Bioterrorism Public Health Prevention

1. BIOTERRORISM AND
PUBLIC HEALTH

2. What is Bioterrorism?
• Terrorism: is the deliberate use of, or threatened use of,
violence to achieve political, religious or ideological
objectives.
• Bioterrorism: is the use of infective organisms to achieve
this goal.

3. History of Bioterrorism
• Bioterrorism is not new. Examples include:
• 6th century BC--Assyrians used rye ergot to poison the wells of its
enemies
• 400 BC--Scythian archers dipped arrows in decomposing bodies or
manure to cause wound infections
• 15th-18th centuries--smallpox-laden clothing and blankets were
given to enemies to induce outbreaks

4. Modern Day Bioterrorism 1st ½ of the
20th century
• Many industrialized nations, including the US, had
offensive biological weapons programs
• Biological Weapons Convention (1972)—treaty developed
by international community preventing stockpiling of
biological agents and research into offensive biological
weapons
• Despite being signatories of treaty, several countries, particularly
Iraq and the Soviet Union, continued active biological weapons
production

5. Modern Day Bioterrorism 90’s
• Concern for bioterrorism mounted in the 1990’s…
• 1991 dissolution of former USSR led to a mass exodus of
bioweapons scientists to other countries.
• 1995, Iraq revealed its extensive bioweapons research and
production capabilities during the Persian Gulf War.
• A Russian defector disclosed details of the former Soviet
Union’s bioweapons program, including extensive production
capabilities and genetic engineering of more virulent and
resistant biological organisms.
• After its successful 1995 attack on Tokyo with sarin
(chemical agent), an investigation into Japanese cult Aum
Shinrikyo revealed that the terrorist group had attempted to
obtain and deploy botulinum toxin and anthrax on several
occasions.

6. Bioterrorism Today
• Centers for Disease Control and Prevention
(CDC) has identified 6 “Category A” biological
agents that pose a threat to national security,
considered high priority because of:
• Ease of dissemination or transmissibility from person-to•
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person;
High mortality rates;
Serious public health implications;
Ability to cause social disruption and public panic; and
Special preparedness requirements.
• 6 agents are smallpox, anthrax, plague,
tularemia, botulism, and viral hemorrhagic fevers.

7. Bioterrorism Case Study: Anthrax
On October 16, 2001, a 47 year old US Postal Service employee
at the Brentwood processing facility in Washington DC
developed fatigue, vomiting and diarrhea. He was initially
diagnosed with the flu. Progressive symptoms prompted a
second visit to the ER. By this time, concerns over an anthrax
attack were well-publicized, and the physician recognized
Joseph Curseen’s case as pulmonary anthrax. He was
admitted to ICU, but on October 22, Mr. Curseen became 3rd
person to die as a result of a biological attack on the US.
An extensive investigation revealed that B. anthracis spores had
been delivered through the mail to several media outlets and
Senator Daschle’s office.
Once it was over, 22 people had developed anthrax and 5 had
died. To date, the perpetrator remains at large, although a
suspect identified

8. Anthrax
• Caused by the organism Bacillus anthracis
• Transmitted as spores which can survive for long periods in the
environment
• Can occur naturally in the US (very uncommon)
• Clinical presentation: anthrax causes three different types of infection
• Cutaneous (skin form)—black lesion
• Intestinal (abdominal form)
• Inhalational (lung form)—presents with high fever, chest pain, cough and
severe shortness of breath; 89-96% fatal if untreated
• Treatable with antibiotics
• Not contagious (no person-to-person spread)
• Public health strategies
• Identification of source of release and population exposed
• Institution of treatment and prophylactic protocols
• Information management
• Coordination of the local, state and federal response

9. Smallpox
• Caused by a virus
• Naturally occurring smallpox eradicated in 1977 through a vigorous
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worldwide vaccination campaign
Clinical presentation—approximately 12 days after exposure, patient
develops flu-like symptoms then the characteristic rash: similar to
chickenpox, but all lesions are in the same stage of development and
tend to be more prominent on the face and extremities
Highly contagious
No proven treatment, just supportive therapy
Vaccination available for exposures
Key public health strategies
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Disease surveillance
Rapid laboratory confirmation
Isolation of contagious patients
Contact tracing
Institution of an aggressive vaccination program

10. Plague
• Caused by Yersinia pestis bacteria
• Naturally occurring outbreaks still occur worldwide
• Clinical presentation--plague can take on many forms
• Most notorious form is bubonic plague which is transmitted by fleas
and causes large, painful swollen lymph nodes (glands) termed
“buboes”
• An aerosol attack would result in pneumonic (lung) plague,
presenting as flu-like symptoms with watery then bloody
sputum leading to severe respiratory distress, shock and death
• Treatable with antibiotics if detected early
• Nearly 100% fatality rate when not treated
• Public health strategies
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Syndromic surveillance
Identification of the source of the outbreak and exposed population
Contact tracing
Distribution of prophylactic antibiotics

11. Botulism
• Caused by botulinum toxin, a nerve toxin produced by
bacteria Clostridium botulinum
• Clinical presentation—following a terrorist attack with
aerosolized botulinum toxin, patients would present with
paralysis in a descending fashion
• Weakness of the eye muscles causes double vision
• Weakness of the face and neck muscles causes difficulty speaking
and swallowing
• Ultimately, weakness of the respiratory muscles leads to
respiratory arrest
• Mental status is unaffected

12. Botulism
• Botulism is not contagious
• Recovery can take weeks to months
• Key public health strategies
• Surveillance—botulism is a reportable disease
• Development of surge capacity—ill patients require ventilators and
ICU care, both of which are limited in the US health system

13. Tularemia
• Caused by the bacteria Francisella tularensis
• If released into atmosphere, bacteria are highly virulent via
inhalational;
• as few as 10-50 organisms could infect and individual
• Clinical presentation—can occur in various forms, affecting
different parts of the body
• Aerosol dissemination would result in non-specific flu-like symptoms
including fever, cough, chest pain and pneumonia, potentially severe
• Not contagious
• Treatable with antibiotics--fatality rate drops from 35% to 1-3%
with treatment
• Public health measures
• Identification of the source of the outbreak to identify exposed
population
• Prophylactic antibiotic distribution
• Development of tularemia vaccine

14. Viral Hemorrhagic Fevers (VHF’s)
• Comprised of 15 related viruses, 7 of which fall under CDC’s
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category A status (e.g Ebola)
Each virus has specific s/s and predilection for certain organs,
but all result in uncontrollable bleeding
Sporadic outbreaks occur naturally
Clinical presentation—VHF should be suspected in any patient
presenting with severe flu-like illness, low blood pressure,
bruising of the skin and bleeding from the eyes, nose, mouth,
and/or intestines
No curative treatment; requires aggressive ICU supportive care
Moderately to highly contagious
Public health measures
• Isolation and possibly quarantine
• Contact tracing
• Development of healthcare system surge capacity

15. Bioterrorism poses challenges for
public health
• Attack is likely to be covert
• Delay in onset of illness (incubation period)--makes
identification of the release site and other exposed individuals
difficult
• Many biological agents cause non-specific, flu-like illnesses
initially, which can delay diagnosis of the disease
• Most clinicians are unfamiliar with diseases related to biological
terrorism due to the rarity of naturally occurring cases
• Very mobile society--contagious diseases have the potential to
spread rapidly across borders
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16. Examples of public health strategies for
combating bioterrorism
• Epidemiologic investigation —the process of investigation that
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determines the presence of an outbreak or biological attack,
confirms the diagnosis, establishes the case definition, traces
exposures and contacts, and characterized the outbreak or
attack (where, when, etc.)
Isolation —separation of patients with a communicable disease
from non-infected individuals, preventing transmission of
infection to others and allowing focused care
Prophylaxis —medical intervention to prevent disease;
antibiotics and antivirals are chemoprophylactics (medications),
and vaccines are referred to as immunoprophylactics
Quarantine —enforced isolation of the sick or exposed from
healthy people to contain the spread of disease
Surge capacity —ability to expand healthcare during periods of
excessive and/or prolonged demand

17. Examples of public health strategies for
combating bioterrorism (con’t)
• Syndromic use of certain symptom complexes
and other health-related data to detect a potential
outbreak or biological attack in its early phases so
that public health measures may be rapidly
mobilized to decrease morbidity and mortality;
examples of surrogate data sources include
school absenteeism, sale of over-the-counter
medications, and ED presenting complaints

18. Conclusion
• Biological weapons pose a significant threat to our nation.
• Public health professionals play a vital role in preparing
for and responding to a biological attack.
• Preparation for biological terrorism improves the public
health infrastructure for other current and emerging
infectious diseases, such as pandemic influenza and
Severe Acute Respiratory Syndrome (SARS).