
 Patients may present with GI symptoms (N/V, abd
pain)
 Treated with antibiotics
Plague (cont)
BBiological
terrorism release clues:
- Pneumonic plague outbreak 1-6 days after
exposure
- Initial severe respiratory illness
- Death occurs quickly after onset of illness
- Infection in persons with no known risk
factors
Plague (cont)
BBiological
terrorism release clues (cont)
- Occurrence of cases in areas not known to
have previous cases
- Absence of prior rodent deaths (which may
be present after natural disaster)
Plague vs. Anthrax presentation
Plague (yersinia pestis)
Plague
Cause
Yersinia pestis
Incubation
2-6 days
Mortality (without
treatment)
Infectious Dose
50% (bubonic); near 100%
(pneumonic)
Small
Treatable?
Yes; antibiotics and
supportive care
Pneumonic: Yes
Bubonic: No
Human to Human
Transmission?
Botulism
 Most
potent naturally occurring lethal substance
known to man
 Possible routes of exposure: Ingestion (food),
Inhalation (terrorist), Injection (drug users), dirty
wound
 In 1999…………. 174 cases
26
food borne
107 intestinal / infant
41 wound
Botulism (cont)
CCardinal
Signs
- Fever is absent (unless infection is present)
- Neurological symptoms are symmetrical
- Patient remains responsive
- Heart rate normal or slow
- Sensory deficits do not occur (except for
blurred vision)
Botulism (cont)
IIncubation
period
- Food borne: 12-36 hours (preformed toxin)
- Intestinal (Infant): 1-2 weeks
- Wound: 4-14 days
Botulinum Toxin
Cause
Clostridium botulinum
Incubation
2 hours – 8days, average 1272 hours (foodborne)
High
Mortality
Lethal Dose
Treatable?
Human to Human
Transmission?
1 ng/kg (about
0.00000009g/200lb person)
Yes; antitoxin and
supportive care
No
Tularemia
 Reservoir: Numerous wild animals (i.e.: rabbits, beavers,
some ticks)
 Can also be found in contaminated water, soil, vegetation
 Infections occur in North America (US: 171 cases / year) –
AKA Rabbit Fever, Deer Fly Fever
 Infection caused by handling infectious animal tissues or
fluids, direct contact with contaminated water, food, soil and
inhalation of aerosols.
Tularemia (francisella
tularensis)
Tularemia
Cause
Francisella tularensis
Incubation
1-14 days, average 3-5
days
Varies; 5%-60%
Mortality (without
treatment)
Infectious Dose
Treatable?
Human to Human
Transmission?
10 organisms
Yes; antibiotics and
supportive care
No
Hemorrhagic Fevers
 Ebola, Marburg, Lassa, Junin & related viruses
 Presentation: Initially febrile illness, malaise,
myalgias, H/A, vomiting, diarrhea followed by
bleeding, hypo tension, shock
 Mode of Transmission: Contact with infected
blood or other materials, higher risk at late stages
of illness
Hemorrhagic Fevers (cont)
 Incubation period (days):
- Ebola 2-21,
-Lassa, commonly 6-21
- Junin 7-16
- Marburg 3-9,
 Diagnostic Tests Available
 Significant number of people with
hemorrhagic fever symptoms
 Intensive supportive care
 Standard and Contact Precautions
Hemorrhagic Fever
Cause
Varies; viral
Incubation
Varies; days to weeks
Mortality (without
treatment)
Infectious Dose
Varies; high (as much as
80%)
Unknown
Treatable?
No; supportive care only
Human to Human
Transmission?
Yes
Key Points
 Increase Level of Awareness
 Be familiar with Workplace Plan
 Be familiar with County Plan
 Have a Family Plan
 No “I” in Response – It’s a Team Effort
Personal Protective Equipment
 Be sure that it is Appropriate to
the hazard(s)