2. Terror Is Real !

3. Terrorism: Are We Ready? Barbara Russell, RN,MPH,CIC,ACRN

4. Biological and Chemical Terrorism: How Real is the Threat?

5. What is Terrorism?  No single definition  FBI: “The unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives.”

6. “Kill 1, Frighten 10,000” Sun Tzu

7. Anthrax 2001  22 confirmed or suspected cases  11 inhalation (confirmed)  11 cutaneous (7 confirmed, 4 suspected)

8. Inhalation Anthrax (11) 9 confirmed - exposed to mail (other 2 possible) 55% (6) survived

9. Types of Terrorism  Biological  Nuclear  Incendiary  Chemical  Explosive  B-NICE

10. Target Selection  SSymbolic target to audience or terrorist Economic, political, social or religious value Highly visible and photogenic Random: To create confusion Diversionary Asymmetrical attack

11. Timing  Anniversary of significant historical event  Highly visible event in the area  Increase in international tensions

12. Chemical & Biological Terrorism 1984: The Dalles, Oregon, Salmonella (salad bar) 1991: Minnesota, ricin toxin (hoax) 1994: Tokyo, Sarin and attack 1995: Arkansas, ricin toxin (hoax) 1995: Ohio, Yersinia pestis (sent in mail) 1997: Washington DC, “Anthrax” (hoax) 1998: Nevada, non-lethal strain of B. anthracis 1998: Multiple “Anthrax” hoaxes

13. Chemical Warfare Agents

16. Tokyo Subway Attack Odon March 20, 1995, terrorists released sarin, an organophosphate (OP) nerve gas at several points in the Tokyo subway system, killing 11 and injuring more than 5,500 people.  Concealed in lunch boxes and soft-drink containers and placed on subway train floors. It was released as terrorists punctured the containers with umbrellas before leaving the trains..On April 19th, 1995 repeat attack in subway which the same terrorist group killed seven and injured more than 200 people.

17. Chemical Warfare Agents (CWA)  Lethal CWA’s  Nerve gas (Sarin, Tabun, soman, and VX)  Organophosphates- anticholinesterase  Colorless, odorless, tasteless  Cyanides  Vesicants (=blistering ) agents – mustard gas

18. Nerve Gas Agents  All nerve agents belong chemically to the group of organo-phosphorus compounds.  Stable and easily dispersed, highly toxic and have rapid effects both when absorbed through the skin and via respiration.  Nerve agents can be manufactured by means of fairly simple chemical techniques. The raw materials are inexpensive and generally readily available.

19. Chemical  Chemical agents are toxic, but… - They can be detected - You can protect yourself - Victims can be decontaminated  Can be inhaled, absorbed through the skin or injected

20. Nerve Agent Symptoms  Salivation  Lacrimination  Urination  Defecation  Gastrointestinal pain  Emesis  SLUDGE

21. Decontamination  Removes the agent from the patient  Reduces the chance of secondary spread  Helps the victim psychologically

22. Nerve Gas Poisoning  Eyes: excessive lacrimation and pain.  Skin: excessive sweating  Muscles: involuntary twitching  Respiratory: Mucous secretion, dyspnea  Digestive: excessive salivation, abdominal pain  Symptoms: minutes to 2 hours  Treatment: Atropine, 2-PAM (pralidoxime-2-chloride)  Decontamination: Soap & Water, Chlorox

23. Sulfur Mustard Poisoning  Eyes: reddening, congestion, pain 1/2 -12 hours  Skin: itching, burning, erythema, large blisters (1-12 hours)  Respiratory: burning throat, cough, dsypnea. (2-12 hours)  Digestive: abdominal pain, nausea, blood stained vomiting and diarrhea  Treatment: none  Decontamination: Soap & Water, Chlorox  Care: watch for leukopenia, debride bullae

24. “I’m confident that we can defend against chemical warfare. The one that really scares me to death is biological” Colin Powell - 1993

25. Potential Biological Weapon Agents

26. Characteristics of a Biological Attack:  Civilian Targets Likely.  Possibility of Large Numbers of Casualties.  Symptoms May Not Appear For Days.  Initial Symptoms Likely to be Non-Specific.  Diagnoses Will Depend Heavily Upon Laboratory Tests.  Complex Epidemiology.  Ongoing Need to Care for Large Numbers of Patients  Concerns About Availability of Drugs, Supplies, Staff Members.  Legal Considerations.  Coordination with Local, State, and Federal Authorities.

27. Potential Bioterrorism Agents  Bacterial Agents  Anthrax  Brucellosis  Cholera  Plague, Pneumonic  Tularemia  Viruses  Smallpox  VEE  VHF  Biological Toxins  Botulinum  Staph Entero-B  Ricin  T-2 Mycotoxins Source: U.S.A.M.R.I.I.D.

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

29. Anthrax - The Weapon  Bacillus anthracis (coal = anthrakis) because of black coal like lesions  Aerobic, gram-positive, spore forming, non-motile bacillus species.  Inhalation Anthrax:  Most morbidity and mortality as aerosolized biological weapon.  Disease occurs 2 to 43 days after exposure.

30. Anthrax - The Disease  Inhalation anthrax:  Hemorrhagic thoracic lymphadenitis  Hemorrhagic mediastinitis  Hemorrhagic meningitis  Two Stages  1. Fever, cough, dyspnea, headache, vomiting, chills, weakness  2. Sudden fever spikes, dyspnea, shock, cyanosis, hypotension  Mortality: 89%!!!!

31. Anthrax: Diagnosis, Prevention, Treatment  CXR: widened mediastinum  Blood culture shows growth after 2-6 hours  Vaccine: Licensed since 1970, 88% effective, not available!  Treatment: PNC, Doxycycline, Ciprofloxacin, first generation cephalosporin, vacomycin, clindamycin

32. Anthrax CauseBacillus anthracis Incubation1-60 days, average 7 days Mortality (without treatment) Cutaneous: 20% Intestinal: 25%-60% Inhalation: Usually fatal Infectious DoseVaried; 8,000-50,000 spores (inhalation) Treatable?Yes; antibiotics and supportive care Human to Human Transmission? No

33. Anthrax (bacillus anthracis)

34. What is smallpox?  Serious, contagious, viral disease that causes a fever and distinctive rash  Treatment: supportive  Historically, 30% of smallpox patients died, many developed scars especially on face, some became blind  Prevented by smallpox vaccine (>95% effective)

35. How is smallpox spread?  By direct, prolonged face-to-face contact  Less commonly, indirectly by contaminated bedding or clothing  Rarely spread by air  Transmission prevented by using airborne and contact precautions in health care settings

36. What is the risk of smallpox?  1972: routine smallpox vaccination discontinued in U.S.  1977: last naturally-acquired case in world  Deliberate release is possible but risk is unknown  Health care workers at higher risk due to exposure to most severely ill patients  In Europe from 1950-71, 50% of smallpox transmission was in hospitals

37. How the skin looks with successful vaccine “take”

38. Smallpox CauseVariola major Incubation7-17 days, average 12-14 days Mortality (without treatment) 30% Infectious DoseSmall Treatable?Supportive care; vaccine after exposure Human to Human Transmission? Yes - Airborne

39. Smallpox vs. Chickenpox SmallpoxChickenpox Distribution of pox Centrifugal distribution (face, arms, legs) More covered parts of body, trunk Stage of pox development All at same stage of development Various stages of development Unique presentation Pox found on palms and soles of feet Uncommon to find pox on palms and soles of feet

40. Smallpox (variola major)

41. Treatment  Treatment of smallpox is limited to supportive therapy and antibiotics as required for treating secondary bacterial infections.  There are no proven antiviral agents effective in treating smallpox.

42. Plague  Found in rodents and their fleas in many parts of the world  Bites from an infected flea  Bubonic, septicemic, pneumonic  Seen in rural areas (US: 10-15 cases per year)  Two recent human cases of primary pneumonic plague contracted from cats

43. Plague (cont)  US: 390 cases from 1947-1996 - 84% bubonic (standard precautions) - 13% septicemic (standard precautions) - 2% pneumonic (droplet precautions)  Patients may present with GI symptoms (N/V, abd pain)  Treated with antibiotics

44. Plague (cont)  BBiological terrorism release clues: - Pneumonic plague outbreak 1-6 days after exposure - Initial severe respiratory illness - Death occurs quickly after onset of illness - Infection in persons with no known risk factors

45. Plague (cont)  BBiological terrorism release clues (cont) - Occurrence of cases in areas not known to have previous cases - Absence of prior rodent deaths (which may be present after natural disaster) Plague vs. Anthrax presentation

46. Plague (yersinia pestis)

47. Plague CauseYersinia pestis Incubation2-6 days Mortality (without treatment) 50% (bubonic); near 100% (pneumonic) Infectious DoseSmall Treatable?Yes; antibiotics and supportive care Human to Human Transmission? Pneumonic: Yes Bubonic: No

48. Botulism  Most potent naturally occurring lethal substance known to man  Possible routes of exposure: Ingestion (food), Inhalation (terrorist), Injection (drug users), dirty wound  In 1999…………. 174 cases  26 food borne  107 intestinal / infant  41 wound

49. Botulism (cont)  CCardinal Signs - Fever is absent (unless infection is present) - Neurological symptoms are symmetrical - Patient remains responsive - Heart rate normal or slow - Sensory deficits do not occur (except for blurred vision)

50. Botulism (cont)  IIncubation period - Food borne: 12-36 hours (preformed toxin) - Intestinal (Infant): 1-2 weeks - Wound: 4-14 days

51. Botulinum Toxin CauseClostridium botulinum Incubation2 hours – 8days, average 12- 72 hours (foodborne) MortalityHigh Lethal Dose1 ng/kg (about 0.00000009g/200lb person) Treatable?Yes; antitoxin and supportive care Human to Human Transmission? No

52. Tularemia  Reservoir: Numerous wild animals (i.e.: rabbits, beavers, some ticks)  Can also be found in contaminated water, soil, vegetation  Infections occur in North America (US: 171 cases / year) – AKA Rabbit Fever, Deer Fly Fever  Infection caused by handling infectious animal tissues or fluids, direct contact with contaminated water, food, soil and inhalation of aerosols.

53. Tularemia (francisella tularensis)

54. Tularemia CauseFrancisella tularensis Incubation1-14 days, average 3-5 days Mortality (without treatment) Varies; 5%-60% Infectious Dose10 organisms Treatable?Yes; antibiotics and supportive care Human to Human Transmission? No

55. Hemorrhagic Fevers  Ebola, Marburg, Lassa, Junin & related viruses  Presentation: Initially febrile illness, malaise, myalgias, H/A, vomiting, diarrhea followed by bleeding, hypo tension, shock  Mode of Transmission: Contact with infected blood or other materials, higher risk at late stages of illness

56. Hemorrhagic Fevers (cont)  Incubation period (days): - Ebola 2-21, - Marburg 3-9, -Lassa, commonly 6-21 - Junin 7-16  Diagnostic Tests Available  Significant number of people with hemorrhagic fever symptoms  Intensive supportive care  Standard and Contact Precautions

57. Hemorrhagic Fever CauseVaries; viral IncubationVaries; days to weeks Mortality (without treatment) Varies; high (as much as 80%) Infectious DoseUnknown Treatable?No; supportive care only Human to Human Transmission? Yes

59. Key Points  Increase Level of Awareness  Be familiar with Workplace Plan  Be familiar with County Plan  Have a Family Plan  No “I” in Response – It’s a Team Effort

60. Personal Protective Equipment  Be sure that it is Appropriate to the hazard(s)