Bioterrorism

Introduction:- Bioterrorism is terrorism involving the intentional release or dissemination of biological agents. These agents are bacteria, viruses, or toxins, and may be in a naturally occurring or a human-modified form. For the use of this method in warfare, see biological warfare. A bioterrorism attack is the deliberate release of viruses, bacteria, toxins or other harmful agents used to cause illness or death in people, animals, or plants. These agents are typically found in nature, but it is possible that they could be mutated or altered to increase their ability to cause disease, make them resistant to current medicines, or to increase their ability to be spread into the environment. Biological agents can be spread through the air, water, or in food. Terrorists tend to use biological agents because they are extremely difficult to detect and do not cause illness for several hours to several days. Some bioterrorism agents, like the smallpox virus, can be spread from person to person and some, like anthrax, cannot. Bioterrorism is an attractive weapon because biological agents are relatively easy and inexpensive to obtain, can be easily disseminated, and can cause widespread fear and panic beyond the actual physical damage they can cause.Military leaders, however, have learned that, as a military asset, bioterrorism has some important limitations; it is difficult to employ a bioweapon in a way that only the enemy is affected and not friendly forces. A biological weapon is useful to terrorists mainly as a method of creating mass panic and disruption to a state or a country. However, technologists such as Bill Joy have warned of the potential power which genetic engineering might place in the hands of future bio-terrorists. The use of agents that do not cause harm to humans but disrupt the economy have been discussed.[A highly relevant pathogen in this context is the foot-and-mouth disease (FMD) virus, which is capable of causing widespread economic damage and public concern (as witnessed in the 2001 and 2007 FMD outbreaks in the UK), whilst having almost no capacity to infect humans. History Early use Biological terrorism dates as far back as Ancient Rome, when faeces were thrown into faces of enemies. This early version of biological terrorism continued on into the 14th century where the bubonic plague was used to infiltrate enemy cities, both by instilling the fear of infection in residences, in hopes that they would evacuate, and also to destroy defending forces that would not yield to the attack. The use of disease as a weapon in this stage of history exhibited a lack of control aggressors had over their own biological weapons. Primitive medical technology provided limited means of protection for the aggressor and a battle's surrounding geographical regions. After the battle was won, the inability to contain enemies who escaped death led to widespread epidemics affecting not only the enemy forces, but also surrounding regions' inhabitants. Due to the use of these biological weapons, and the apparent lack of medical advancement necessary to defend surrounding regions from them, widespread epidemics such as the bubonic plague quickly moved across all of Europe, destroying a large portion of its population. The victims of biological terrorism in fact became weapons themselves. This was noted in the Middle Ages, but medical advancements had not progressed far enough to prevent the consequences of a weapons use. Over time, biological warfare became more complex. Countries began to develop weapons which were much more effective, and much less likely to cause infection to the wrong party. One significant enhancement in biological weapon development was the first use of anthrax. Anthrax effectiveness was initially limited to victims of large dosages. This became a weapon of choice because it is easily transferred, has a high mortality rate, and could be easily obtained. Also, variants of the anthrax bacterium can be found all around the world making it the biological weapon of choice in the early 19th century. Another property of anthrax that helped fuel its use as a biological weapon is its poor ability to spread far beyond the targeted population. Anthrax could not be spread from person to person. 20th century By the time World War I began, attempts to use anthrax were directed at animal populations. This generally proved to be ineffective. Shortly after the start of World War I, Germany launched a biological sabotage campaign in the United States, Russia, Romania, and France. At that time, Anton Dilger lived in Germany, but in 1915 he was sent to the United States carrying cultures of glanders, a virulent disease of horses and mules. Dilger set up a laboratory in his home in Chevy Chase, Maryland. He used stevedores working the docks in Baltimore to infect horses with glanders while they were waiting to be shipped to Britain. Dilger was under suspicion as being a German agent, but was never arrested. Dilger eventually fled to Madrid, Spain, where he died during the Influenza Pandemic of 1918. In 1916, the Russians arrested a German agent with similar intentions. Germany and its allies infected French cavalry horses and many of Russia’s mules and horses on the Eastern Front. These actions hindered artillery and troop movements, as well as supply convoys. American biological weapon development began in 1942. President Franklin D. Roosevelt placed George W. Merck in charge of the effort to create a development program.[8] These programs continued until 1969, when by executive order President Richard Nixon shut down all programs related to American offensive use of biological weapons. US President Richard M. Nixon announced his new policy on biological warfare at a press conference in the Roosevelt Room of the White House on November 25, 1969. “Biological weapons have massive, unpredictable, and potentially uncontrollable consequences,” he declared. “They may produce global epidemics and impair the health of future generations.” He then stated that, in recognition of these dangers, the United States had decided to destroy its entire stockpile of biological agents and confine its future biological research program to defensive measures, such as vaccines and field detectors.As the 1970s passed, global efforts to prevent the development of biological weapons and their use were widespread. On August 10, 1972, President Richard M. Nixon formally transmitted the Biological Weapons Convention to the United States Senate for ratification. In his transmittal, he states: "I am transmitting herewith, for the advice and consent of the Senate to ratification, the Convention on the Prohibition of the Development, Production, and Stockpiling of Bacteriological (Biological) and Toxin Weapons, and on their Destruction, opened for signature at Washington, London and Moscow on April 10, 1972. The text of this Convention is the result of some three years of intensive debate and negotiation at the Conference of the Committee on Disarmament at Geneva and at the United Nations. It provides that the Parties undertake not to develop, produce, stockpile, acquire or retain biological agents or toxins, of types and in quantities that have no justification for peaceful purposes, as well as weapons, equipment and means of delivery designed to use such agents or toxins for hostile purposes or in armed conflict. In 1972 police in Chicago arrested two college students, Allen Schwander and Stephen Pera, who had planned to poison the city's water supply with typhoid and other bacteria. Schwander had founded a terrorist group, "R.I.S.E.", while Pera collected and grew cultures from the hospital where he worked. The two men fled to Cuba after being released on bail. Schwander died of natural causes in 1974, while Pera returned to the U.S. in 1975 and was put on probation. Since that time, efforts to use biological warfare has been more apparent in small radical organizations attempting to create fear in the eyes of large groups. Some efforts have been partially effective in creating fear, due to the lack of visibility associated with modern biological weapon use by small organizations. 1984 - USA - Rajneeshee bioterror attack In Oregon in 1984, followers of the Bhagwan Shree Rajneesh attempted to control a local election by incapacitating the local population. This was done by infecting salad bars in 11 restaurants, produce in grocery stores, doorknobs, and other public domains with Salmonella typhimurium bacteria in the city of The Dalles, Oregon. The attack infected 751 people with severe food poisoning. However, there were no fatalities. This incident was the first known bioterrorist attack in the United States in the 20th century.[12] 1993 - Japan - Aum Shinrikyo anthrax release in Kameido In June 1993 the religious group Aum Shinrikyo released anthrax in Tokyo. Eyewitnesses reported a foul odor. The attack was a total failure, infecting not a single person. The reason for this, ironically, is that the group used the vaccine strain of the bacterium. The spores recovered from the attack showed that they were identical to an anthrax vaccine strain given to animals at the time. These vaccine strains are missing the genes that cause a symptomatic response.[13] 21st century 2001 - USA - Anthrax Attacks In September and October 2001, several cases of anthrax broke out in the United States in the 2001 anthrax attacks, caused deliberately. Letters laced with infectious anthrax were delivered to news media offices and the U.S Congress. The letters killed 5. Tests on the anthrax strain used in the attack pointed to a domestic source, possibly from the biological weapons program. Still the attacks provoked efforts to define biodefense and biosecurity, where more limited definitions of biosafety had focused on unintentional or accidental impacts of agricultural and medical technologies. Bioterrorism Agent Categories Bioterrorism agents can be separated into three categories, depending on how easily they can be spread and the severity of illness or death they cause. Category A agents are considered the highest risk and Category C agents are those that are considered emerging threats for disease. Category A These high-priority agents include organisms or toxins that pose the highest risk to the public and national security because: • They can be easily spread or transmitted from person to person • They result in high death rates and have the potential for major public health impact • They might cause public panic and social disruption • They require special action for public health preparedness. Category B These agents are the second highest priority because: • They are moderately easy to spread • They result in moderate illness rates and low death rates • They require specific enhancements of CDC's laboratory capacity and enhanced disease monitoring. Category C These third highest priority agents include emerging pathogens that could be engineered for mass spread in the future because: • They are easily available • They are easily produced and spread • They have potential for high morbidity and mortality rates and major health impact. Planning and response Planning may involve the development of biological identification systems. Until recently in the United States, most biological defense strategies have been geared to protecting soldiers on the battlefield rather than ordinary people in cities. Financial cutbacks have limited the tracking of disease outbreaks. Some outbreaks, such as food poisoning due to E. coli or Salmonella, could be of either natural or deliberate origin. Preparedness Biological agents are relatively easy to obtain by terrorists and are becoming more threatening in the U.S., and laboratories are working on advanced detection systems to provide early warning, identify contaminated areas and populations at risk, and to facilitate prompt treatment. Methods for predicting the use of biological agents in urban areas as well as assessing the area for the hazards associated with a biological attack are being established in major cities. In addition, forensic technologies are working on identifying biological agents, their geographical origins and/or their initial son. Efforts include decontamination technologies to restore facilities without causing additional environmental concerns. Early detection and rapid response to bioterrorism depend on close cooperation between public health authorities and law enforcement; however, such cooperation is currently lacking. National detection assets and vaccine stockpiles are not useful if local and state officials do not have access to them. Biosurveillance In 1999, the University of Pittsburgh's Center for Biomedical Informatics deployed the first automated bioterrorism detection system, called RODS (Real-Time Outbreak Disease Surveillance). RODS is designed to draw collect data from many data sources and use them to perform signal detection, that is, to detect the a possible bioterrorism event at the earliest possible moment. RODS, and other systems like it, collect data from sources including clinic data, laboratory data, and data from over-the-counter drug sales.In 2000, Michael Wagner, the codirector of the RODS laboratory, and Ron Aryel, a subcontractor, conceived of the idea of obtaining live data feeds from "non-traditional" (non-health-care) data sources. The RODS laboratory's first efforts eventually led to the establishment of the National Retail Data Monitor, a system which collects data from 20,000 retail locations nation-wide. On February 5, 2002, George W. Bush visited the RODS laboratory and used it as a model for a $300 million spending proposal to equip all 50 states with biosurveillance systems. In a speech delivered at the nearby Masonic temple, Bush compared the RODS system to a modern "DEW" line (referring to the Cold War ballistic missile early warning system). The principles and practices of biosurveillance, a new interdisciplinary science, were defined and described in the Handbook of Biosurveillance, edited by Michael Wagner, Andrew Moore and Ron Aryel, and published in 2006. Biosurveillance is the science of real-time disease outbreak detection. Its principles apply to both natural and man-made epidemics (bioterrorism). Data which potentially could assist in early detection of a bioterrorism event include many categories of information. Health-related data such as that from hospital computer systems, clinical laboratories, electronic health record systems, medical examiner record-keeping systems, 911 call center computers, and veterinary medical record systems could be of help; researchers are also considering the utility of data generated by ranching and feedlot operations, food processors, drinking water systems, school attendance recording, and physiologic monitors, among others. Intuitively, one would expect systems which collect more than one type of data to be more useful than systems which collect only one type of information (such as single-purpose laboratory or 911 call-center based systems), and be less prone to false alarms, and this appears to be the case. In Europe, disease surveillance is beginning to be organized on the continent-wide scale needed to track a biological emergency. The system not only monitors infected persons, but attempts to discern the origin of the outbreak. Researchers are experimenting with devices to detect the existence of a threat: • Tiny electronic chips that would contain living nerve cells to warn of the presence of bacterial toxins (identification of broad range toxins) • Fiber-optic tubes lined with antibodies coupled to light-emitting molecules (identification of specific pathogens, such as anthrax, botulinum, ricin) New research shows that ultraviolet avalanche photodiodes offer the high gain, reliability and robustness needed to detect anthrax and other bioterrorism agents in the air. The fabrication methods and device characteristics were described at the 50th Electronic Materials Conference in Santa Barbara on June 25, 2008. Details of the photodiodes were also published in the February 14, 2008 issue of the journal Electronics Letters and the November 2007 issue of the journal IEEE Photonics Technology Letters. The United States Department of Defense conducts global biosurveillance through several programs, including the Global Emerging Infections Surveillance and Response System. Response to bioterrorism incident or threat Government agencies which would be called on to respond to a bioterrorism incident would include law enforcement, hazardous materials/decontamination units and emergency medical units. The US military has specialized units, which can respond to a bioterrorism event; among them are the US Marine Corp's Chemical Biological Incident Response Force and the U.S. Army's 20th Support Command (CBRNE), which can detect, identify, and neutralize threats, and Objective of the study General objective To analysis of Bioterrorism in public health aspects Specific objective • To explain about public health aspect on Bioterrorism in global context • To describe about the challenges of Bioterrorism. Methodology For collection of data the tools used are internet search, library search, reference books. The collected information was analyzed and compiled. For these procedures many software used are Internet Explorer, Adobe Reader, Ms. Office, etc. Result:- • Definition of Terrorism o ‘Terrorism’ - derives from the Latin ‘terrere’  Means to frighten o There are different types of terrorism  Instrumental:  To force a group into taking some action or complying with a demand  Example:-National Republic Army’s desire to end British control  Retribution:  Perpetrators are primarily interested in destroying their enemies  Target is hated not because of what they do but for the very fact that they exist  Examples:-Radical Islamic terrorists, White supremacists • The Terrorist Mind:- The terrorist mind uses 3 basic forms of rationalization: o Rationalization #1  No target population is entirely innocent, because they are evil by association with the enemy group o Rationalization # 2  Victims may be innocent, but war is hell, and in all noble struggles there is always collateral damage o Rationalization #3  The greater the number on innocent lives lost, the better  Targeting innocent is not a side effect, but in fact is their goal • Comparing Psychological Profiles o Street Criminal  Decreased verbal IQ  Poor planning  Frequent substance abuse  Early developmental antisocial pattern o Political Terrorist  Normal verbal IQ  Well-organized  Rare substance abuse, if any  No such pattern seen • Terrorist Typologies o Crusaders:  Most ideologically driven of terrorist  Motivated by their devotion to their cause  Example - Islamic Jihad, Neo-Nazism o Criminals:  Essentially violent individuals  In search of an excuse to express their antisocial impulses in the name of a ‘noble cause’ o Crazies:  May have some mental disorders  They easily revert their loyalties to the group  Result in dangerous instability in their commitment and behavior • Secret Service Profiles of Terrorists o Crusading Terrorists o Ideologically motivated by their religion or political convictions o Ultraconservative Political Terrorist o They believe in individual rights over the repressive or ultraliberal government o Often involved in militia groups o Religious Terrorists o Believe that they are accountable to no one but God o Therefore justify killing in His name and for His purpose o Criminal Terrorist o More of an opportunist than an idealist o Act for personal gain rather than for a cause o Theories behind terrorism have either: o Completely ignored individual psychological factors o Conceptualized the terrorist mind as mentally disturbed o Psychological insight into personality theory o APA defines personality disorder as: o “An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” o There are 10 different personality disorders, divided into 3 categories o Terrorist leaders tend to have a narcissistic or paranoid personality disorder • Terrorist Personalities: Narcissistic Personality o Traits include: o Grandiosity, entitlement, and arrogance o Need for admiration o Lack of empathy for others’ feelings and opinions o Classic terrorist leaders convinced of their own authority and infallibility o Regard themselves as above the law • Terrorist Personalities: Paranoid Personality o Traits include: o Pervasive distrust and suspiciousness o Others’ actions and motives are almost invariably interpreted as deceptive, persecutory, or malevolent o Philosophy here is to have a racial or religious exclusionary focus • Terrorist Personalities: True Believers and Unstable Deceivers o Borderline Personality o Traits include: o Erratic and intense relationships o Alternates between over-idealization and devaluation of others o Self-damaging impulsiveness o Emotional instability o Inappropriately intense anger and/or mood swings o Chronic feelings of emptiness  This may lead to the quest for stimulation through provocation or escalation of conflict • Terrorist Personalities: Borderline Personality o They form powerful allegiances to group leaders and ideologies o But their behavioral patterns of changeability makes them unreliable long-term loyalists o Devotion to take great risks makes them useful for dangerous terrorist missions o Example - suicide bombers o Unpredictability of their attachment may work to the advantage of law enforcement authorities • Terrorist Personalities: True Believers and Unstable Deceivers o Antisocial Personality o Traits include: o Consistent disregard for, and violation of, the rights of others o Impulsivity o Criminal behaviors o Sexual promiscuity o Substance abuse o Parasite and/or predatory lifestyle o May possess some similar qualities of entitlement ad self-importance as a narcissist • Terrorist Personalities: Antisocial Personality vs. others o However, antisocial have a complete lack of empathy and conscience o Often become skilled assassins and bombers of their group o Unlike narcissists and paranoid types, they are not true loyalists o This is all a game for them!! o When pressured by authorities they easily betray their group psychology to save their own skin o They are very manipulative so information has to be checked carefully • Terrorist Personalities: Good Soldiers and Worker Bees o Avoidant personality o Traits include: o Pattern of social inhibition o Feelings of inadequacy o Hypersensitivity to criticism o Makes them feel important by the admiration from the people and fellow group members o The organized and ideological certainty of these organizations provide them opportunities to work behind the scenes o They are never on the front lines • Terrorist Personalities: True Believers and Unstable Deceivers o Dependent personality o Traits include: o Pattern of submissive and clinging behavior o Excessive need for care and nurturance o They cling to others to receive guidance and direction • Terrorist Personalities: Dependent Personality o A charismatic cult leader is the perfect object of their desire o Their nature of being loyal and perseverance is very strong and is exploited by the terrorists o Dependents and Borderline get their “meaning and validation” from these groups hence they are fiercely loyal • Terrorist Personalities: Limelight Seekers and Loose Cannons o Histrionic Personality o Traits include: o Pattern of excessive emotionality o Attention-seeking behaviors o Need for excitement o Flamboyant and theatrical in speech and behavior o Impressionistic and impulsive • Terrorist Personalities: Histrionic Personality o These are the “showboats” of any organization o Enjoy being center of attention o Terrorist organizations use them as the frontline in the legitimate worlds of entertainment, the media, and politics o Hunger for recognition may make them change their loyalties o They can become a liability to the organization • Terrorist Personalities: Loose Cannons Traits include: o Pattern of severe deficits in social skills o Generalized withdrawal from life o Sometimes impairment in perceptual and cognitive skills Schizoid personality o Detachment from social interaction o Restricted range of emotional expressions o They are happy when left by themselves Schizotypal personality o More serious disturbances of thinking and more bizarre behavior • Terrorist Personalities: Schizoid and Schizotypal Personalities o We think these two personality disorders really represent a point in a continuum from schizoid to schizotypal to outright schizophrenia o Their psychology may lead them in a philosophical and spiritual quest that end up in a social and religious movement with terrorist ties o They keep to themselves - but show fierce commitment • Introduction:-Bioterrorist event o Release of biological agent into civilian population o Purpose  Creating fear  Illness  Death  Disruption of social and economic infrastructure • Biological agents o Infectious agents  Contagious  Noncontiguous o Biologically produced toxins  Act as chemical agents within human body • Agents of Concern o Agent selection 1. Potential for public health impact 2. Delivery potential  Estimation of ease for development and dissemination  Potential for person-to-person transmission of infection 3. Public perception (fear) of the agent 4. Special requirements for public health preparedness o Ranking category o Class A agents: most severe potential for widespread illness and death  Variola major (small pox)  Bacillus anthracis (anthrax)  Yersinia pestis (plague) o Class B agents: less potential o Class C agents: future threats  Class A Agents • Variola major (small pox) o Incubation: 12-14 days o S&S:  Initially: fever, severe myalgias, prostration  Within 2 days: papular rash on face spreading to extremities → rash on palms and soles → trunk  Lesions progress at same rate • Vesicular → pustular → scabs • Bacillus anthracis (Cutaneous anthrax) o Incubation: usually < 1 day, up to 2 weeks o S&S:  Macule or papule enlarging into eschar  Surrounding vesicles and edema  Sepsis possible • Bacillus anthracis (GI anthrax) o Incubation: usually 1-7 days o S&S:  Abdominal pain  Vomiting  GI bleeding leading to sepsis  Mesenteric adenopathy on CT • Bacillus anthracis (Oropharyngeal anthrax) o Incubation: usually 1-7 days o S&S:  Sore throat  Ulcers on base of tongue  Marked unilateral neck swelling • Bacillus anthracis (Inhalational anthrax) o Incubation: usually < 1 week o S&S:  1st stage: fever, dyspnea, cough, headache, vomiting, abdominal pain, chest pain  2nd stage: dyspnea, diaphoresis, shock  Hemorrhagic mediastinitis with widened mediastinum on CXR • Yersinia pestis (Bubonic plague) o Incubation: 2-8 days o S&S:  Fever, chills, painful swollen lymph nodes  Nodes progress to bubo (possibly suppurative) • Yersinia pestis (Pneumonic plague) o Incubation: 2-3 days o S&S:  Fever, chills, cough, dyspnea, nausea, vomiting, abdominal pain  Clinical condition consistent with gram-negative sepsis • Yersinia pestis (Primary septicemic plague) o Incubation: 2-8 days o S&S:  After bubo formation, clinical condition consistent with gram-negative sepsis, DIC • Clostridium botulinum (Food-born botulism) o Incubation: 1-5 days o S&S:  GI symptoms  Followed by symmetric cranial neuropathies, blurred vision  Progresses to descending paralysis • Clostridium botulinum (Inhalational botulism) o Incubation: 12-72 hours o S&S:  Symmetric cranial nerve palsies  Progresses to descending paralysis • Francisella tularensis (Tularemia) o Incubation: 2-5 days o S&S:  Abrupt nonspecific febrile illness  Progressing to pleuropneumonitis  May have mucocutaneous lesions • Filoviruses and arenaviruses (Ebola virus) o Viral hemorrhagic fevers o Incubation: 2 days – 3 weeks, depending on the virus o S&S:  Initial: nonspecific febrile illness, sometimes with rash  Progresses to hematemesis, diarrhea, shock  Class B Agents • Coxiella burnetii (Q fever) o Incubation: 2-3 weeks o S&S:  Fever, myalgias, headache  30% develop pneumonia • Brucella spp (Brucellosis) o Incubation: 2-4 weeks o S&S:  Fever, myalgias, back pain  Possible CNS infections, endocarditis • Burkholderia mallei (Glanders) o Incubation: 10-14 days o S&S:  Suppurative ulcers  Pneumonia  Pulmonic abscesses  Sepsis • Alpha viruses (VEE, EEE, WEE) o Encephalitis o Incubation: variable o S&S:  Fever  Headache  Aseptic meningitis  Encephalitis  Focal paralysis  Seizures • Rickettsia prowazekii (Typhus fever) o Incubation: 7-14 days o S&S:  Fever  Headache  Rash • Chlamydia psittaci (Psitticosis) o Incubation: 6-19 days o S&S:  Fever  Headache  Dry cough  Pneumonia  Endocarditis • Toxins o Ricin, Staphlococcus, Enterotoxin B • Food safety threats o Salmonella, Eschericia coli O157:H7 • Water safety threats o Vibrio cholera, Cryptosporidium parvum  Class C Agents • Emerging threats o Nipah virus o Hanta virus • Recognition of Bioterrorist Event 1. Patient presents with signs, symptoms, or immediately available diagnostic results that obviously indicate a suspect disease process. 2. Patient presents with protean symptoms, but an astute clinician establishes enough criteria (suspicious historical information, signs, symptoms, short turn-around lab results, public health corroborative information, etc.) to designate the patient as a presumptive case until diagnostic confirmation can be accomplished. 3. Patient presents, is evaluated and admitted or released, but not suspected as being a victim of bioterrorism. Diagnostic test results (blood cultures, immunoassays, etc.) subsequently establish a diagnosis, potentially even post mortem. 4. Multiple patients present over a defined period with similar symptoms or historical characteristics, raising the suspicions of a practitioner and causing that individual to report the concern. Further investigation with diagnostic testing and/or public health epidemiological investigation of the cohort establish the cause. 5. Public health surveillance systems establish unusual patterns of signs, symptoms, or disease in the community and correlate with further investigation to establish the etiology. • Recognition of Bioterrorist Event o Emergency physician should know o Basic pathological principles for each agent o Modes of dissemination and transmission o Disease signs and symptoms o Recommended diagnostic testing o Recommended therapy  Immunizations, medicines, or prophylaxis o Infectious control practices o Pictorial resources o Confirmatory tests o Respond to notification of potential disease by another health or medical professional o Querying the source for methodology of testing that produced the concern o Exposure to an unidentified substance o Source substance and where obtained o Coordination with outside agencies, such as law enforcement and public health o Patient exposure risk stratification • Design and Implementation of Community Surveillance Systems o Clinical duties are minimally affected - Does not consume valuable clinician or support staff time and attention o Financial investment is not carried by the hospital or professional staff o Patient privacy and hospital proprietary issues are addressed appropriately o Participation in the system provides direct benefit to the acute care medical community - All pertinent epidemiologic information is disseminated in real time to the practitioners • Initial Response to a Potential Bioterrorist Threat • Within hospital environment o Infection control procedures o Notification of hospital departments  Administration  Infectious disease  Infection control  Laboratory services  Security  Environmental services o Activation of Emergency Operations Plan (EOP)  Preplanned surge capacity configuration  Security dept – aid in protection of facility and staff  Media relations o Notification of jurisdictional public health department • Information that needs to be conveyed to public health department 1. Diagnosed or suspected agent of concern 2. Whether it is a presumed or definitive diagnosis and how many diagnoses were made 3. Patient demographics (including occupation) 4. Recent history of travel or participation in special events (i.e. mass gatherings, high-profile events, or at- risk gatherings) 5. Patient condition 6. Initial testing performed and further diagnostic testing being conducted 7. Treatment being provided 8. Public health assistance required (including testing) 9. Preferred method of contacting hospital or treating physicians for follow-up • Protective equipment o Gowns, gloves, respiratory masks • Patient isolation • Patient decontamination o Removal of clothing o Soap and warm water o NO bleach • Integration with Local Department of Health • Development of community wide patient evaluation and treatment protocol o Screening o Testing o Treatment methodologies o Patient and public education • Clear and concise definition for the suspicious agent • Reporting requirements (surveillance) for suspected or diagnosed cases o Type of information o Method of reporting (e.g. phone, fax, Internet) o Contact methods (e.g. 24 hr access for technical advice) • Treatment, Prophylaxis, and Immunizations • Agent: Variola major • Vaccination: Vaccinia vaccination o Not recommended for general public use o Contraindicated in immunocompromised pts and pts with eczema o Useful in preventing disease if given within 4 days of exposure • Prophylaxis: Vaccinia immunoglobin o Within 2-3 days of exposure o Limited supplies available o Consider giving it to those with contraindications to the vaccine • Treatment: o Mainly supportive • Treatment, Prophylaxis, and Immunizations • Agent: Bacillus anthracis • Vaccination: Anthrax vaccination o 6 part series at 0,2, and 4 week, then 6,12, and 18 months o Annual boosters required o Not available to the public o Animal models: efficatious in inhalational anthrax • Prophylaxis: o Cipro or doxy for 60 days o Amoxicilin if strain not resistant to treatment • Treatment: o Cipro or doxy (amoxicillin if strain not resistant) in combo with 2 others, including clindamycin, rifampin, imipenem, aminoglycoside, chloramphenicol, vancomycin, streptomycin, and some macrolides • Agent: Yersinia pestis • Vaccination: none • Prophylaxis: o Cipro or doxy for 7 days o Alt: chloramphenicol • Treatment: o Streptomycin or gentamycin o Alt: doxy, cipro, chloramphenicol • Treatment, Prophylaxis, and Immunizations • Agent: Clostridium botulinum • Vaccination: o Not available to public o Pentavalent toxoid of C botulinum toxin types A-E o 3-part series, with yearly booster • Prophylaxis: none • Treatment: o Antitoxin: from local public health agency o Antitoxin may preserve remaining neurologic function, BUT does not reverse paralysis o May require prolonged, assisted mechanical ventilation and supportive care • Agent: Francisella tularensis • Vaccination: o Live, attenuated vaccine under FDA investigation • Prophylaxis: o Cipro or doxy for 14 days • Treatment: o Streptomycin or gentamycin o Alt: doxy, cipro, chloramphenicol • Agent: Filoviruses and arenaviruses (e.g. Ebola virus) • Vaccination: none • Prophylaxis: none • Treatment: o Supportive therapy o Ribavirin may have applicability in arenaviruses • Treatment for Bioterrorism • General Emergency Operation Plans o Need to have enough staff to handle large surge in general patient volume • Specialty requirements o Patient with unusual medical conditions o Patients who may be contagious o Contamination risks to staff and other patients • Disease containment o Isolation o Designation of staff to care for infected vs. noninfected patients o Proper personal protective equipment • Management of personnel o Need more personnel to care for more patients o Staff reluctance to care for potentially infectious patients • Logistics o Limited supply of drugs and medical supplies o Sharing of critical supplies, staff, and equipment among local hospitals o National Pharmaceutical Stockpile • Patient Management o Addressing requirements of each patient encounter o Preprinted instructions  Category of risk stratification  Why patient placed in that category  How disease transmitted  Measures to prevent spread  Early signs and symptoms of disease  Appropriate steps if symptoms occur • Patient Management o Appropriate follow-up o Proper record keeping o Organization of charts • Vaccinations o Not to be given in a pre-event setting to general public • Recommended therapies o Usually not for pregnant or lactating women o Usually not approved for children o Should be given if risk of infection and its consequences exceeds risks of the medications or vaccines • Fatality Management o Bodies are considered evidence o Processed through coroner or medical examiner • WHY PUBLIC HEALTH? • CHEMICAL o effects immediate and obvious o victims localized by time and place o overt o illicit immediate response o first responders are police, fire, EMS • BIOLOGICAL o effects delayed and not obvious o victims dispersed in time and place o no first responders o unless announced, attack identified by medical and public health personnel • Tokyo subway 1995 / Sarin o Effects within minutes o Victims self-reported to authorities, self- transported to hospitals o First responders  fire, police, EMS o Agent identified: 3 hrs o Event over: 12-24 hrs • Oregon USA 1984 / Salmonella o County Health Department  first reports of foodborne illness: several days  two waves of illness over 5 weeks o County Health Department and CDC  751 victims and 10 restaurants identified: weeks - months o Criminal investigation  source identified: 12 months  criminal charges: 18 months • PUBLIC HEALTH • Examples of biological assaults: Note: all incidents were discovered by public health officials and initially presented as an unusual cluster in time and place of an uncommon disease o 1996 Shigella dysenteriae USA o 1984 Salmonella USA o 1970 Ascaris suum Canada o 1966 Typhoid Japan o 1965 Hepatitis USA • Announced attack o Primary response: law enforcement, EMS • Hoax o Variation on announced attack o Increasing occurrence  1992: 1 event affecting 20 people  1998: 37 events affecting 5529 people • Bioterrorism Alleging Use of Anthrax and Interim Guidelines for Management -- United States, 1998 o MMWR February 5, 1999 48(04);69-74 o http://www.cdc.gov/epo/mmwr/preview/ mmwrhtml/rr4904a1.htm • Preparedness and prevention • Detection and surveillance • Diagnosis and characterization of agents • Response • Communication • Preparedness and prevention o Coordinated preparedness plans o Coordinated response protocols o Performance standards  self-assessment, simulations, exercises • Detection and surveillance o Develop mechanisms for detecting, evaluating, and reporting suspicious events o Integrate surveillance for illness and injury resulting from WMD terrorism into disease surveillance system • Diagnosis and characterization of agents o Multilevel laboratory response network  link clinical labs and public health agencies in all states, districts, territories, and selected cities and counties to CDC and other labs o Transfer diagnostic technology from federal to state level o CDC Rapid Response and Technology Lab • Response o Epidemiologic investigation  if requested by state health agency, CDC will deploy response teams to investigate unexplained or suspicious illness o Medical treatment and prophylaxis  vaccine / antibiotic stockpile and transportation o Environmental decontamination • Communication o Effective communication with the public  use news media to limit panic and disruption of daily life o Effective communication with health care and public health personnel  coordination of activities  access emergency information  rapid notification and information exchange • Issues: o Existing local, regional, and national surveillance systems  Adequate to detect traditional agents  Inadequate to detect potential bio-warfare agents o Specific training for health care professionals  clinical personnel will be “first responders” o Civilian biodefense plans are usually based on HAZMAT models  Assumes responders enter a high exposure environment near the source  Assumes site of exposure is separate from the health care facility  Assumes no time pressure for decontamination  Maximum protection is provided for a minimum number of workers / rescuers o HAZMAT  OSHA mandates use of PPE based on site hazard, but site hazards are more easily defined at the point of release  Traditional HAZMAT products are expensive, take time to set up, and are inadequate for large numbers of patients  Difficult to train and maintain proficiency in a civilian work force with high turnover Conclusions o Preparation for a biological mass disaster requires coordination of diverse groups of medical and non-medical personnel o Preparation cannot occur without support and participation by all levels of government o Preparation must be a sustained and evolutionary process References 1. CDC. Norwalk-like virus--associated gastroenteritis in a large, high-density encampment---Virginia, July 2001. MMWR 2002;51:661--3. 2. CDC. Public health aspects of the Rainbow Family of Living Light annual gathering---Allegheny National Forest, Pennsylvania, 1999. MMWR 2000;49:324. 3. Wharton M, Spiegel RA, Horan JM, et al. A large outbreak of antibiotic-resistant shigellosis at a mass gathering. J Infect Dis 1990;162:1324--8. 4. CDC. About extreme heat. Atlanta, GA: US Department of Health and Human Services, CDC; 2004. Available at http://www.bt.cdc.gov/disasters/extremeheat/about.asp. 5. CDC. Heat-related illnesses and deaths: United States, 1994--1995. MMWR 1995;44:465--8. 6. CDC. Heat-related deaths---Dallas, Wichita, and Cooke counties, Texas, and United States, 1996. MMWR 1997;46:528--31. 7. McGeehin MA, Mirabelli M. The potential impacts of climate variability and change on temperature-related morbidity and mortality in the United States. Environ Health Perspect 2001;109(Suppl 2):185--9.