1. NURSING IN THE ERA OF BIOTERRORISM NURSING IN THE ERA OF BIOTERRORISM

2. Accurate information is the best defense against panic and confusion in the event of a crisis.

3. Definition of Bioterrorism Premeditated threat or actual use of biological weapons to produce disease or death in people, animals, or plants. Premeditated threat or actual use of biological weapons to produce disease or death in people, animals, or plants. Biological weapons: microbes or their toxins. Biological weapons: microbes or their toxins.

4. Biological Weapons

5. Bioterrorism Overview Microorganisms or their toxins can be in liquid or powder form. Microorganisms or their toxins can be in liquid or powder form. Various delivery methods are possible: Various delivery methods are possible: aerosol aerosol envelope or package envelope or package food or water contamination food or water contamination Exposure can be isolated to a single area or can be more widespread. Exposure can be isolated to a single area or can be more widespread.

6. Bioterrorism Microorganisms as biologic weapons would most likely result in illness occurring days to weeks after attack and would affect persons dispersed from the site.

7. Biological Agents: Types and Characteristics BacteriaViruses Biological Toxins

8. CDC Categories Category A: Category A: easily disseminated OR transmitted person to person easily disseminated OR transmitted person to person susceptible population susceptible population potential for panic / disruption potential for panic / disruption requires special action for treatment requires special action for treatment high morbidity and mortality high morbidity and mortality examples: anthrax, smallpox, plague, botulism, viral hemorrhagic fevers examples: anthrax, smallpox, plague, botulism, viral hemorrhagic fevers

9. CDC Categories Category B: Category B: moderately easy to disseminate moderately easy to disseminate moderate morbidity, low mortality moderate morbidity, low mortality examples: Q fever, brucellosis, glanders, some toxins examples: Q fever, brucellosis, glanders, some toxins Category C: Category C: emerging pathogens that could be engineered for mass dissemination in the future emerging pathogens that could be engineered for mass dissemination in the future potential for high morbidity and mortality potential for high morbidity and mortality examples: hantavirus, tickborne viruses, MDR TB examples: hantavirus, tickborne viruses, MDR TB

10. Isolation Precautions Standard (“blood and body fluid”): Standard (“blood and body fluid”): gloves gloves mask with face shield mask with face shield gown gown Airborne: Airborne: standard plus negative pressure room and N95 mask (“duckbill mask”) standard plus negative pressure room and N95 mask (“duckbill mask”)

11. HANDWASHING HANDWASHING

12. Gram positive bacillus that forms spores Gram positive bacillus that forms spores Spores found in soil worldwide Spores found in soil worldwide Humans usually infected by contact with infected animals or contaminated animal products Humans usually infected by contact with infected animals or contaminated animal products No person-to-person transmission of inhalation anthrax No person-to-person transmission of inhalation anthrax Anthrax: Overview Anthrax: Overview

13. Anthrax: Cutaneous Most common form (95%) Most common form (95%) Inoculation of spores in skin Inoculation of spores in skin Incubation: hours to days Incubation: hours to days Progression: Progression: 1. small papule 2. ulcer surrounded by vesicles 3. painless eschar with edema Death: Death: untreated – 20% untreated – 20% treated – rare treated – rare

19. Anthrax: Gastrointestinal Ingestion of contaminated meat Ingestion of contaminated meat Fever, vomiting, bloody diarrhea Fever, vomiting, bloody diarrhea Intestinal eschar similar to cutaneous anthrax lesion Intestinal eschar similar to cutaneous anthrax lesion Progression to general toxemia Progression to general toxemia Mortality 50% despite treatment Mortality 50% despite treatment

20. Anthrax Testing Nasal Swab: Nasal Swab: A tool for epidemiology, not diagnosis A tool for epidemiology, not diagnosis Limitations: Limitations: positive test indicates exposure, not infection positive test indicates exposure, not infection false positives have been seen (positive test does not prove infection) false positives have been seen (positive test does not prove infection) false negatives (negative test does not rule out anthrax infection) false negatives (negative test does not rule out anthrax infection)

21. Anthrax Testing Nasal Swab: Nasal Swab: A tool for epidemiology, not diagnosis A tool for epidemiology, not diagnosis Limitations: Limitations: positive test indicates exposure, not infection positive test indicates exposure, not infection false positives have been seen (positive test does not prove infection) false positives have been seen (positive test does not prove infection) false negatives (negative test does not rule out anthrax infection) false negatives (negative test does not rule out anthrax infection) Serologic tests: Serologic tests: Available at special labs but not used for routine screening Available at special labs but not used for routine screening

22. Anthrax Testing Nasal Swab: Nasal Swab: A tool for epidemiology, not diagnosis A tool for epidemiology, not diagnosis Limitations: Limitations: positive test indicates exposure, not infection positive test indicates exposure, not infection false positives have been seen false positives have been seen negative test does not rule out anthrax infection negative test does not rule out anthrax infection Serologic tests: Serologic tests: Available at special labs but not used for routine screening Available at special labs but not used for routine screening Blood cultures: Blood cultures: Probably best test for symptomatic individual at risk Probably best test for symptomatic individual at risk

23. ANTHRAX: Treatment Inhalation anthrax or cutaneous anthrax with systemic involvement: Inhalation anthrax or cutaneous anthrax with systemic involvement: ciprofloxacin (400mg, IV, q12h) or doxycycline (100 mg, IV, q12h) ciprofloxacin (400mg, IV, q12h) or doxycycline (100 mg, IV, q12h) combine with one of the following: combine with one of the following: rifampin, vancomycin, penicillin, ampicillin, clindamycin, clarithromycin rifampin, vancomycin, penicillin, ampicillin, clindamycin, clarithromycin Treat for 60 days Treat for 60 days

24. Anthrax: Other Treatment Uncomplicated cutaneous anthrax: Uncomplicated cutaneous anthrax: Cipro (500 mg, po, bid) or doxycycline (100 mg, po, bid) Cipro (500 mg, po, bid) or doxycycline (100 mg, po, bid) Prophylaxis for exposure: Prophylaxis for exposure: Cipro (500 mg, po, bid) or doxycycline (100 mg, po, bid) Cipro (500 mg, po, bid) or doxycycline (100 mg, po, bid) Children or breastfeeding mothers: amoxicillin Children or breastfeeding mothers: amoxicillin Levoquin- adults 18 and older Levoquin- adults 18 and older Treat for 60 days Treat for 60 days

25. 2.2 KG’S OF ANTHRAX SPRINKLED FROM A 20 TH FLOOR HIGH RISE IN NEW YORK CITY WOULD KILL / INFECT OVER 120,000 PEOPLE 2.2 KG’S OF ANTHRAX SPRINKLED FROM A 20 TH FLOOR HIGH RISE IN NEW YORK CITY WOULD KILL / INFECT OVER 120,000 PEOPLE

26. Plague: Overview Yersinia pestis (gram-negative coccobacillus) Yersinia pestis (gram-negative coccobacillus) About 10 U.S. cases/yr (SW) About 10 U.S. cases/yr (SW) Two major forms Two major forms Very contagious via respiratory droplets Very contagious via respiratory droplets

27. Plague Epidemics 3 major recorded epidemics: 550, 1350 (Black Death), 1850 (China) 550, 1350 (Black Death), 1850 (China) 30% - 60% mortality in infected continents 30% - 60% mortality in infected continents

28. Plague GOOD NEWS: GOOD NEWS: future epidemics unlikely due to sanitation, public health practices, and antibiotics. future epidemics unlikely due to sanitation, public health practices, and antibiotics. BAD NEWS: BAD NEWS: US and Russia and other countries have developed techniques to aerosolize plague, eliminating need for fleas to spread the infection. US and Russia and other countries have developed techniques to aerosolize plague, eliminating need for fleas to spread the infection.

29. Plague as a Bioweapon Infected fleas could spread bubonic form (less likely scenario) Infected fleas could spread bubonic form (less likely scenario) Aerosolized organisms would spread pneumonic form (more likely scenario) Aerosolized organisms would spread pneumonic form (more likely scenario)

30. Plague: Bubonic Bite from infected flea Bite from infected flea Sudden onset flu-like syndrome Sudden onset flu-like syndrome Buboes: Buboes: tender, enlarged lymph nodes (inguinal, axillary, cervical) tender, enlarged lymph nodes (inguinal, axillary, cervical) Can spread to lungs (hematogenous) Can spread to lungs (hematogenous) Can also lead to endotoxic septicemic phase Can also lead to endotoxic septicemic phase

31. Plague: Pneumonic Inhalation of organisms (aerosol) Inhalation of organisms (aerosol) Incubation: 1-3 days Incubation: 1-3 days Sudden onset flu-like syndrome Sudden onset flu-like syndrome Pneumonia progresses rapidly to hypoxemia, cyanosis, hemoptysis Pneumonia progresses rapidly to hypoxemia, cyanosis, hemoptysis Endotoxin: septic shock with DIC, ARDS, death Endotoxin: septic shock with DIC, ARDS, death

32. Plague Disease Complex Inhalational of plague organisms Flu-like Syndrome Sudden onset 2 -3 days

33. Plague Disease Complex Fulminant Pneumonia Flu-like Syndrome Sudden onset productive cough bilateral infiltrates cyanosis 2 -3 days 24 hrs Inhalational of plague organisms

34. Plague Disease Complex ARDS DIC Fulminant Pneumonia Flu-like Syndrome Sudden onset 2 -3 days 24 hrs Inhalational of plague organisms

35. Plague Disease Complex ARDS DIC Fulminant Pneumonia Flu-like Syndrome Sudden onset 2 -3 days 24 hrs Inhalational of plague organisms Endotoxemia Respiratory failure Circulatory collapse

36. Plague Disease Complex ARDS DIC Fulminant Pneumonia Flu-like Syndrome Sudden onset 2 -3 days 24 hrs Inhalational of plague organisms Endotoxemia Respiratory failure Circulatory collapse Flu-like syndrome Tender buboes 2 - 10 days

37. Pneumonic Plague: Isolation precautions SECONDARY TRANSMISSION IS POSSIBLE - EASILY SECONDARY TRANSMISSION IS POSSIBLE - EASILY USE STANDARD AND AIRBORNE PRECAUTIONS USE STANDARD AND AIRBORNE PRECAUTIONS

38. Management / Prophylaxis Antibiotic therapy Antibiotic therapy IV amino glycoside and IV doxycycline IV amino glycoside and IV doxycycline Ciprofloxacin Ciprofloxacin Antibiotic resistant strains exist Antibiotic resistant strains exist Supportive measures Supportive measures Prophylaxis for respiratory droplet exposure: Prophylaxis for respiratory droplet exposure: oral doxycycline or oral ciprofloxacin for 7-10 days oral doxycycline or oral ciprofloxacin for 7-10 days vaccine - no longer manufactured in U.S. vaccine - no longer manufactured in U.S.

39. Plague: Diagnostic Tests No widely available rapid tests No widely available rapid tests Gram stain of body fluids or lymph node aspirate may reveal gram-negative organisms Gram stain of body fluids or lymph node aspirate may reveal gram-negative organisms Blood cultures should be positive within 2 days. Blood cultures should be positive within 2 days. Confirmatory testing via government labs (antigen detection, immunoassays, and PCR) Confirmatory testing via government labs (antigen detection, immunoassays, and PCR)

40. Viruses as Bioweapons Viral Hemorrhagic Fevers: Viral Hemorrhagic Fevers: Ebola Ebola Lassa Lassa Marburg Marburg Smallpox Smallpox

41. Viral Hemorrhagic Fevers Group of illnesses caused by several RNA viruses Group of illnesses caused by several RNA viruses All can be used as bioweapons All can be used as bioweapons Examples: Ebola, Marburg, Lassa Examples: Ebola, Marburg, Lassa Mortality can be very high (90% for Ebola) Mortality can be very high (90% for Ebola)

42. VHF: Occurrence Naturally occurring infections can occur via transmission from infected rodents and arthropods Naturally occurring infections can occur via transmission from infected rodents and arthropods Readily transmissible from person to person via body fluids: Readily transmissible from person to person via body fluids: great risk for healthcare workers great risk for healthcare workers VHF very rare in US: VHF very rare in US: usually travelers to endemic areas usually travelers to endemic areas

43. CURRENT OUTBREAK Current outbreak in Africa Current outbreak in Africa 80-89% MORTALITY 80-89% MORTALITY

44. VHF: Pathophysiology Variable incubation (2-21 days) Variable incubation (2-21 days) Flu-like symptoms with high fever Flu-like symptoms with high fever Increased vascular permeability causes: Increased vascular permeability causes: hemorrhage in GI tract and mucous membranes hemorrhage in GI tract and mucous membranes petechial or ecchymotic rash petechial or ecchymotic rash edema edema hypotension hypotension Rapid progression to shock and death Rapid progression to shock and death

45. VHF: Lab Testing No widely available rapid tests No widely available rapid tests Government labs can provide nucleic acid assays Government labs can provide nucleic acid assays Routine labs reveal clotting abnormalities: Routine labs reveal clotting abnormalities: elevated PT and PTT, decreased platelets elevated PT and PTT, decreased platelets

46. VHF: Treatment Supportive treatment Supportive treatment IV ribavirin used occasionally for Lassa fever. IV ribavirin used occasionally for Lassa fever. Vaccines under development Vaccines under development Postexposure prophylaxis with oral ribavirin may be useful Postexposure prophylaxis with oral ribavirin may be useful Contact and respiratory precautions necessary Contact and respiratory precautions necessary

47. Smallpox Variola virus Variola virus Characteristic skin lesions Characteristic skin lesions About 30% mortality in unvaccinated About 30% mortality in unvaccinated Last known natural case: Somalia in 1977 Last known natural case: Somalia in 1977

49. Smallpox as a Bioweapon Can be aerosolized Can be aerosolized Highly contagious Highly contagious No effective treatment No effective treatment Vaccination ceased in 70’s Vaccination ceased in 70’s Stable in the environment (contamination for months) Stable in the environment (contamination for months)

50. Smallpox: Pathophysiology Virus inhaled or deposited on mucous membranes Virus inhaled or deposited on mucous membranes Goes to lymph nodes, incubates for 7-17 days Goes to lymph nodes, incubates for 7-17 days Release into blood causes flu-like symptoms Release into blood causes flu-like symptoms Rash begins 2-3 days later Rash begins 2-3 days later Death due to toxemia of viral antigens and circulating immune complexes Death due to toxemia of viral antigens and circulating immune complexes

51. Smallpox: Skin lesions Macular (flat, red) rash 2-3 days after flu symptoms Macular (flat, red) rash 2-3 days after flu symptoms Starts on face, forearms, hands (+ palms and soles) Starts on face, forearms, hands (+ palms and soles) Rash evolves synchronously in an area Rash evolves synchronously in an area Evolves into tense vesicles Evolves into tense vesicles Scabs form in 7-10 days if patient lives Scabs form in 7-10 days if patient lives Infectious until all scabs are shed. Infectious until all scabs are shed.

55. Day 3 Day 5 Day 7

56. Chickenpox with characteristic rose-colored macules, papules, vesicles, pustules, necrotic pustules, and crusted lesions occurring simultaneously.

57. Herpes zoster (varicella virus) with characteristic grouping of vesicles Herpes zoster showing dermatomal distribution of lesions

58. Prodromeyesminimal or none Smallpox vs. Chickenpox Smallpox Chickenpox

59. Prodromeyesminimal or none Distribution out to inin to out Smallpox vs. Chickenpox Smallpox Chickenpox

60. Prodromeyesminimal or none Distribution out to inin to out Lesionspainful / deeppruritic / superficial Progressionsynchronousasynchronous Palms / Solesyesno Smallpox vs. Chickenpox Smallpox Chickenpox

61. Smallpox vs. Chickenpox

62. Smallpox: Diagnosis CLINICAL PRESENTATION AND PATIENT HISTORY IS THE KEY TO DIAGNOSIS CLINICAL PRESENTATION AND PATIENT HISTORY IS THE KEY TO DIAGNOSIS No widely available rapid test No widely available rapid test Electron microscopy to confirm presence of variola virus particles Electron microscopy to confirm presence of variola virus particles

63. Smallpox: Treatment and Prophylaxis No effective treatment No effective treatment Animal trials with cidofovir are promising Animal trials with cidofovir are promising Vaccinia immune globulin may be useful Vaccinia immune globulin may be useful Vaccination within 3-4 days of ALL potential contacts may prevent or lessen disease Vaccination within 3-4 days of ALL potential contacts may prevent or lessen disease

64. Smallpox: Precautions Airborne and Contact Isolation Airborne and Contact Isolation Airborne Isolation: Airborne Isolation: negative pressure room negative pressure room anteroom anteroom closed ventilation system closed ventilation system N95 mask (Duckbill mask) N95 mask (Duckbill mask) Contact Isolation: Contact Isolation: strict use of PPE and handwashing strict use of PPE and handwashing

65. Smallpox: Precautions Patients may be cohorted Patients may be cohorted Laundry kept separate and in Red Bag Laundry kept separate and in Red Bag Limit number of personnel in contact Limit number of personnel in contact Mask patient if in-hospital transport Mask patient if in-hospital transport Contacts placed under 18 day fever surveillance (>100.5 reportable) Contacts placed under 18 day fever surveillance (>100.5 reportable)

66. Smallpox Vaccine Vaccination in U.S. ended in 1972 except military personnel Vaccination in U.S. ended in 1972 except military personnel Not known if previous vaccination is protective now Not known if previous vaccination is protective now Not a benign vaccine: side effects and fatalities Not a benign vaccine: side effects and fatalities Possibly MANY deaths if given to all in US Possibly MANY deaths if given to all in US

67. Smallpox Vaccine Vaccine is for vaccinia, a closely related and more benign virus Vaccine is for vaccinia, a closely related and more benign virus Vaccine contraindicated in some, unless exposure has occurred: Vaccine contraindicated in some, unless exposure has occurred: Immunosuppressed (hiv / cancer/transplant patients Immunosuppressed (hiv / cancer/transplant patients chronic steroid usage (eyedrops) chronic steroid usage (eyedrops) eczema or chronic exfoliative skin disorders eczema or chronic exfoliative skin disorders pregnancy pregnancy age under 18 age under 18 CARDIAC DISEASE- Mi’s / Myopathy / Angina CARDIAC DISEASE- Mi’s / Myopathy / Angina

68. Smallpox Vaccine Virus sheds from vaccine site for up to 6 weeks Virus sheds from vaccine site for up to 6 weeks Shedding can infect household contacts with vaccinia Shedding can infect household contacts with vaccinia Some serious vaccine reactions: Some serious vaccine reactions: encephalitis, severe vaccinia, anaphylaxis, Stevens-Johnson encephalitis, severe vaccinia, anaphylaxis, Stevens-Johnson Auto-inoculation of orifices can occur Auto-inoculation of orifices can occur

69. AUTO-INNOCULATION

74. NEW JERSEY CLINICS NORTHWEST- Sussex/Passaic/Warren/Morris NORTHWEST- Sussex/Passaic/Warren/Morris St Joe’s and ID Associates St Joe’s and ID Associates NORTHEAST- Bergen/Essex/Hudson NORTHEAST- Bergen/Essex/Hudson Hackensack / UMDNJ- Newark Hackensack / UMDNJ- Newark CENTRALEAST- Middlesex/Union/Monmouth/Ocean CENTRALEAST- Middlesex/Union/Monmouth/Ocean Raritan Bay Medical Center Raritan Bay Medical Center

75. CENTRALWEST- Somerset/Mercer/ Hunterdon CENTRALWEST- Somerset/Mercer/ Hunterdon Hunterdon Hospital Hunterdon Hospital South- Camden/Burlington/Atlantic/Salem South- Camden/Burlington/Atlantic/Salem Our Lady of Lourdes and Shore Hospitals Our Lady of Lourdes and Shore Hospitals

76. VACCINATION REPORT HEALTH CARE WORKERS HEALTH CARE WORKERS NEW JERSEY- 619 NEW JERSEY- 619 NYC- 138 NYC- 138 PENNSYLVANIA- 67 PENNSYLVANIA- 67 NEVADA – 0 NEVADA – 0 MINNESOTA- 1439 MINNESOTA- 1439 TENNESSEE- 2407 TENNESSEE- 2407

77. VACCINATORS NEW JERSEY - 50 NEW JERSEY - 50

78. FEDERAL VACCINATION PROGRAM IS NOW ON “HOLD” FEDERAL VACCINATION PROGRAM IS NOW ON “HOLD”

79. BIOLOGICAL TOXINS

80. BOTULINUM – BO-TOX BOTULINUM – BO-TOX RICIN RICIN STAPHYLOOCCAL ENTEROTOXIN B (not reviewed) STAPHYLOOCCAL ENTEROTOXIN B (not reviewed) T-2 MYCOTOXINS (not reviewed) T-2 MYCOTOXINS (not reviewed) RICIN RICIN

81. Botulinum Toxin 7 neurotoxins produced by Clostridium botulinum 7 neurotoxins produced by Clostridium botulinum Among the most toxic substances known Among the most toxic substances known May be found in naturally contaminated food May be found in naturally contaminated food As a bioweapon, likely to be delivered by aerosol As a bioweapon, likely to be delivered by aerosol No person-to-person transmission No person-to-person transmission Multiple cases without common food source suggests bioterrorism Multiple cases without common food source suggests bioterrorism

82. Botulinum Toxin: Mechanism of Action Site: neuromuscular junction (pre-synaptic) Site: neuromuscular junction (pre-synaptic) Action: binds at acetylcholine release sites to prevent release Action: binds at acetylcholine release sites to prevent release Effect: muscle weakness (skeletal and cranial nerve distribution) Effect: muscle weakness (skeletal and cranial nerve distribution) Does not cross the blood-brain barrier: Does not cross the blood-brain barrier: patients remain alert and afebrile patients remain alert and afebrile

83. Botulinum Toxin: Clinical Findings Botulism onset: about 1-3 days Botulism onset: about 1-3 days Cranial nerve palsies early: Cranial nerve palsies early: Eye: blurred vision, photophobia, diplopia, ptosis Eye: blurred vision, photophobia, diplopia, ptosis Throat: dysarthria, dysphagia Throat: dysarthria, dysphagia Skeletal muscle weakness later: Skeletal muscle weakness later: symmetrical, descending, progressive symmetrical, descending, progressive abrupt respiratory failure abrupt respiratory failure

84. Botulinum Toxin: Differential Diagnosis Differential Diagnosis: Differential Diagnosis: tetanus, myasthenia gravis, Guillain-Barre tetanus, myasthenia gravis, Guillain-Barre Botulism differentiated by: Botulism differentiated by: more cranial nerve involvement more cranial nerve involvement facial muscles more involved than below neck facial muscles more involved than below neck lack of sensory changes lack of sensory changes

85. Botulinum Toxin: Lab Laboratory testing: Laboratory testing: generally not helpful generally not helpful detection of toxin in serum is possible detection of toxin in serum is possible

86. Botulinum Toxin: Treatment Do not wait for lab confirmation Do not wait for lab confirmation Administer antitoxin: Administer antitoxin: available from CDC but very limited supplies available from CDC but very limited supplies only binds to circulating toxin to prevent progression only binds to circulating toxin to prevent progression will not reverse symptoms already present will not reverse symptoms already present anaphylaxis and serum sickness may result anaphylaxis and serum sickness may result do not prophylax exposed but asymptomatic patients do not prophylax exposed but asymptomatic patients Respiratory support necessary Respiratory support necessary Recovery takes weeks to months Recovery takes weeks to months

87. RICIN

88. Ricin Potent protein toxin derived from castor beans Potent protein toxin derived from castor beans Easily produced / Recently found in France Easily produced / Recently found in France Inhibits protein synthesis Inhibits protein synthesis Causes necrotizing airway lesions: Causes necrotizing airway lesions: tracheitis tracheitis bronchitis and bronchiolitis bronchitis and bronchiolitis interstitial pneumonia with ARDS interstitial pneumonia with ARDS

89. Ricin Inhalation as an aerosol produces severe respiratory symptoms: Inhalation as an aerosol produces severe respiratory symptoms: day 1: cough, fever, dyspnea day 1: cough, fever, dyspnea day 2-3: pulmonary edema, resp failure, death day 2-3: pulmonary edema, resp failure, death Specific serum test is available Specific serum test is available No treatment available other than supportive No treatment available other than supportive

90. Chemical Weapons

91. Nerve agents Nerve agents Vessicants (blistering agents) Vessicants (blistering agents) Pulmonary agents Pulmonary agents Blood agents (cyanide) Blood agents (cyanide) Riot Control agents Riot Control agents

92. Nerve Agents Most toxic of all the synthetic chemical agents. Most toxic of all the synthetic chemical agents. Very similar to organophosphate insecticides. Very similar to organophosphate insecticides. Death within minutes when inhaled or absorbed through skin. Death within minutes when inhaled or absorbed through skin. Developed in WW2 by Germany but not used. Developed in WW2 by Germany but not used. U.S. completed development after WW2. U.S. completed development after WW2. Examples: Examples: SARIN SARIN

93. Nerve Agents: Effects Smooth muscle hyper stimulation Smooth muscle hyper stimulation Glandular hyper stimulation Glandular hyper stimulation Skeletal muscle hyper stimulation Skeletal muscle hyper stimulation

94. Nerve Agents: Effects Smooth muscle hyper stimulation: Smooth muscle hyper stimulation: vomiting and diarrhea vomiting and diarrhea urination urination bronchospasm bronchospasm small pupils (miosis) small pupils (miosis)

95. Nerve Agents: Effects Glandular hyper stimulation: Glandular hyper stimulation: salivation salivation lacrimation lacrimation increased airway secretions increased airway secretions increased GI secretions increased GI secretions

96. Nerve Agents: Effects Skeletal muscle hyper stimulation at first: Skeletal muscle hyper stimulation at first: Fasciculations Fasciculations Later, skeletal muscle exhaustion: Later, skeletal muscle exhaustion: weakness followed by flaccid paralysis weakness followed by flaccid paralysis

97. Nerve Agents: Effects SLUDGE reaction: Salivation Salivation Lacrimation Lacrimation Urination Urination Defecation Defecation Generalized twitching Generalized twitching Emesis Emesis

98. Nerve Agents: Decontamination Removal of contaminated clothing Removal of contaminated clothing Copious irrigation and washing with soap and water Copious irrigation and washing with soap and water BIOSUITS- NO CONTACT WITH AGENT BIOSUITS- NO CONTACT WITH AGENT

99. Mark 1 Nerve Agent Antidote Kit ATROPINEPROTOPAMVALIUM

100. Sources of Radioactive Material High-level sources (plutonium, uranium): High-level sources (plutonium, uranium): nuclear power plants and weapons sites nuclear power plants and weapons sites high security; more difficult to obtain and handle high security; more difficult to obtain and handle Low-level sources (cobalt-60, strontium-90, cesium-137, americium-241): Low-level sources (cobalt-60, strontium-90, cesium-137, americium-241): hospitals hospitals construction sites construction sites food irradiation plants food irradiation plants smoke detectors smoke detectors

101. Key Point: Avoidance Avoidance prevents or minimizes effects: Avoidance prevents or minimizes effects: TIME: decrease time near source of radiation DISTANCE: increase distance from source SHIELDING: increase barriers between you and source

102. Decontamination Spray light water mist on clothes to decrease radioactive dust Spray light water mist on clothes to decrease radioactive dust Remove clothes (up to 90% decrease in radioactivity exposure) Remove clothes (up to 90% decrease in radioactivity exposure) Washing skin and hair with soapy water Washing skin and hair with soapy water

103. Treatment Potassium Iodide: Potassium Iodide: may prevent thyroid cancer after radiation exposure may prevent thyroid cancer after radiation exposure NJ dispensed it to those who live within 10 mi. of nuclear plant NJ dispensed it to those who live within 10 mi. of nuclear plant blocks thyroid uptake of radioactive iodine blocks thyroid uptake of radioactive iodine

104. Treatment Depends on specific radioactive substance and mode of exposure (inhaled, ingested, skin). Depends on specific radioactive substance and mode of exposure (inhaled, ingested, skin). Call Poison Control if available. Call Poison Control if available. Meticulously clean contaminated wounds. Meticulously clean contaminated wounds. For ingestions, lavage, laxatives, and ion-exchange resins may be indicated. For ingestions, lavage, laxatives, and ion-exchange resins may be indicated.

105. Bombing Frequency Worldwide, 50% of terrorist attacks are bombings. Worldwide, 50% of terrorist attacks are bombings. In U.S., over 85% of terrorist attacks are bombings. In U.S., over 85% of terrorist attacks are bombings.

106. Dramatic, low risk, draw attention Dramatic, low risk, draw attention Few skills needed Few skills needed Can execute attack remotely Can execute attack remotely Large groups not required Large groups not required Components readily available Components readily available Forensic evidence difficult to identify, collect and assemble Forensic evidence difficult to identify, collect and assemble Why Use Explosives?

107. BOMB COOKBOOK HUNDREDS OF SITES ON INTERNET HUNDREDS OF SITES ON INTERNET BOOKS- BOOKS- “Bombs for Dummies” “Bombs for Dummies” Most supplies available in home depot and garden shops Most supplies available in home depot and garden shops

108. “Dirty Bombs” A type of radiological dispersion device. A type of radiological dispersion device. Combines conventional explosives with radioactive materials in the form of powder or pellets. Combines conventional explosives with radioactive materials in the form of powder or pellets. Disperses radioactive material. Disperses radioactive material. Causes fear and contaminates land and buildings for prolonged periods. Causes fear and contaminates land and buildings for prolonged periods.

109. “Dirty Bombs” Dangers of dirty bombs: Dangers of dirty bombs: if low-level radioactive sources used, primary danger is blast itself if low-level radioactive sources used, primary danger is blast itself gauging degree of radioactive contamination due to fallout is difficult gauging degree of radioactive contamination due to fallout is difficult most probable sources would not provide enough radiation to cause acute radiation sickness most probable sources would not provide enough radiation to cause acute radiation sickness environmental contamination environmental contamination

110. REMEMBER- REMEMBER- REPORT ANY SUSPICIOUS ILLNESSES REPORT ANY SUSPICIOUS ILLNESSES CLUSTERING OF CASES CLUSTERING OF CASES UNUSUAL NUMBERS OF PATIENTS WITH SAME COMPLAINTS UNUSUAL NUMBERS OF PATIENTS WITH SAME COMPLAINTS

111. SUSPECTED BIOLOGICAL INCIDENTS- REPORTABLE: FOLLOW HANDOUT SUSPECTED BIOLOGICAL INCIDENTS- REPORTABLE: FOLLOW HANDOUT 1- LOCAL AND / OR STATE DOH 1- LOCAL AND / OR STATE DOH 2- LOCAL / STATE POLICE / FBI 2- LOCAL / STATE POLICE / FBI 3- BIOTERRORISM TASK FORCE 3- BIOTERRORISM TASK FORCE 4- CDC – FEDERAL TASK FORCE- ETC 4- CDC – FEDERAL TASK FORCE- ETC