Bioterrorism

1. Bioterrorism

2. Goals and Objectives What is bioterrorism? What are the biological agents of terror? What�s my role?

3. Bioterrorism The use of organisms or toxins to kill or sicken people, animals, or plants 1346 Tartars catapulted corpses over the walls of Kaffa to spread plague 1754 Blankets used by smallpox patients distributed to Native Americans 1939 Japanese army accused of dropping plague-infected fleas over Manchurian China

4. The Makings of a Biological Weapon Infectivity Stability Ease of production, dissemination, and transmission Morbidity and mortality of resultant disease(s) Ability to cause public panic

5. Smallpox It�s smallpox, don�t do nothing Vaccinia immune globulin only given to high-risk populations (pregnant, immunosuppressed) Cidofovir (used for CMV) has in vitro activity against smallpox, but clinical effectiveness unknown Smallpox vaccine should be given within 4 days of exposure to provide partial protection Pt should monitor BID for temp > 38� x 17 days

6. Smallpox Causative agent: Variola virus dsDNA orthopoxvirus of family Poxviridae Host: humans Last case: 1977 Mortality: 30% Incubation: 7-17 days Symptoms: High fever, malaise, vomiting, headache, backache, abdominal pain

7. Smallpox The Rash: Face and extremities Same stage Macules?papules? pustules?scabs (8 days) Other forms: Hemorrhagic Malignant Differentiate from: Chickenpox (varying stages, favors trunk) Human monkeypox (lymphadenopathy)

8. Smallpox Vaccine Live vaccinia virus Partial protection if given within 4 days Lots of complications Lots of contraindications Immune globulin available

9. Anthrax Causative agent: Bacillus anthracis Gram positive aerobic spore-forming bacillus Inhalational form most likely to be used Mortality: up to 100% Incubation: 1-7 days Up to 43 days Symptoms: phase-dependent

10. Anthrax Prodrome Flu-like, without coryza Second phase Severe dyspnea, respiratory distress, shock Meningitis (50%) Enlarged hilar/mediastinal nodes Widened mediastinum Pleural effusions

11. Anthrax Other forms Cutaneous Gastrointestinal Treatment Fluoroquinolone/Doxycycline x 60 days, plus One or two additional agents until sensitivities Vaccination Isolation: none

12. Plague Causative agent: Yersinia pestis Gram negative rod Forms: Bubonic plague Septicemic plague Pneumonic plague Mortality: 100% If not treated within 24 hrs of symptom onset

13. Bubonic Plague Inoculation: flea bite Incubation: 2-7 days Symptoms: Fever, chills, weakness, headache Findings: Buboes, papules, vesicles DIC

14. Pneumonic Plague Inoculation: aerosolized Y.pestis Incubation: 2-4 days Symptoms: High fevers, headache, myalgias, dyspnea, hemoptysis, sepsis Findings: �Watery,� blood-tinged sputum, patchy bronchopneumonia on CXR Stridor, cyanosis, death

15. Plague Treatment: Streptomycin x 7-10 days Alternatives � Gentamicin, Doxycycline Prophylaxis: Fluoroquinolone/Doxycycline Isolation: Bubonic � standard precautions Pneumonic � droplet/airborne

16. Botulism Causative agent: Clostridium botulinum Gram positive spore-forming rod 8 different toxins � A and B in US Types: Foodborne Wound Gastrointestinal Aerosolized Dr. 90210

17. Botulism Incubation: 12-72 hours Symptoms: Diplopia Dysphonia Dysarthria Dysphagia Descending, symmetric, flaccid paralysis Findings: EMG � normal conduction with reduced amplitude

18. Botulism Treatment: antitoxin Isolation: none

19. Tularemia Causative agent: Francisella tularensis Gram negative, intracellular coccobacillus Most likely pneumonic form from aerosolization Incubation: 3-5 days Up to 21 days Symptoms: Fever, headache, malaise, chest pain, sore throat, abd pain, dry cough, coryza Fever may be relapsing and remitting

20. Tularemia Treatment: Streptomycin/Gentamicin Vaccination: Prophylaxis: ??? Isolation: Standard

21. Viral Hemorrhagic Fevers Causative agents: small RNA viruses Category A: Ebola fever Marburg fever Lassa fever Argentine hemorrhagic fever Bolivian hemorrhagic fever

22. Viral Hemorrhagic Fevers Symptoms: Fever, myalgias, headache, vomiting, diarrhea (~4 d) Severe prostration, nondependent edema, hypotension, mental status changes, shock Petechial hemorrhage, hemorrhage of mucous membranes, DIC Treatment: Supportive Ribavirin Isolation: Standard, plus Contact-droplet Airborne

23. Let�s recap�

24. What�s Your Role? Change your underwear Immediate isolation Wear personal protective gear Notify appropriate authorities Collect necessary specimens Provide prophylaxis

25. Isolation No human to human transmission in: Tularemia Botulism Anthrax Droplet: Pneumonic plague Airborne/Contact-droplet: Smallpox Viral hemorrhagic fever

26. The End.