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Association of Occupational and Environmental Clinics Edward W. Cetaruk, M.D. Toxicology Associates University of Colorado Health Sciences Center Denver,

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Presentation on theme: "Association of Occupational and Environmental Clinics Edward W. Cetaruk, M.D. Toxicology Associates University of Colorado Health Sciences Center Denver,"— Presentation transcript:

1 Association of Occupational and Environmental Clinics Edward W. Cetaruk, M.D. Toxicology Associates University of Colorado Health Sciences Center Denver, Colorado, USA Worker Preparedness and Response to Bioterrorism

2 Section 1 An Overview of Biological Weapons Objectives: 1) To be able to list biological agents that may be weaponized 2) To describe the process of weaponization 3) To develop an understanding of the bioterrorist threat 4) To be able to recognize a biological attack

3 POTENTIAL IMPACT PROBABILITY/LIKELIHOOD NUCLEAR WEAPON IMPROVISED NUCLEAR DEVICE RADIOACTIVE MATERIAL CHEMICAL AGENT OR TOXIC INDUSTRIAL CHEMICAL BIOLOGICAL AGENT Probability vs. Potential Impact

4 Oldest of the NBC triad of agents Used for > 2,000 years Sieges of middle ages Smallpox blankets given to Native Americans Germany in World War I Japan in World War II Modern Bioterrorism History of Biological Warfare

5 Sarin Nerve Agent attacks 1994 and 1995 Sarin Nerve Agent attacks 1994 and 1995 Attempted Botulinum Toxin release multiple times Attempted Botulinum Toxin release multiple times Anthrax released multiple times Anthrax released multiple times Attempted to obtain Ebola virus in Zaire Attempted to obtain Ebola virus in Zaire Aum Shinrikyo Cult

6 Anthrax Letters United States

7 Anthrax Anthrax Botulinum Toxin A Botulinum Toxin A Brucellosis Brucellosis Glanders Glanders Marburg Virus Marburg Virus Plague Plague Q Fever Q Fever Salmonella Salmonella Smallpox Smallpox Staph Enterotoxin B Staph Enterotoxin B Monkey Pox Monkey Pox Ricin Ricin Tularemia Tularemia VEE VEE VHFs VHFs Weaponized Biowarfare Agents

8 Biological Agents of Highest Concern Category A Variola major (Smallpox) Variola major (Smallpox) Bacillus anthracis (Anthrax) Bacillus anthracis (Anthrax) Yersinia pestis (Plague) Yersinia pestis (Plague) Francisella tularensis (Tularemia) Francisella tularensis (Tularemia) Botulinum toxin (Botulism) Botulinum toxin (Botulism) Filoviruses and Arenaviruses (Viral hemorrhagic fevers) Filoviruses and Arenaviruses (Viral hemorrhagic fevers) ALL suspected or confirmed cases should be reported to health authorities immediately ALL suspected or confirmed cases should be reported to health authorities immediately

9 Anthrax 1-5 Days++ Plague 2-3 Days Q Fever Days Tularemia 2-10 Days Smallpox 7-17 Days Viral encephalitides V(2-6d); E&W (7-14 d) VHFs4-21 Days Botulinum toxin 1-5 Days Staph. enterotoxin B 1-6 Hours Incubation Periods of Selected Biological Agents

10 Anthrax8,000 (or fewer) spores Plague organisms Q Fever 1-10 organisms Tularemia organisms Smallpox organisms Viral encephalitides organisms VHFs1-10 organisms Botulinum toxin ug/kg Infective Aerosol Doses of Selected Biological Agents

11 (bronchioles) 1-5 (alveoli) Infection Severity Particle Size (Micron, Mass Median Diameter) The ideal aerosol contains a homogeneous population of 2 or 3 micron particulates that contain one or more viable organisms Maximum human respiratory infection is a particle that falls within the 1 to 5 micron size Less Severe More Severe Aerosol Size and Infectivity

12 Large epidemic with high illness and death rate Immunocompromised individuals may have first susceptibility Respiratory symptoms predominate Infection non-endemic for region Multiple, simultaneous outbreaks Multi-drug-resistant pathogens Sick or dead animals Delivery vehicle or intelligence information Epidemiologic Clues

13 Travel history Local Distant Infectious contacts Employment history Activities over the preceding 1 to 2 weeks Epidemiologic Information

14 Section 2 Bioterrorism and the Workplace Section 2 Bioterrorism and the Workplace Objectives: 1) To be able to develop practices and procedures to defend workers and the workplace from a bioterrorist attack 2) To respond the unique risks faced by first responders 3) To be able to choose and use the correct PPE needed for biological weapons

15 Bioterrorism Educational Needs of the Worker Awareness Awareness Fundamental understanding of biowarfare agents Fundamental understanding of biowarfare agents Recognition and handling of suspicious mail or dissemination devices Recognition and handling of suspicious mail or dissemination devices PPE and workplace safety PPE and workplace safety Recognition of bioterrorist attack Recognition of bioterrorist attack Post exposure management Post exposure management

16 Primary Care Personnel Primary Care Personnel Hospital ER Staff Hospital ER Staff Public Health Professionals Public Health Professionals Emergency Response Personnel Emergency Response Personnel Laboratory Personnel Laboratory Personnel Law Enforcement Law Enforcement Public Public Military Military Bioterrorism : Who are First Responders?

17 First Responders Often dealing with unknown agent(s) Often dealing with unknown agent(s) May be exposed to infectious agent May be exposed to infectious agent May be exposed to infectious patients May be exposed to infectious patients May be targeted with secondary devices May be targeted with secondary devices May be first to notice the epidemiological pattern of a bioweapons attack May be first to notice the epidemiological pattern of a bioweapons attack

18 Emergency Plan All Hazards Approach All Hazards Approach Identify areas with risk of exposure Identify areas with risk of exposure Develop controls to minimize risk Develop controls to minimize risk Engineering Controls Engineering Controls Administrative Controls Administrative Controls Housekeeping Controls Housekeeping Controls PPE for workers PPE for workers Develop response and recovery plan Develop response and recovery plan Training and Exercises Training and Exercises

19 Emergency Plan Exposure to Biological Agent Policies and Procedures for handling suspicious mail or packages Policies and Procedures for handling suspicious mail or packages Plan for facility response Plan for facility response Plan for involving appropriate authorities Plan for involving appropriate authorities Medical Surveillance Medical Surveillance Training and Exercises Training and Exercises

20 Handling of Suspicious Mail Do not shake, empty contents Do not shake, empty contents Do not carry, show others, or allow others to examine it Do not carry, show others, or allow others to examine it Do not sniff, touch, look closely at it, or any contents that may have spilled Do not sniff, touch, look closely at it, or any contents that may have spilled Leave on stable surface, alert others, leave area, close doors, shut off ventilation Leave on stable surface, alert others, leave area, close doors, shut off ventilation Wash hands with soap and water Wash hands with soap and water Notify law enforcement Notify law enforcement Create list of persons with potential contact Create list of persons with potential contact

21 Personal Protective Equipment  Level A SCBA, EncapsulationSCBA, Encapsulation Level of protection for entering contaminated, unsecured sceneLevel of protection for entering contaminated, unsecured scene  Level B  Level C  Level D

22 Personal Protective Equipment Respirators Powered Air-Purifying Respirator (PAPR) HEPA filter face masks (N95, N100) HEPA filter face masks (N95, N100) Respirators must be in compliance with Respirators must be in compliance with OSHA respiratory standard (29 CFR ) Respirators must be fit tested Respirators must be fit tested

23 Powered Air Purifying Respirator ( PAPR)

24 PPE Respirators Respirators should be used in accordance with a respiratory-protection program that complies with the OSHA respiratory-protection standard (29 CFR ). N95N100

25 The respirator is properly positioned over your nose and mouth at all times The respirator is properly positioned over your nose and mouth at all times The top strap or head harness assembly is positioned high on the back of the head The top strap or head harness assembly is positioned high on the back of the head The lower strap is worn at the back of the neck below the ears The lower strap is worn at the back of the neck below the ears The straps are snug enough to keep the respirator from moving but not overly tight The straps are snug enough to keep the respirator from moving but not overly tight Nothing (beards, head coverings, etc.) passes between the skin of the face and the respirator’s sealing edge Nothing (beards, head coverings, etc.) passes between the skin of the face and the respirator’s sealing edge Personal Protective Equipment Respirators

26 PPE Dermal Protection Disposable Disposable Reusable Reusable Overgarments, Booties, Hoods, Gloves Overgarments, Booties, Hoods, Gloves All PPE should be decontaminated prior to leaving potentially contaminated area All PPE should be decontaminated prior to leaving potentially contaminated area PPE should be removed and discarded prior to removing face mask PPE should be removed and discarded prior to removing face mask

27 Section 3 Anthrax as a Biological Weapon Objectives: 1) To understand the microbiology and epidemiology of anthrax 2) To understand the pathophysiology of the different anthrax clinical syndromes 3) To be able to recognize cutaneous anthrax 4) To be able to recognize an intentional anthrax release 5) To be able to treat patients with anthrax

28 Bacterium Spores may survive > 100 yrs Worldwide soil distribution Common disease of herbivores Herbivores in USA vaccinated Man infected via animal products Woolsorter’s Disease Anthrax Microbiology & Epidemiology

29 Source: WHO World Anthrax Data Site Anthrax Worldwide Occurrence

30 Spore enters skin, GI tract, or lung Germinates in macrophage Transported to regional lymph nodes Local production of toxins Swelling and Tissue Death Toxemia Anthrax Pathophysiology

31 Cutaneous Gastrointestinal Inhalational Multiple forms can be seen as the result of a BW attack Anthrax Clinical Syndromes

32 Anthrax Gastrointestinal Abdominal pain, usually accompanied by bloody vomiting or diarrhea, followed by fever and signs of sever infection Abdominal pain, usually accompanied by bloody vomiting or diarrhea, followed by fever and signs of sever infection GI anthrax is sometimes seen as mouth and throat ulcerations with tender neck glands and fever GI anthrax is sometimes seen as mouth and throat ulcerations with tender neck glands and fever Develops after ingestion of contaminated, poorly cooked meat. Develops after ingestion of contaminated, poorly cooked meat. Incubation period: 1–7 days Incubation period: 1–7 days Case-fatality: 25–90% (role of early antibiotic treatment is undefined) Case-fatality: 25–90% (role of early antibiotic treatment is undefined)

33 Anthrax: Cutaneous Begins as a papule, progresses through a vesicular stage to a depressed black necrotic ulcer (eschar)Begins as a papule, progresses through a vesicular stage to a depressed black necrotic ulcer (eschar) Edema, redness, and/or necrosis without ulceration may occurEdema, redness, and/or necrosis without ulceration may occur Form most commonly encountered in naturally occurring casesForm most commonly encountered in naturally occurring cases Incubation period: 1–12 daysIncubation period: 1–12 days Case-fatality:Case-fatality: Without antibiotic treatment:20%Without antibiotic treatment:20% With antibiotic treatment:1%With antibiotic treatment:1%

34 JAMA. 2002;287: Hospital Day 5 2 months after discharge Hospital Day 12 Cutaneous Anthrax

35 Incubation Period: 1-6 days Incubation Period: 1-6 days A brief prodrome resembling a “viral-like” illness, characterized by muscle aches, fatigue, fever, with or without respiratory symptoms, nausea, vomiting, abdominal pain A brief prodrome resembling a “viral-like” illness, characterized by muscle aches, fatigue, fever, with or without respiratory symptoms, nausea, vomiting, abdominal pain Early Symptoms: malaise, fever, fatigue, non- productive cough, chest discomfort Early Symptoms: malaise, fever, fatigue, non- productive cough, chest discomfort Confusion, neck stiffness, and headache suggest meningitis (seen in 50% of patients) Confusion, neck stiffness, and headache suggest meningitis (seen in 50% of patients) Inhalational Anthrax Clinical Presentation

36 After initial onset of illness, symptoms may remain mild or even improve slightly before worsening Terminal Phase: dyspnea, stridor, cyanosis, shock, chest wall edema, meningitis, widened mediastinum with effusion with overall toxic/septic clinical picture

37 Presenting Symptoms Symptomsn=10 Fever, chills10 Sweats, often drenching 7 Fatigue, malaise, lethargy 10 Cough9 Nausea or vomiting 9 Dyspnea8 Chest discomfort or pleurisy7 Myalgias6 Headache5 Confusion4 Abdominal pain 3 Sore throat 2 Rhinorrhea1 Emerg Infect Dis vol.7, no. 6, 2001

38 Clinical picture of sudden onset of respiratory distress with mediastinal widening on x-ray A small number of patients may present with GI or cutaneous anthrax Gram stain of blood and blood cultures - but these may be late findings in the course of the illness ELISA, FA, PCR and immunohistology testing may confirm diagnosis but samples must go to reference laboratory Anthrax Diagnosis

39 Acute Treatment Usually futile in severe mediastinitis patients who inhaled or ingested spores Ciprofloxacin mg IV q 8 to 12 hr Doxycycline mg IV q 12 hr Vaccination Post-exposure Oral prophylaxis Ciprofloxacin (500 mg PO q12 h) X 60 days and until 3 doses of vaccine Doxycycline (100 mg PO q12 h) X 60 days and until 3 doses of vaccine Vaccination Anthrax Treatment

40 FDA approved 1970 FDA approved 1970 Cell Free filtrate (NO organisms, dead or alive) Cell Free filtrate (NO organisms, dead or alive) Adverse effects 1-3% Adverse effects 1-3% Bioport Corporation Bioport Corporation Anthrax Vaccine

41 Laboratory Workers Increased number of highly pathogenic bacterial and viral samples Increased number of highly pathogenic bacterial and viral samples Increased need for universal precautions Increased need for universal precautions Increased need for security, including maintaining chain of custody for forensic samples Increased need for security, including maintaining chain of custody for forensic samples Increased need for decontamination procedures Increased need for decontamination procedures Laboratory Response Network (LRN) Laboratory Response Network (LRN)

42 Laboratory Workers Decontamination and Disinfection Effective sporicidal solutions: Commercially-available bleach diluted to 0.5% Sodium hypochlorite (1 part household bleach to 9 parts water) Commercially-available bleach diluted to 0.5% Sodium hypochlorite (1 part household bleach to 9 parts water) Rinse off concentrated bleach to avoid caustic effects Rinse off concentrated bleach to avoid caustic effects Approved sporicidal agents Approved sporicidal agents

43 Section 4 Plague as a Biological Weapon Objectives: 1) To be able to describe the pathophysiology and epidemiology of plague. 2) To be able to recognize and treat the different clinical forms of plague. 3) To be able to control the secondary transmission of plague

44 Plague History 200,000,000 deaths Biblical (I Sam.) BC, Philistines Major Pandemics 541- Plague of Justinian ‘Black Death’ Modern Pandemic

45 Plague Distribution Began in China Southwest to India South to Vietnam Trans-Pacific to United States

46 Plague Epidemiology Vector: fleas, >80 species Xenopsylla cheopis (Oriental rat flea) Fleas feed on plague-infected mammal Bacteria multiply in gut Coagulum blocks gut Plague organisms are regurgitated into bite wound with next feeding Photo: Ken Gage, Ph.D., CDC, Fort Collins, CO

47 Reservoir: mammals, >200 species. Rattus rattus (Black rat) Ground squirrels, prairie dogs, cats Plague Epidemiology

48 Plague Pathogenesis Yersinia pestis - a Gram negative, nonmotile, nonsporulating bacteria Yersinia pestis - a Gram negative, nonmotile, nonsporulating bacteria Size: 0.5–0.8 × 1.5–2.0 µm Size: 0.5–0.8 × 1.5–2.0 µm Normally a disease of rodents Normally a disease of rodents Virulence Factors: antiphagocytic fraction 1 capsule, pH 6 antigen, antiphagocytic Yops H and E, V antigens, Yop M, and plasminogen activator Virulence Factors: antiphagocytic fraction 1 capsule, pH 6 antigen, antiphagocytic Yops H and E, V antigens, Yop M, and plasminogen activator

49 Plague Pathophysiology Lung Meninges Liver Spleen Inoculation or inhalation (1-10 organisms) (100-20,000 organisms) Macrophage Lymphatics Regional lymph nodes Blood

50 Bubonic Plague Clinical Presentation Incubation 1-8 days (mode 3-5 days) Sudden onset of flu-like syndrome (Fever, rigors, malaise, myalgias, nausea) Bubo formation - within 24 hours Swollen, infected lymph node (very painful!) Cutaneous findings in 25% of cases Mortality:Untreated 60% Treated <5%

51 Photographs: Ken Gage, Ph.D., Centers for Disease Control and Prevention, Fort Collins, CO Bubonic Plague

52 Pneumonic Plague Clinical Presentation 2 to 3 day incubation period followed by high fever, muscle aches, chills, headache Cough with bloody sputum within 24 hours pneumonia progresses rapidly – shortness of breath, stridor, cyanosis, difficulty breathing, chest pain respiratory failure, shock, bleeding In contrast to anthrax, Plague pneumonia and sepsis develop acutely and may be fulminant Patchy lung infiltrates or consolidation seen on chest x-ray

53 Pneumonic Plague Photograph by Ken Gage, Ph.D., Centers of Disease Control and Prevention, Fort Collins, CO.

54 Plague Transmission PNEUMONIC BUBONIC and SEPTICEMIC SECONDARY PNEUMONIC and OROPHARYNGEAL Fleas (active or dormant) Rodent Aerosol Surface contact

55 Plague Diagnosis Gram stain and culture of lymph node aspirates, sputum, or CSF samples Bipolar staining “Safety Pin” may be present Immunoassays are also available Photomicrograph: Ken Gage, Ph.D., Centers for Disease Control and Prevention, Fort Collins, CO.

56 Plague - Treatment Antibiotic Therapy: Streptomycin (choice)15-30 mg/kg IM bid x 10 days Gentamicin - 2 mg/kg IV then mg/kg q8h or 5 mg/kg IV q24h x 10 days Doxycycline mg IV then 100 mg bid x days Ciprofloxacin mg IV q12h x 10 days

57 Plague Control of Secondary Transmission Secondary transmission is possible and likely Standard, contact, and aerosol precautions for at least 48 hrs until sputum cultures are negative or pneumonic plague is excluded

58 Section 5 Smallpox as a Biological Weapon Objectives: 1) To be able to describe the epidemiology and microbiology of smallpox 2) To be able to recognize clinical smallpox 3) To be able control the secondary transmission of smallpox 4) To describe treatment and vaccination options for smallpox.

59 Smallpox The world’s first eradicated disease The world’s first eradicated disease last endemic case in Somalia last endemic case in Somalia two laboratory cases in Britain two laboratory cases in Britain WHO declares global eradication of smallpox WHO declares global eradication of smallpox

60 Smallpox Variola (Var-ï-óla) virus: an Orthopox virus, both minor and major forms of smallpox exist Structure is a large DNA virus Declared eradicated in 1980 and the U.S. stopped its civilian vaccination in 1981, U.S. military stopped in 1985

61 1763- French & Indian War Fort Ticonderoga Lord Jeffrey Amherst World War II Unit 731 experiments in China Cold War USSR arsenal Smallpox as a Bioweapon

62 Infectious via aerosol Vaccination discontinued Decreased potency of vaccine stocks Severe morbidity and mortality Transmissible Clinical inexperience “Brand-name” recognition Why would smallpox Make A Good Biological Weapon?

63 Incubation 7-17 days (mean 12) Infection of respiratory mucosa Minor viremia: seeding of liver, spleen Major viremia: seeding of skin Acute onset fever, rigors, headache, vomiting Virus cultured from blood Clinical Smallpox Prodrome

64 Enanthem Exanthem begins on face, hands, forearms spreads to lower extremities centrifugal distribution Macules  papules  vesicles  pustules  scabs/crusts  scars Clinical Smallpox

65 Breman & Henderson, NEJM, 346(17), April, 2002

66 Smallpox Day 3 of Rash From: Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988: 10–14. Photographs by I. Arita.

67 Smallpox Day 5 of Rash From: Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988: 10–14. Photographs by I. Arita.

68 Smallpox Day 7 of Rash From: Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988: 10–14. Photographs by I. Arita.

69 Smallpox

70 Smallpox Clinical Forms Variola Major 30% fatal in unvaccinateds 3% fatal in vaccinateds Variola Minor Flat-Type Smallpox Hemorrhagic Smallpox Modified-Type Smallpox Variola Sine Eruptione

71 Variola Minor From: Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988: 10–14. Photographs by I. Arita.

72 Flat-type Smallpox From Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988: 33. Photograph by F. Dekking

73 Hemorrhagic Smallpox From Herrlich A, Mayr A, Munz E, Rodenwaldt E. Die pocken; Erreger, Epidemiologie und klinisches Bild. 2nd ed. Stuttgart, Germany: Thieme; 1967.

74 Smallpox vs. Chickenpox VariolaVaricella Incubation 7-17 days days Prodrome 2-4 days minimal Distributioncentrifugalcentripetal Evolutionsynchronousasynchronous Scabs Form days 4-7 days Scabs Separate days <14 days Infectivityseparationscabbing

75 Smallpox Management of Contacts Immediate vaccination or boostingImmediate vaccination or boosting VIG 0.6 ml/kgVIG 0.6 ml/kg Pregnant patientsPregnant patients Dermatoses patientsDermatoses patients ?? Normal hosts?? Normal hosts Limited data: Vaccine + VIG better than vaccine alone?Limited data: Vaccine + VIG better than vaccine alone? STRICT quarantine x 17 daysSTRICT quarantine x 17 days

76 Vaccination Employs Vaccinia virus Given by scarification One dose protective for 5-10 years Must keep vaccinia immunoglobulin (VIG) on hand to treat complications of vaccination

77 Complications of Vaccination Normal host Inadvertent Autoinoculation (skin, eye) Generalized vaccinia Erythema multiforme Encephalitis Pregnancy - fetal vaccinia Dermatoses/Burns - eczema vaccinatum Immunocompromised - vaccinia necrosum

78 From Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988: 298. Photograph by C. H. Kempe Ocular Vaccinia

79 From Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988: 298. Photograph by C. H. Kempe Vaccinia Necrosum

80 Eczema Vaccinatum N Engl J Med, Vol. 346, No. 17, April 25, 2002

81 Public health emergency Supportive care Vaccinia Immunoglobulin Strict quarantine until scabs off At least 17 days Codofovir Smallpox Therapy

82 Section 6 Other Viruses as Biological Weapons Objectives: 1)To become familiar with viral hemorrhagic fever viruses (VHFs) and Venezuelan equine encephalitis virus pathophysiology 2)To be familiar with necessary PPE to able to limit the secondary spread of VHF 3)To be able to treat victims of these biological agents

83 Viral Hemorrhagic Fevers Microbiology RNA viruses causing high fevers and generalized vascular damage Filoviruses (Ebola, Marburg) Human infections by insect bites or by contact with blood and body fluids Photograph: Robert Swanepoel, PhD, DTVM, MRCVS, National Institute of Virology, Sandringham, South Africa.

84 RNA viruses causing high fevers and generalized vascular damage May be spread by aerosol, on fomites, and by oral secretions and eye drainage in animals Human infections by contact with blood and body fluids Viral Hemorrhagic Fevers (VHFs)

85 VHF Pathogenesis Fever, muscle aches, prostration Cases evolve into shock and generalized mucous membrane hemorrhage Conjunctival injection, petechial hemorrhage, and hypotension Abnormal kidney and liver function tests  poor prognosis Mortality varies; % Ebola Zaire Disease severity and survival depends on various host factors; target organ is the blood vessel system.

86 First reported case in Sudan Reston, VA health facility among imported monkeys April Ebola epidemic Kikwit, Zaire Ebola outbreak in Alice, TX - monkeys Gabon patient infection transferred to Johannesburg clinic healthcare worker 50 to 80% mortality rate in humans - extensive hemorrhage, shock, and end organ failure 2002 – Gabon – most recent outbreak Ebola Virus

87 VHF Treatment Blood pressure resuscitation and monitoring Careful fluid management Use of colloids (e.g. plasma) Vasopressors and inotropes Cautious sedation and analgesia No anti-platelet drugs or IM injections Coagulation studies and replacement of clotting factors, platelet transfusions

88 Prevention of Secondary VHF Transmission Animal studies indicate aerosol transmission possible Single room with adjoining anteroom as only entrance Handwashing station with decontamination solution Negative air pressure room if possible Strict barrier precautions (PPE): Gloves, gown, mask. shoe covers, protective eyeware/faceshield Consider HEPA respirator (e.g. N95) for severe hemorrhage, vomiting, diarrhea, cough

89 Prevention of Secondary VHF Transmission Chemical toilet All body fluids disinfected Disposable equipment/sharps into rigid containers and autoclaved/incinerated Double-bag refuse-outside bag disinfected Electronic/mechanical equipment must be disinfected

90 Venezuelan Equine Encephalitis (VEE) Alphavirus spread by mosquitoes Alphavirus spread by mosquitoes Endemic to Central and South America, Mexico, and Florida Endemic to Central and South America, Mexico, and Florida Highly infectious - 100% of exposed individuals develop symptoms Highly infectious - 100% of exposed individuals develop symptoms Low mortality rate - 1% Low mortality rate - 1%

91 ?? Inhalational Mosquito-borne Febrile syndrome lasting 3 days, º fever chills, headache, photophobia, sore throat Weakness for weeks Recovery Mild CNS symptoms for 3 days Liver Damage More severe CNS signs % mortality 20% Children 4% Adult cases 1 to 5 day incubation VEE Clinical Course

92 DIAGNOSIS DIAGNOSIS Immunoassay Immunoassay Viral Culture Viral Culture Serologic Testing Serologic Testing TREATMENT Supportive No antiviral medication exists VEE Diagnosis & Treatment

93 Section 7 Toxin Weapons Objectives: 1)To be able to explain how each of the presented toxin weapons act 2)To be able to recognize victims to toxin weapon poisoning 3)To understand that toxin weapons are NOT infectious and CANNOT be secondarily spread

94 Neurotoxin produced by Clostridium botulinum - Botulism Most lethal compound per weight (15,000 times more toxic than the nerve agent VX) Different toxicity if inhaled or ingested Botulinum Toxin

95 Botulinum Toxin Normal Muscle Contraction Acetylcholine MUSCLE CONTRACTION Motor Nerve Muscle NMJ

96 Botulinum Toxin Botulinum-Paralyzed Muscle BOTOXBOTOXBOTOXBOTOX NO MUSCLE CONTRACTION NMJ Motor Nerve Muscle

97 Descending paralysis Descending paralysis Bulbar Palsies Bulbar Palsies Blurred vision Blurred vision Dilated pupil Dilated pupil Double vision Double vision Drooping eyelids Drooping eyelids Light intolerance Light intolerance Difficulty swallowing Difficulty swallowing Difficulty speaking Difficulty speaking Respiratory failure Respiratory failure Botulism Signs & Symptoms “Floppy” baby flaccid paralysis

98 Clinical diagnosis: bulbar palsies with descending paralysis Mouse neutralization assay confirms diagnosis Treatment is supportive Long-term mechanical ventilation Antitoxins are available but must be administered early to be effective CDC vaccine protective for A,B and E toxins Botulism Diagnosis and Treatment

99 Ricin Potent toxin - a protein byproduct of castor bean processing for castor oil Potent toxin - a protein byproduct of castor bean processing for castor oil 5 times more toxic per weight than VX 5 times more toxic per weight than VX Blocks protein synthesis within the cell, causes cell death, and airway tissue death and swelling when inhaled Blocks protein synthesis within the cell, causes cell death, and airway tissue death and swelling when inhaled

100 Ricin Diagnosis & Treatment Fever, chest tightness, cough. Fever, chest tightness, cough. Shortness of breath, nausea, and joint pain. Shortness of breath, nausea, and joint pain. Ingestion causes severe diarrhea, hemorrhage, and necrosis of the liver, spleen, and kidneys - shock and death within 3 days Ingestion causes severe diarrhea, hemorrhage, and necrosis of the liver, spleen, and kidneys - shock and death within 3 days Treatment is supportive, including airway management Treatment is supportive, including airway management No antitoxin or vaccine available No antitoxin or vaccine available

101 Common cause of food poisoning in improperly handled foods Common cause of food poisoning in improperly handled foods 80% of exposed individuals develop symptoms 80% of exposed individuals develop symptoms Symptoms vary by route of exposure - can be aerosolized or introduced into food system Symptoms vary by route of exposure - can be aerosolized or introduced into food system Staphylococcal Enterotoxin B (SEB)

102 Sudden onset of high fever, headache, chills, muscle aches, and non-productive cough, and malaise. Sudden onset of high fever, headache, chills, muscle aches, and non-productive cough, and malaise. Inhalational:Severe shortness of breath & chest pain with larger doses Ingestion: Nausea, vomiting, and diarrhea SEB Signs & Symptoms

103 Supportive Care: Oxygenation Hydration Supportive Care: Oxygenation Hydration Most victims will recover Most victims will recover No vaccine available No vaccine available No antibiotic is effective No antibiotic is effective SEB Treatment


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