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BIOTERRORISM health preparedness

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1 BIOTERRORISM health preparedness
Dr.T.V.Rao MD Dr.T.V.Rao MD

2 Definition of Bioterrorism
"Bioterrorism” - The unlawful use, or threatened use, of microorganisms or toxins derived from living organisms to produce death or disease in humans, animals, or plants. The act is intended to create fear and intimidate governments or societies in the pursuit of political, religious, or ideological goals. Lecture: Bioterrorism is the unlawful use or threatened use…(It is important to note that in order to be legally accused of an act of bioterrorism, you do not need to have the substance. The threat alone is grounds for jail time.)…of microorganisms or their byproducts to produce death or disease in humans, animals, or plants. Here is another key point. Bioterrorism is not only an attack on humans. An act of bioterrorism may be an attack on animal or even plant populations. The intent of these acts is the same as any other act of terrorism. The intent is to create fear and intimidate societies in pursuit of goals that conflict with them. Transition: The pursuits of these weapons have been limited to nations or state-sponsored programs throughout most of the 20th century. However, there are reasons why it is becoming more possible for small groups or individuals to build their own program. Dr.T.V.Rao MD Note: There is no single, universally accepted definition of bioterrorism.

3 History of Biological Warfare
1346 Siege of Kaffa; plague 1763 French and Indian War; smallpox WW I German program; anthrax, glanders 1925 Geneva protocol bans biological weapons WW II Japanese program; anthrax, plague, cholera, shigella Recorded incidents of biowarfare harken back to the 6th century BC; most ancient acts involved the poisoning of wells/water supplies. The first recorded large scale act involving intentional disease spread occurred in 1346 during the siege of Kaffa, now a city in the Ukraine, when the Tartar army hurled its plague-ridden dead over the walls of the besieged city. In 1763 during the French and Indian war, there is evidence to suggest that an English general intentionally gave blankets contaminated with smallpox scabs to Native Americans loyal to the French. The resulting epidemic decimated the tribes. The Germans had a bioweapons program in WWI. There are recorded incidents where they tried to intentionally infect horses and other transport animals with the agents of anthrax and glanders. Soon after WWI, the Geneva protocol was signed banning biological weapons. All countries in attendance signed except Japan. Shortly before the start of WWII, the Japanese bioweapons program began in earnest, producing agents to cause diseases such as anthrax, plague, cholera and shigellosis. Field experiments were conducted on Chinese prisoners of war and civilians. Tens of thousands died as a result of this testing. One experiment involved dropping ceramic bomblets containing plague-infected fleas and grain on Chinese cities including Nanking. The grain attracted rats which were bitten by fleas and subsequently infected with plague. This enabled the disease to spread into the human population. Dr.T.V.Rao MD

4 History of Biological Warfare (cont.)
1941 George W. Merck named U.S. civilian head of Chemical Warfare Service later changed to War ResearcService 1946 U.S. announces its involvement in bioweapons research 1969 Nixon eliminates offensive biological warfare program When reports about Japan’s bioweapons program started filtering in, President Roosevelt launched a research program on biological agents in George W. Merck, Merck Pharmaceuticals, was named head of the Army’s Chemical Warfare Service. Camp Detrick, Frederick, MD, developed into a site for biological weapons research and development. In 1946, the U.S. publicly announced its involvement in bioweapons research. In 1969, the World Health Organization issued a report that describes the unpredictability of biological weapons. Later that year, President Nixon shut down the U.S. offensive biological warfare program and limited biological weapons research to defensive purposes only. Dr.T.V.Rao MD

5 History of Biological Warfare (cont.)
1972 Biological Weapons Convention 1979 Accidental release of B. anthracis spores at bioweapon research center, Sverdlovsk, U.S.S.R Scientists from the former U.S.S.R. involved in biological weapons research defect to the West In 1972, the Biological Weapons Convention Treaty, which called for all countries to destroy their stocks of bioweapons and to cease all offensive bioweapons research, was signed by 103 nations, including the U.S. and the former Soviet Union. The interpretation of offensive versus defensive biological weapons research is somewhat problematic. Because of the concern of laboratory-acquired smallpox infections, the WHO (World Health Organization) recommended consolidating all variola virus stocks. Officially, only 2 laboratories, one in the U.S. and one in Russia, retained stocks of smallpox virus. It is postulated that other laboratories in Russia and perhaps other countries maintained the smallpox virus despite this recommendation. In 1979, Bacillus anthracis spores were accidentally released at a bioweapons research facility in Sverdlovsk, U.S.S.R, resulting in at least 68 deaths due to inhalational anthrax. Most cases occurred within 2-5 days following the accident although some had longer incubation periods -- up to 43 days in one case. This long incubation period has obvious ramifications for antibiotic post-exposure prophylaxis. In the early 1990s, during the breakup of the former Soviet Union, scientists involved in bioweapons research defected to the West and began discussing their activities with Western government officials. Dr.T.V.Rao MD

6 Domestic Biological Terrorism
1984 Rajneesh cult members contaminate salad bar with Salmonella typhimurium in Oregon 1992 Ricin attack planned by Minnesota militia 2001 Anthrax releases in FL, DC, NY, NJ The U.S. has experienced bioterrorism events prior to the anthrax release that occurred in the Fall of Members of the Rajneeshee (Rahj-NEE-shee) cult in Oregon had experimented with various bioweaponery prior to their 1984 act of bioterrorism. The cult sought to influence the outcome of upcoming municipal elections by deliberately contaminating salad bars of local restaurants with Salmonella typhimurium. Despite causing illness in over 700 persons, they still lost the election. Minnesota has not been immune to bioterrorism. In 1992, members of the Minnesota Patriots Council, a militia group, planned to kill local authorities with ricin, a potent toxin obtained from castor beans. And the most recent and terrifying act of bioterrorism occurred in Fall 2001, when Bacillus anthracis spores were placed in at least 7 envelopes passing through U.S. mail facilities in Florida, Washington, D.C., New York and New Jersey. Twenty-two confirmed or suspected cases of anthrax resulted, 5 of whom died. Dr.T.V.Rao MD

7 Biological Terrorism The use of biological agents to intentionally produce illness or intoxication in a susceptible population Dr.T.V.Rao MD

8 Biological Agents Ranking System
Public Health impact criteria based on: Morbidity and mortality Delivery potential Public perception (fear, civil disruption) Public health preparedness needs The Centers for Disease Control and Prevention (CDC) has developed a ranking system for potential biological agents based on the following criteria: •The level of morbidity and mortality associated with a disease •Delivery potential of the disease (which involves the ability to be aerosolized) •Public perception (certain diseases generate greater fear and civil disruption) •And public health preparedness needs, such as needs for vaccine or mass chemoprophylaxis (preventive treatment). Dr.T.V.Rao MD

9 CDC Select Agents* – Bacteria
• Bacillus anthracis (spores) • Brucella abortus • Brucella melitensis • Brucella suis • Burkholderia mallei (aka Pseudomonas mallei) • Burkholderia pseudomallei (aka Pseudomonas pseudomallei) • Clostridium (botulinum- producing species) • Coxiella burnetii • Francisella tularensis • Rickettsia prowazekii • Rickettsia rickettsii • Yersinia pestis n = 12 * Not including agents only on USDA lists. Dr.T.V.Rao MD

10 CDC Select Agents* – Fungi
• Coccidioides immitis • Coccidioides posadasii n = 2 * Not including agents only on USDA lists. Dr.T.V.Rao MD

11 CDC Select Agents* – Viruses I
• Central European Tick-borne encephalitis • Cercopithecine herpesvirus 1 • Crimean-Congo haemorrhagic fever • Eastern Equine encephalitis • Ebola • Far Eastern Tick-borne encephalitis • Flexal South American haemorrhagic fever • Guanarito South American haemorrhagic fever • Hendra • Junin South American haemorrhagic fever • Kyasanur Forest disease • Lassa fever • Marburg * Not including agents only on USDA lists. Dr.T.V.Rao MD

12 CDC Select Agents* – Viruses II
• Machupo South American haemorrhagic fever • Monkeypox • Nipah • Omsk haemorrhagic fever • Reconstructed 1918 influenza • Rift Valley fever • Russian Spring and Summer encephalitis • Sabia South American haemorrhagic fever • Variola major (smallpox) • Variola minor (alastrim) • Venezuelan Equine encephalitis n = 24 * Not including agents only on USDA lists. Dr.T.V.Rao MD

13 CDC Select Agents* – Toxins
• Abrin • Botulinum neurotoxins • Clostridium perfingens epsilon toxin • Conotoxins • Diacetoxyscirpenol • Ricin • Saxitoxin • Shiga-like ribosome-inactivating proteins • Shigatoxin • Staphylococcal enterotoxins • Tetrodotoxin • T-2 toxin n = 12 * Not including agents only on USDA lists. Dr.T.V.Rao MD

14 Bioweapon-related Diseases
anthrax botulism brucellosis cholera food poisoning glanders hemorrhagic fever lassa fever melioidosis plague psittacosis Q-fever salmonellosis shigellosis smallpox tularemia typhoid fever typhus viral encephalitis Dr.T.V.Rao MD

15 Additional Potential Bioterrorism Agents
• Chlamydia psittaci • Cryptosporidium parvum • Escherichia coli O157:H7 • hantavirus • Salmonella species • Shigella species • Vibrio cholerae Dr.T.V.Rao MD

16 Potential Bioterrorism Agents
Potentially thousands NATO NBC Handbook lists 31 agents CDC created Category A, B, & C lists Based on: Ease of dissemination Potential for Public Health Impact Potential for Public Panic and Social Disruption Lecture: Almost any organism that causes disease may be used as a weapon. But in order to carry out effective planning and training, the list of threats must be narrowed to only those that pose the greatest risk. NATO has listed 31 agents of concern based on the focus of state-sponsored biological weapons programs around the world. However, in 1999, the CDC convened a group of scientists to review the existing threat information. Using the criteria shown here: ease of dissemination, potential public health impact, and potential for public panic, they categorized threat lists. The “A” list is comprised of the greatest threats, the “B” list are also agents of concern but this list includes those agents that are more difficult to disseminate or have less of an impact on public health. Category “C” agents include the diseases that are emerging threats such as SARS. Dr.T.V.Rao MD

17 Bioterrorism agent classification system CDC
The Centers for Disease Control (2004) have placed agents in one of three priority categories for initial public health preparedness efforts: A, B, or C. Agents Dr.T.V.Rao MD

18 CLASSIFYING BIOTERROR AGENTS
CLASS A Contagious High death rates and high health impact on the public ANTHRAX, BOTULISM, SMALLPOX, TULAREMIA, PLAGUE CLASS B Moderately easy to spread Some illness & death rates TYPHUS, WATER SAFETY THREATS, SALMONELLA CLASS C Easily available Easily produced and spread Have potential for high death & illness rates NIPAH VIRUS Hey look, a llama! Never can be too careful… Dr.T.V.Rao MD

19 Critical biological agents Category A
Can be easily disseminated or transmitted person-to- person Cause high mortality, with potential for major public health impact Might cause public panic and social disruption Require special action for public health preparedness MMWR 49;RR-4, April 21, 2000 Dr.T.V.Rao MD

20 Category A agents include
variola major (smallpox) Bacillus anthracis (anthrax) Yersinia pestis (plague) Clostridium botulinum toxin (botulism) Francisella tularensis (tularaemia) filoviruses Ebola hemorrhagic fever Marburg hemorrhagic fever arenaviruses Lassa (Lassa fever) Junin (Argentine hemorrhagic fever) and related viruses MMWR 49;RR-4, April 21, 2000 Dr.T.V.Rao MD

21 Category B Are moderately easy to disseminate
Cause moderate morbidity and low mortality Require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance MMWR 49;RR-4, April 21, 2000 Dr.T.V.Rao MD

22 Category B agents Coxiella burnetti (Q fever);
Brucella species (brucellosis) Burkholderia mallei (glanders) alpha viruses Venezuelan encephalomyelitis eastern and western equine encephalomyelitis ricin toxin from Ricinus communis (castor beans) epsilon toxin of Clostridium perfringens Staphylococcus enterotoxin B. MMWR 49;RR-4, April 21, 2000 Dr.T.V.Rao MD

23 Cryptosporidium parvum
subset of List B agents includes pathogens that are food- or waterborne - these pathogens include Salmonella species Shigella dysenteriae Escherichia coli O157:H7 Vibrio cholerae Cryptosporidium parvum Dr.T.V.Rao MD

24 Fick-borne hemorrhagic fever viruses Tick-borne encephalitis viruses
Category C Includes emerging pathogens that could be engineered for mass dissemination in the future Nipah virus Hantaviruses Fick-borne hemorrhagic fever viruses Tick-borne encephalitis viruses Yellow fever Multidrug-resistant tuberculosis Dr.T.V.Rao MD

25 Biological Delivery Methods
Food / Water Aircraft sprayers Vehicle sprayers Hand sprayers Mail Air handling systems Human Vector Animal Vector Lecture: Biological agents may be delivered in many ways. The most common methods include contaminating food and water sources or aerosolizing agents with spray devices. It is also possible to use human or animal disease carrying hosts to deliver an attack. We learned through the anthrax attacks of 2001 that other, less frequently considered, delivery methods such as the mail might be employed. Transition: However, the worst-case delivery scenario is a large-scale aerosol release during a thermal inversion. Dr.T.V.Rao MD

26 Key Indicators of a Biological TERROR Event
Occurrence of vector-borne disease where there is no vector Cluster of sick or dead animals Atypical seasonality Geographic Pattern of Illness More respiratory presentation of disease Dr.T.V.Rao MD

27 The Ideal Bioterror Weapon Would Be
contagious virulent robust difficult to detect drug-resistant user-controllable No natural agent meets all of these criteria. Thus, sooner or later, terrorists may decide to devise novel weapons using the techniques of synthetic biology to enhance or replace the characteristics of pre-existing organisms or toxins. Countermeasures must be pursued vigorously – in advance. Dr.T.V.Rao MD

28 Preparation for BT Attack
Familiarize medical staff with BT agents Incorporate into Disaster Planning Decontamination & Infection Control Communications with key agencies Laboratory, Respective health authorities of the Nation. Contacts to obtain stockpiled supplies: antibiotics, immune sera, vaccines, etc. Security preparations These are important things that can be done now to improve preparedness for a BT attack Familiarity with likely agents and clinical syndromes is the first step It might be helpful to discuss surveillance programs within the hospital with infection control team Although all hospitals have disaster plans, they are usually for natural disasters such as earthquakes, floods, etc. Few hospitals have specific plans for some of the things that are likely to happen in a BT attack, but it could be very helpful to do so. Some things that would be critical in disaster plans include: Decontamination and infection control – decontamination showers, isolation rooms, cohorting plans Phone numbers of critical communications Local public health dept. is especially important for physicians. Number should be posted in ER, ICU, etc. Contacts to obtain resources that would likely be in short supply. May need to go to federal agencies for help. Security preparations could be important to maintain order in the chaos and panic that would likely occur Dr.T.V.Rao MD

29 What To Do if You Suspect a Bioterrorist Disease
IMMEDIATELY NOTIFY: Hospital Infection Control Isolation: Smallpox, plague, hemorrhagic fevers Laboratory Hospital Administration Local Public Health Department Dr.T.V.Rao MD

30 What does Public Health Do in a Bioterrorist Event?
Assess health impacts in the community Environmental health assesses water safety and sanitation Public health nurses coordinate with Shelter Operations Acute communicable disease tracks infectious diseases Injury program tracks injuries and fatalities Health Officer coordinates information for the public and health care providers Public Health Laboratories identify agents (either in-house or through referral to State governments or health authorities ) Dr.T.V.Rao MD

31 Special Problems with BT
Identifying a covert attack Social disruption Prophylaxis for large populations Decontamination Secondary transmission Now we’d like to move to more general issues involved in BT attacks These are some of the important issues that would be likely to come up in the response to a BT attack, so let’s talk about some of them in more detail Dr.T.V.Rao MD

32 Technology At Work Forensic teams work hard to identify biological agents, their origins and effects Dr.T.V.Rao MD

33 Technology At Work Labs are working on advanced detection systems to detect early attacks, identify at-risk areas, and to give proper treatment Dr.T.V.Rao MD

34 Technology At Work Bio surveillance: Real- Time-Outbreak Disease Surveillance system made its debut in This collects data from labs, hospitals, and environmental studies in order to detect bioterror attacks as early as possible. Dr.T.V.Rao MD

35 bioterrorism bioagent warning systems
Wyatt-Lorenz was founded as a spin-off of Wyatt Technology Corporation ("WTC") with a unique mission: To provide immediate bioterrorism bioagent warning systems for the protection of people and property from biological and chemical threats. These Bioterrorism threats are often directed toward elements of the private sector long ignored by the Department of Defense and Department of Homeland Security Dr.T.V.Rao MD

36 Special Problems with BIOTERRORISM
Specialized labs needed for some agents Risks to laboratory workers Limited resources Communication between agencies Dr.T.V.Rao MD

37 Preparation for BIOTERRORISM Attack
Familiarize medical staff with BT agents Incorporate into Disaster Planning Decontamination & Infection Control Communications with key agencies Laboratory, CDC, Police, FBI, etc. Contacts to obtain stockpiled supplies: antibiotics, immune sera, vaccines, etc. Security preparations These are important things that can be done now to improve preparedness for a BT attack Familiarity with likely agents and clinical syndromes is the first step It might be helpful to discuss surveillance programs within the hospital with infection control team Although all hospitals have disaster plans, they are usually for natural disasters such as earthquakes, floods, etc. Few hospitals have specific plans for some of the things that are likely to happen in a BT attack, but it could be very helpful to do so. Some things that would be critical in disaster plans include: Decontamination and infection control – decontamination showers, isolation rooms, cohorting plans Phone numbers of critical communications Local public health dept. is especially important for physicians. Number should be posted in ER, ICU, etc. Contacts to obtain resources that would likely be in short supply. May need to go to federal agencies for help. Security preparations could be important to maintain order in the chaos and panic that would likely occur Dr.T.V.Rao MD

38 Classification of Bioterrorism Laboratories
D - High level characterization (seek evidence of molecular chimeras) and secure banking of isolates Safety & proficiency to probe for universe of bio- and chemical agents in non-clinical specimen Level D Lab BSL-4 C - Safety and proficiency sufficient to probe, type, perform toxigenicity testing Level C Lab BSL-3 B - Safety and proficiency adequate to confirm & characterize susceptibility Not a direct correspondence with Categories A, B, C, in previous slides. This slide illustrates the laboratory component of identifying biological agents. Examples: BSL – level 4 smallpox only CDC & USAMRIID can test Clinical symptoms determine rule-out – local, state health depts. Etc. Level A – BSL 2 Level B – BSL 3 Level C – BSL 3 Level D – BSL 4 ebola, smallpox Level B Lab Work at BSL-3 with BT agents A - Adequate safety to rule-out and forward organisms Level-A Labs - Assess Risks for Aerosols and Use Biosafety Cabinet Dr.T.V.Rao MD

39 What To Do if You Suspect a Bioterrorist Disease
IMMEDIATELY NOTIFY: Hospital Infection Control Isolation: Smallpox, plague, hemorrhagic fevers Laboratory Hospital Administration Local Public Health Department Dr.T.V.Rao MD

40 Public Health’s Role in Bioterrorism Event
Health Officer coordinates information for the public and medical providers Community Health and PHN’s provide education, information to the public and to community providers Treatment and prophylaxis Quarantine Dr.T.V.Rao MD

41 Project Bioshield "We refuse to remain idle when modern technology might be turned against us. We will rally the great promise of American science and innovation to confront the greatest danger of our timeFormer President George W. Bush, at the signing of the Project Bio shield Act of 2004 Authorized spending of $5.6 billion over a span of 10 years in order to pay for vaccines and medical facilities in case of national biological emergency Gave the National Institute of Health grants to pursue medical research & technology Emergency Use Authorization – EUA – gave access to best medical responses in case of an emergency as declared by the Secretary of Human Healthy & Services OR Secretary of Homeland Security Dr.T.V.Rao MD

42 Coordinating with system is priority
Coordinating with the Public Health System Dr.T.V.Rao MD

43 What We Need To Prepare for Bioterrorism
More trained epidemiologists to speed detection Increased laboratory capacity Health Alert Network Medical professionals “back to school” National Pharmaceutical Stockpile Dr.T.V.Rao MD

44 How can Hospitals Prepare?
Familiarize medical staff and lab with bioterrorist threat agents Incorporate BT planning into disaster planning Infection control Notification procedures and contact numbers Daily surveillance and reporting Security preparations Media Personal Protective Equipment (PPE) Dr.T.V.Rao MD

45 Is it a True Terrorism ? Outbreak of rare disease
Seasonal disease at wrong time Unusual age distribution Unusual clinical symptoms Unusual epidemiologic features Outbreak in region normally not seen Dr.T.V.Rao MD

46 Steps in Preparing Public Health Agencies for Biological Attacks
Enhance epidemiologic capacity to detect and respond to biological attacks. Supply diagnostic reagents to state and local public health agencies. Establish communication programs to ensure delivery of accurate information. Enhance bioterrorism-related education and training for health-care professionals. MMWR 49;RR-4, April 21, 2000 Dr.T.V.Rao MD

47 BIOTERRORISM AND THE PUBLIC HEALTH SECTOR
Preparation for a biological mass disaster requires coordination of diverse groups of medical and non-medical personnel Preparation can not occur without support and participation by all levels of government Preparation must be a sustained and evolutionary process Dr.T.V.Rao MD

48 Created by Dr.T.V.Rao MD for ‘e” Learning Resources for Medical and Public Personal on Bioterrorism
Dr.T.V.Rao MD


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