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Biological Weapons
Biological Weapons
Leland S. Rickman, M.D. Associate Clinical Professor of Medicine Division of Infectious Diseases Director, Epidemiology Unit UCSD Medical Center UC San Diego
Outline
Brief history of biowarfare Potential impact and effects of BT Transmission of BT agents Clues to BT Most likely BW agents Rational perspectives Management Overview of potential pre-exposure prophylaxis, post-exposure prophylaxis and therapy
Probable
China Iran North Korea Libya Syria Taiwan
Possible
Cuba Egypt Israel
Source: Committee on Armed Services, House of Representatives. Special Inquiry into the Chemical and Biological Threat. Countering the Chemical and Biological Weapons Threat in the Post-Soviet World. Washington, D.C.: U.S. Government Printing Office; 23 Feb 1993. Report to the Congress.
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BIOTERRORISM: IMPACT
Direct infection: Mortality, morbidity Indirect infection: Person-to-person transmission, fomite transmission Environmental impact: Environmental survival, animal infection Other: Social, political, economic
General difficulties in weaponizing a biologic agent Ability to procure a virulent strain (e.g., anthrax, tularemia) Ability to culture large amounts of the agent Ability to process agent into a suitable form (e.g., anthrax spores) Ability to safely handle and store the agent (may be difficult for hemorrhagic fever viruses)
General difficulties in weaponizing a biologic agent Ability to disseminate the agent as an aerosol Ability to generate aerosol particles of the proper size (1-10 u) Ability to assess climatic effects in order to disseminate agent effectively Different Federal agencies have reached different conclusions regarding the likelihood of an attack using a biologic agent
CHARACTERISTICS OF BIOWARFARE
Potential for massive numbers of casualties Ability to produce lengthy illnesses requiring prolonged and intensive care Ability of certain agents to spread via contagion Paucity of adequate detection systems Diminished role for self-aid and buddy aid, thereby increasing sense of helplessness
CHARACTERISTICS OF BIOWARFARE
Presence of an incubation period, enabling victims to disperse widely Ability to produce non-specific symptoms, complicating diagnosis Ability to mimic endemic infectious diseases, further complicating diagnosis
Explosives
Fairly self-limited
Multiple simultaneous patients with similar clinical syndrome Severe illness among healthy Predominantly respiratory symptoms Unusual (nonendemic) organsims Unusual antibiotic resistance patterns Atypical clinical presentation of disease Unusual patterns of disease such as geographic co-location of victims Intelligence information Reports of sick or dead animals or plants
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Moderately easy to disseminate cause moderate morbidity and low mortality Require specific enhancements of CDCs diagnostic capacity and enhanced disease surveillance
Major risks
Heart disease: 1 in 400 Cancer: 1 in 600 Stroke: 1 in 2,000 Flu & pneumonia: 1 in 3,000 MVA: 1 in 7,000 Being shot by a gun: 1 in 10,000
USA Today: October 16, 2001
Falling down: 1 in 20,000 Crossing the street: 1 in 60,000 Drowning: 1 in 75,000 House fire: 1 in 100,000 Bike accident:1 in 500,000 Commercial plane crash: 1 in 1 million Lightening strike: 1 in 3 million Shark attack: 1 in 100 million Roller coaster accident: 1 in 300 million
PERSON-TO-PERSON ACQUISITION
Disease Andes virus
Anthrax Ebola, Lassa, Marburg, Congo-Crimean, AHF, BHF Smallpox Plague (pneumonic) Q fever
Transmission Undefined
Contact with skin lesions Contact with infective fluid, droplet? Contact, droplet, airborne Droplet Contact with infected placenta
Risk Low
Rare High High High Rare
Contact
Lassa Fever Ebola Marburg virus Smallpox Pneumonic plague Inhalational anthrax Venezuelan equine encephalitis Botulism Brucellosis Cholera Q fever Pulmonary tularemia
S S S S S S S S S S S S
A A A A
C C C C D
Droplet
Precautions
Standard
Airborne
FOMITE ACQUISITION
Agents acquired from contaminated clothes
Variola major (smallpox) Bacillus anthracis (anthrax) Coxiella burnetii (Q fever) Yersinia pestis (plague)
Management
Remove clothing, have patient shower Place contaminated clothes in impervious bag, wear PPE Decontaminate environmental surfaces with EPA approved germicidal agent or 0.5% bleach (1:10 dilution)
BW AGENTS CHARACTERISTICS
Disease ID Incubation Duration Mortality * 3-5 d High 4 wks 1-6 d Mod-High High Very low Mod
Anthrax** 8,000-50,000 spores 1-6 d Smallpox Plague** Q fever Tularemia 1-10 organisms 100-500 organisms 1-10 organisms 10-50 organisms ~12 (7-17d) 2-3 d
VHF-viral hemorrhagic fevers US Army, Biological Casualties 2001 VHF 1-10 organisms 4-21 d 7-16Handbook, d Mod-High * Untreated, ** Pneumonic form
VHF-viral hemorrhagic fevers, PEP-postexposure prophylaxis *Aerosol exposure; **Pneumonic form; ^FDA approved vaccine (not available); #IND + IND BHF, RVF; @ CCHF, Lassa US Army, Biological Casualties Handbook, 2001
STEPS IN MANAGEMENT
1. Maintain an index of suspicion 2. Protect thyself 3. Assess the patient 4. Decontaminate as appropriate 5. Establish a diagnosis 6. Render prompt therapy 7. Practice good infection control
STEPS IN MANAGEMENT
8. Alert the proper authorities 9. Assist in the epidemiologic investigation 10. Maintain proficiency and spread the gospel