Kristelle Ann Perez Beverly Jade Raquio Christian Joy Villanueva

Biological Warfare

So whats the ISSUE with BIOLOGICAL WARFARE?

Biological Warfare can wipe out an entire population in seconds Harm animals and damage harvest crops Inexpensive to produce such weapons Almost anyone can make them WE BELIEVE THAT BW ARE FAR TO HARMFUL TO BE EFFECTIVELY AND HUMANLY USED IN WARFARE *AGAINST PRODUCTION OF BW WEAPONS

History of Issue
- Biological Weapons are NOT new!! - The first Biological Weapon incident: 6th Century B.C. - 3 Major forms of BW before 20th Century - 1925 Geneva Protocol - 1945 1950 THE UNITED STATES BW PROGRAM - 1966 A SIMULATED BW ATTACK - 1969 Thats What they said A REPORT FROM THE WORLD HEALTH ORGANIZATION - 1966-1971 THE UNITED STATES REACTS - 1972 Biological Weapons Convention - BW In Recent Times - CLOSE to HOME - EASY ACCESS FOR ALL!

Chemistry of Issue
How many BW agents exist? The ideal candidate for BW PRODUCTION OF BIOLOGICAL AGENTS Delivery of Agents WERE NOT GOD, ITS NO MORE CONTROLLABLE THAN THE WIND - AND WE ALL FALL DOWN THE INFRASTRUCTURE OF A COUNTRY

THE ISSUE TODAY Characteristics and Associated Risks

Small amount for affect i Size makes concealment, transportation, and dissemination easy Information on how to develop biological agents is readily available in open source literature, and even now on the Internet.

Have they been used?

Why think about Biological Warfare?

Our future enemies strategies Our future enemies resources Our blind spots

Where do we go from here?

Establish a new mindset Identify personnel Focus on antibiotics Develop and acquire masks Acquire state-of-the-art detectors Focus intelligence Strengthen coordination

Index of Suspicion Are there an unusual number of patients presenting with similar symptoms? Is there an unusual presentation of symptoms? Many cases of unexplained diseases or deaths Patients presenting with similar set of exposures? Diseases normally transmitted by vector not present in area Is this an unexplained case of a previously healthy individual with an apparently infectious disease? Disease outbreak with zoonotic impact

Biological Agents of Highest Concern

Variola major (Smallpox) Bacillus anthracis (Anthrax) Yersinia pestis (Plague) Francisella tularensis (Tularemia) Coxiella burnetii ( Q Fever) Botulinum toxin (Botulism) Filoviruses and Arenaviruses (Viral hemorrhagic fevers)

Report ALL suspected or confirmed illness due to these agents to health authorities immediately

Why These Agents?

Infectious via aerosol Organisms fairly stable in aerosol Susceptible civilian populations High morbidity and mortality Person-to-person transmission (smallpox, plague, VHF) Difficult to diagnose and/or treat Previous development for BW

Nominal lethality/1,000 kgs of different biological weapens

The bioterrorism pathways matrix

Motivation Number of casualties Level of panic Capabilities Group size Technical proficiency Financial resources
Agents Availability Ease of growth Morbidity & mortality Dissemination Ease of dissemination Efficacy of dissemination technique Target Number exposed at target Target vulnerability

Covert vs. Overt Event

Overt
Recognition Response Treatment Responders
Early Early

Covert
Delayed Delayed

Early
Traditional First Responders

Delayed
Health Care Workers

Diagnostic matrix: chemical and biological casualties

Inhalational Anthrax, Plague, Tularemia: Differential Diagnoses

Community acquired pneumonia (CAP)
S. pneumoniae, H. influenzae, Klebsiella spp

Pneumonic Anthrax, Tularemia, Plague, Melioidosis Brucellosis, Q Fever, Histoplasmosis Severe atypical CAP (Legionella, Mycoplasma) Hantavirus pulmonary syndrome (HPS)

Inhaled BWF bacteria

Treatment
Fluoroquinolones (all) Vibramycin Penicillin Aminoglycosides

Prophylaxis
Fluoroquinolones (all) Vibramycin

Anthrax Disease Complex Summary

Inhalational Tracheobronchial Lymphadenitis
1-6 days ABRUPT ONSET Papule vesicle edema + eschar Cutaneous

Hemorrhagic Meningitis

50%

Mediastinitis, cyanosis, stridor, pulmonary edema

24 - 36 hours

GI

Toxic shock and Death

20%

Resolve

Bacteria Bacillus Anthracis

Disease: anthrax Incubation: 1 60 days Length of illness:1 to 2 days Mortality rate: extremely high, death typically occurs within 24 36 hours after onset of severe symptoms Effective dosage: 8.000-50.000 spores casualties/50 kg/city/5*106: 250.000

Chest Radiograph Inhalation Anthrax Note: widened mediastinum diminished air space

Inhalational Anthrax: Evolution

Anthrax Case 3 / October, 2001

Anthrax Case 3/ October, 2001

Anthrax Case 4 / October 19, 2001

Anthrax Case 4 / October 19, 2001

Anthrax Case 4 / October 19, 2001

Anthrax Case 4 / October 19, 2001

Anthrax Case 4 / October 19, 2001

Specimen Collection: B. anthracis

Site Cutaneous Anthrax Specimen Comments Vesicular stage Collect fluid from a previously unopened vesicle with dry sterile Eschar stage Feces Roll swabs beneath the edge of the eschar without removing Provides minimal recovery of agent

Gastrointestinal Useful in later stages of disease. Collect prior to antibiotic use, Anthrax Blood cultures if possible. Nasal swab Collect only within 24 h of exposure Inhalation Anthrax Sputum Collect if respiratory symptoms occur and sputum is being produced. Provides minimal recovery of agent.

Cultures collected 2-8 days post-exposure may yield the Blood cultures organism. Collect prior to antibiotic use.

Cutaneous Anthrax
black eschar (anthracis, Greek for coal) typical red areola

Arm

Neck

Cutaneous anthrax, stemming from wear of infected wool scarf

Hemorrhagic Meningitis

Human autopsy, 1979, Sverdlovsk, hemorrhagic meningitis 2 to inhalation

Plague Disease Complex

Fever/rigors Erythema Tender bubo 1 - 10 cm 9% 24 hrs 2 - 10 days

Inhalational
2 -3 Sudden days onset Fever, URI syndrome Pharyngitis

APTT ecchymosis DIC

Fulminant Pneumonia

Stridor, cyanosis, productive cough, bilateral infiltrates

Systemic Toxicity

Liver enzymes

6% late meningitis

Leukemoid reaction Gram - ve rods in sputum

Respiratory failure & circulatory collapse

Pneumonic Plague: Prevention of Secondary Infection

Secondary transmission is possible and likely

Standard, contact, and droplet precautions for at least 48 hrs until sputum cultures are negative or pneumonic plague is excluded

Plague: Specimen Collection

Site Bubonic Plague Specimen Lymph node aspirate Comments After applying a local anesthetic, obtain specimen by injecting 1 ml of sterile saline into lymph node and aspirating immediately

Blood cultures Collect at least three cultures 15 20 minutes apart to detect bacteremia Sputum, Minimal recovery from sputum. Bronchial or tracheal aspirate bronchial or preferred because of fewer contaminating organisms Pneumonic tracheal Plague Blood cultures Nasal swab Lymphoid Postmortem tissue Examinations Bone marrow Lung tissue Collect only within 24 h of exposure

Clinical clues
Anthrax
Incubation 1 60 d

Plague
2 10 d 12d High T, tender LN, pneumonia

Brucella
56d Variabel Flu-like, aching joints, myalgia

Duration of 1 2 d illness Major S&S High fever, diff breathing pneumonia & death in 2 3 d

Minor S&S T & fatigue

Specific Widened mediastinum

GI symptoms, skin lesions Gram-neg pneumonia + hemoptysis

GI symptoms
Low WBC and platelets

 Bubonic Staph/streptococcal adenitis Glandular tularemia Cat scratch disease Septicemic Other gram-negative sepsis Meningococcemia RMSF TTP

Plague: Differential Diagnosis

Pneumonic Bioterrorism threats Anthrax Tularemia Melioidosis Other pneumonias (CAP, influenza, HPS) Hemorrhagic Leptospirosis

Tularemia Disease Complex Summary

Inhalational 2 - 10 days Abrupt onset Fever, chills headaches 7 - 10 days Primary pulmonary + 2 wks duration Infiltrates, rales Mild liver enzyme Papuleulcer Conjunctiva cutaneous lesions Oropharyngeal pseudomembrane 50% Secondary pleuropulmonary

Alveolar septa Necrosis & cavitation Rhabdomyolysis

Lower nephrotic syndrome

Specimen Collection: F. tularensis

Specimen Serum for serology Comments Collect an acute phase sample as soon as possible after onset of disease. Collect convalescent phase sample 21-28 days after the acute sample. (1ml min.)

Nasal swab Collect only within 24 h of exposure Blood Sputum Ulcer Eye Collect or induce specimen from symptomatic patients. Bronchial or tracheal wash may produce better yield. Collect swab specimen from ulcer on skin or throat Collect swab specimen if eyes affected

Q Fever Clinical Course Summary

CNS symptoms and neck stiffness Inhalation Osteomyelitis Sudden onset Fever (100 - 104 3 - 6 days), malaise, anorexia + headache 2 - 14 day course Meningitis

Mild primary atypical pneumonia ground glass

Late complications

Mild LFT

Chronic infective endocarditis (aortic valve)

Q fever: Clinical Features

AT PRESENTATION

3 DAYS LATER

Specimen Collection: Q. Fever

Specimen Serum for serology

Comments Collect an acute phase sample as soon as possible after onset of disease. Collect convalescent phase sample 10-14 days after the acute sample. (10 -12 ml, 2.5ml minimum)

Clinical clues
Tularemia
Incubation Duration of illness Major S&S 1 10 d 1 3 wks T, headache,

Q-fever
2 14 d 2 14 d Flu-like

Influenza

Cough, T, Catarrh, loss of appetite Weariness Aching limbs

Minor S&S Specific

weightloss irritating cough Elevated LFT

Rickettsiae Coxiella burnetti Symptoms: acute non-differentiated febrile illness with cough, aches, fever, chest pain, pneumonia Leukocytosis in 30%, elevated LFT Prophylaxis: Vaccine available Chemoprophylaxis:Doxycycline 100 mg bid for at least 7 days but start only 8 12 days post exposure. If started too early, prophylaxis prolongs the disease Treatment: Doxycycline 100 mg bid for 5 - 7 days

Smallpox - Clinical Course Summary

Inhalational Exanthema on Macules papules face, arms, hands pustular vesicles 8 - 10 days Replication in regional node of airways 12 day incubation 2 - 3 days

Scabs separate + pt non-infective

Flat Smallpox variants Hemorrhagic Smallpox rapid death before typical lesions

Viremia Acute malaise, fever, rigors, headache + mental status changes

Smallpox: Clinical Features

USAMRICD

Smallpox: Clinical Features

USAMRICD

Smallpox vs. Chickenpox

Variola
Incubation Prodrome Distribution Progression Scab formation rash Scab separation rash 7-17 days 2- 4 days centrifugal synchronous 10-14 d p rash 14-28 d p rash

Varicella
14-21 days minimal/none centripetal asynchronous 4-7 d p <14 d p

Smallpox: Medical Management

Strict airborne precautions and contact isolation of patient Patient infectious until all scabs have separated Notify public health authorities immediately for suspected case Identification of contacts within 17 days of the onset of cases symptoms

Specimen Collection: Smallpox

Specimen Comments

Do not collect or ship any specimens without consultation from MDCH or CDC
Vesicle fluid may be placed as a drop on a clean microscope slide. Store each slide in a separate slide holder. As an alternative, collect fluid from separate lesions onto separate swabs. Include cellular material from base of lesion. Store at 4C for for not more than 6 h. For longer periods store at 20 to 70 C. Aseptically collect material or scrapings and place into a sterile, leakproof, freezable container. Store at 4C for not more than 6 h. For longer periods store at 20 to 70C. Place tissue into a sterile, leakproof, freezable container. Store at 4C for not more than 6 h. For longer periods store at 20 to 70C. Formalin fixed tissue acceptable for histopathology. Place into sterile, freezable, leakproof container. Store frozen at 20 to 70C.

Vesicles

Scabs

Biopsy Autopsy Specimens

VEE Clinical Course Summary

?? Inhalational Mosquito born 1 to 5 day incubation Febrile syndrome lasting 3 days 100- 104 fever chills, headache, photophobia, sore throat 20% Children 4% Adult cases Mild CNS symptoms for 3 days

liver enzymes Weakness for 1 - 2 weeks More severe CNS signs

Recovery

10 - 37% mortality

The VHF RNA Viruses

Acute onset febrile illness High fever, myalgia, GI disturbances Severe systemic illness coagulation abnormalities Lassa Oropharyngeal lesions Machupo Hantaan Pulmonary Syndrome Four Corners Agent Ebola Major organ Marburg necrosis

Renal failure 7 days

Rapid progression into shock and death

Severe bleeding ecchymosis

Congo fever

Jaundice Syndrome

Yellow fever Dengue (2x) Rift Valley

VHF: Patient Isolation

Single room w/ adjoining anteroom (if available) Handwashing facility with decontamination solution Negative air pressure Strict barrier precautions including protective eyewear/faceshield Disposable equipment /sharps in rigid containers with disinfectant then autoclave or incinerate All body fluids disinfected

Specimen Collection: Viral hemorrhagic fever

Site Specimen Comments

Do not collect or ship any specimens without consultation from MDCH or CDC
Ebola, Marburg, Argentine, Junin, Bolivian hemorrhagic fevers and Lassa fever Serum Collect 10 12 ml of serum

Clinical clues: viruses

Variola
Incubation
Duration of illness Major S&S

Venezuelan Yellow equine enc fever

15d
1 2 wks

Approx 12 d
severa1 wks

36d
1 2 wks T, myalgia, prostration. Easy bleeding

Malaise, T, Sudden T, chills, Lesions headache+, after 2-3 d musclepain

Minor S&S
Specific Highly contagious

Nausea, sore throat,diarrea

vasculitis

Clinical clues: toxins

Botulinum
Time to effect 12 36 hrs Duration of illness Major S&S 24 72 hrs Cranial nerve palsy, desc flaccid paralysis

Ricin
Few hrs 3d Sudden T, weakness, cough, APE Convulsions, liver failure

SEB
3 12 hrs Up to 4 wks T, chills, headache, nausea, cough

Minor S&S Specific

Latent period of 3 12 hrs on exposure

Specimen Collection: C. boltulinum

Specimen Comments

Testing must be arranged with MDCH prior to specimen transport (517/335-8063)

Serum Feces Collect 10 ml (3-4 ml minimum) of serum as soon as possible after the onset of symptoms and before administration of antitoxin. 15 25 g of stool should be collected. Store and ship at 4C. DO NOT FREEZE. Do not use preservative. Requires 0.5 cup of food. Food should be left in original container if possible or placed in a sterile unbreakable container. Place containers in leak-proof plastic bags. Store and transport at 4C. If product was originally frozen, do not thaw, ship frozen. Place in an anaerobic collection device. Transport at room temperature.

Food sample

Wound or tissue

Summary: important differentials

Conclusions
The zebra card Unlikely is not unthinkable Be suspicious Protect thyself Assess the patient Decontaminate as appropriate Diagnose Treat Infection control Alert authorities Spread the gospel

Thank you!! For not sleeping:D