Week 16 – Question of the Week: Bioterrorism – Worth worrying about or not?

3 Responses to Week 16 – Question of the Week: Bioterrorism – Worth worrying about or not?

1. Mike M, APRN says:

   October 14, 2011 at 8:48 pm

   It is so very easy for us in the USA to say it is not a threat and no reason to be concerned, because most of us have not seen cases of the diseases most likely to be used as bioattack, and because our only exposure to these types of scenarios is in the sci-fi movies and books. That is, unless you look at bio attacks that have been used in history.

   Intentional use of bio terrorism have been documented numerous times even in recent history.

   A few years ago during the time of the anthrax letters I was working in an ER when a frantic mother brought in a 12-year-old child who had opened a letter with no return address that had an unknown white powder in it that spilled all over him when he opened it. Ask her if it is something we should be prepared for.

   Do I sit around worrying about it? No. Do I sit around worrying about my home burning down or wrecking my car? NO – but I still have both homeowners insurance and car insurance. Although I have not stockpiled antibiotics, I have made a point of studying the potential diseases that may be used in a bio attack.

   The National Disaster Medical System conducted pandemic flu response for disaster responders and I was a participant.

   The Medical Reserve Corp in my county practices giving mass vaccinations during the flu season.

   I was part of a disaster team that provided mass vaccinations post-Katrina.

   These activities all help us be prepared for an intentional bio attack even though they were intended to address potentially pandemic diseases in environments other than an intentional attack.

   Did I get the Smallpox vacination? Yes.

   Worry about it? No. Prepare for it? Yes.

   Reply
2. KF says:

   July 7, 2011 at 4:09 pm

   Here is a nicely compiled list of the most common biological
   disease agents,
   Anthrax
   Botulism
   Plague
   Tularemia
   Smallpox
   Viral Hemorrhagic Fever
   for you to copy and keep in your home medical binders.

   http://www.rnceus.com/course_frame.asp?exam_id=40&directory=biot go
   (go to the above address, and then in the left margin, click on the Chart of Biological Diseases link to copy this in chart form.)

   Biological Diseases
   Agent & Incubation Period

   Signs, Symptoms, Sequelae and
   Mode of Acquisition

   Source

   Vaccine available

   Contagious between
   humans

   Treatment

   Comments

   Anthrax
   (inhalation)
   Bacillus anthracis

   7 days post exposure
   *Resembles a common cold (fever, cough, malaise) which progresses to severe dyspnea, diaphoresis, stridor, cyanosis and shock
   * Chest xray shows a mediastinal widening.
   * Gram positive bacilli seen on blood smear and culture.
   * Hemorrhagic mediastinitis, thoracic
   lymphadenitis, and/or meningitis.
   * Inhalation of spores from contaminated
   animal products * Infected animal
   tissue
   * Spores can live in the soil for years
   * Biological
   warfare agent * Yes … approved for ages 18-65
   * 3 injections given 2 weeks apart, followed
   by 3 more injections at
   6, 12, & 18 months

   extremely unlikely

   Standard precautions
   * Early treatment
   essential
   * Ciprofloxacin
   * Doxycycline
   * Penicillin

   * Special considerations for
   treatment of children, elderly, & pregnant women 90-100% of cases are fatal

   Anthrax
   (cutaneous)
   Bacillus anthracis

   7 days post exposure
   Spores enter the skin
   * Infection more likely with a cut or abrasion on the skin
   * Infection begins with a raised, itchy
   bump that resembles a bug bite
   * Within 1-2 days, a vesicle develops,
   followed by a painless ulcer 1-3 cm in diameter with a black necrotic center
   * Lymph glands in the adjacent area may
   swell

   Infected
   animal tissue,
   hair, fur, hides, leather
   * Spores can live
   in the soil for years
   * Biological warfare agent
   Yes … approved for ages 18-65
   * 3 injections given 2 weeks apart, followed
   by 3 more injections at
   6, 12, & 18 months

   rare

   Standard precautions
   Early treatment is
   essential
   * Ciprofloxacin
   * Doxycycline
   * Penicillin
   * Special considerations for treatment of children, elderly, & pregnant women Death rare
   if treated
   * 20% of
   untreated
   cases are
   fatal

   Anthrax
   (intestinal)
   Bacillus anthracis

   7 days post exposure
   Early symptoms : nausea, vomiting, malaise, anorexia, fever, acute inflammation of the GI tract
   * Advanced symptoms: abdominal pain, vomiting blood, severe diarrhea
   * Illness progresses rapidly
   * Eating undercooked contaminated food Infected animal tissue
   * Spores can live in the soil for years
   * Biological warfare agent Yes … approved for ages 18-65
   * 3 injections given 2 weeks apart, followed
   by 3 more injections at
   6, 12, & 18 months

   rare

   Standard precautions
   Early treatment is
   essential
   * Ciprofloxacin
   * Doxycycline
   * Penicillin
   * Special
   considerations for
   treatment of
   children, elderly,
   and pregnant
   women 25-75% of cases are fatal

   Botulism (foodborne)
   Clostridium botulinum

   Incubation depends on amount bacteria and toxin ingested
   (2 hours to 8 days)
   Early symptoms: abdominal cramps, nausea, vomiting, diarrhea, difficulty seeing, speaking, swallowing.
   * Double or blurred vision, drooping eyelids, slurred speech, dry mouth,
   * Progresses to an acute, afebrile, symmetric, descending flaccid paralysis with multiple cranial nerve palsies, coma
   * The most poisonous substance known, a major bioweapon threat due to its extreme potency, lethality, ease of production, transport, and misuse.

   Contaminated food from restaurants or home canned sources

   Bacteria commonly found in the soil

   Botulinum toxin can be put in food or water supplies but is inactivated by heat, sunlight and chlorine.
   Botulinum toxoid vaccine is available but supplies are scarce and mass outbreaks of disease are rare

   No

   Standard precautions
   * Antitoxin available from CDC; must be administered early in course of disease
   * Supportive care * Presents public health emergency
   * Mortality rate = 8%

   Botulism
   (inhaled)
   Clostridium botulinum

   Incubation depends on amount and rate of toxin absorption
   12 to 80 hours
   * Ptosis, diplopia, blurred vision, dysarthria,
   dysphonia, dysphagia
   * Progresses to an acute, afebrile, symmetric, descending flaccid paralysis with multiple cranial nerve palsies, coma
   * The most poisonous substance known, a major bioweapon threat due to its extreme potency, lethality, ease of production, transport, and misuse. Industrially produced botulinum toxin, diluted for treatment of spastic disorders and cosmetic treatment of wrinkles could be diverted to bioterrorism
   Botulinum toxoid vaccine is available but supplies are scarce and mass outbreaks of disease are rare

   No

   Standard precautions
   * Supportive care As above

   Botulism
   (wound)
   Clostridium botulinum

   Incubation depends on amount bacteria inoculated and rate of toxin production
   * Double or blurred vision, drooping eyelids, slurred speech, dry mouth,
   * Progresses to an acute, afebrile, symmetric, descending flaccid paralysis with multiple cranial nerve palsies, coma
   * Will NOT penetrate intact skin Bacteria found in soil … in recent years black tar heroin from California is a prime source
   as above Standard precautions * Antitoxin available from CDC; must be administered early in course of disease
   * Supportive care Infectious disease that would NOT result from bioterrorism
   Botulism
   (intestinal)
   Clostridium botulinum Lethargy, feeds poorly, constipation, weak
   cry, and poor muscle tone
   * Occasionally susceptible patients may harbor
   C. botulinum in their intestinal tract (most often occurs in infants) Bacteria commonly found in the soil as above Standard precautions

   *Supportive care

   *Antitoxin is not routinely given for infant botulism
   Infectious disease that would NOT result from bioterrorism
   Brucellosis
   (foodborne)
   Brucella species

   Incubation is variable
   * Flu-like symptoms such as fever, sweats, headache, back pain, and physical weakness.
   * In severe cases, the patient may develop hepatitis, arthritis, spondylitis, anemia, leukopenia, thrombocytopenia, meningitis, uveitis, optic neuritis, papilledema, and endocarditis
   * Chronic symptoms may include recurrent fevers, joint pain, and fatigue. Ingesting contaminated milk, dairy, or animal products
   * High risk in unpasteurized milk, ice cream and cheeses None available for humans

   Extremely rare … although may possibly be transmitted through breast milk, sexual contact, or tissue transplantation

   Standard precautions
   Doxycycline and rifampin used in combination for 6 weeks
   * Recovery takes a few weeks to several months Mortality <2%
   Brucellosis
   (inhaled)
   Brucella species As above Inhaling aerosolized Brucella None available for humans

   As above
   Standard precautions
   As above As above
   Brucellosis
   (wound)
   Brucella species As above Transmitted via skin abrasions while handling infected animals. None available for humans As above
   Standard precautions

   As above As above

   Pneumonic Plague
   Yersinia pestis

   Incubation is
   1 – 6 days
   post exposure
   Early signs are fever, headache, weakness, dyspnea and productive cough (bloody or watery sputum)
   * May see nausea, vomiting, abdominal pain, or diarrhea
   * Acutely swollen and painful lymph nodes appear on the 2nd day of the infection, and the overlying skin is erythematous
   * Pneumonia progresses over 2-4 days followed by septic shock and death

   Bacteria carried by rodents and their fleas

   Bioweapon usage would occur after aerosolization of the bacteria
   None at this time, however research is underway Occurs through respiratory droplets during face-to-face contact
   Respiratory Droplet Precautions /
   Strict Isolation
   Early treatment is important
   * Ciprofloxacin
   * Streptomycin
   * Tetracycline
   * Chloramphenicol
   * Doxycycline
   * Special considerations for
   treatment of children, elderly, and pregnant women
   * Resp. isolation precautions, prophylactic antibiotic for close contacts of patient Death can occur in as little as 2-4 days
   Smallpox
   Variola virus

   Incubation is
   7 – 17 days
   post exposure
   Initial symptoms are high fever, fatigue, head and back aches.
   * 2-3 days later, a rash appears in the mouth, on the face, arms, and legs. The rash begin as flat red lesions that evolve at the same rate … after a day or two the lesions become pus-filled and begin to crust early in the second week. Scabs fall off after 3-4 weeks
   * Patients with smallpox are most infectious during the first week of illness, although are contagious until all skin scabs are healed
   * In people exposed to smallpox, the vaccine can be given w/I 4 days to lessen or prevent the illness
   *Infected saliva droplets The U.S. has an emergency supply available
   (has not been routinely used since 1972) Occurs through respiratory droplets during face-to-face contact
   * Can also be
   transmitted by
   contaminated clothing or bedding
   Respiratory Droplet & Airborne
   Precautions
   No proven treatment although research for antivirals continue
   * Supportive care should include intravenous fluids, antipyretics, and antibiotics for secondary infections
   * Patients admitted to the hospital should be placed in negative pressure rooms, staff should use standard precautions to protect against spread of the disease. * Mortality rate = 30%

   Tularemia
   Francisella turarensis

   Incubation is
   1 – 14 days
   post exposure
   Initial symptoms are fever, pharyngitis, headache, body aches, and upper respiratory illness, rapidly progressing to bronchitis, pneumonia, pleuropneumonitis, bacteremia.
   May see nausea, weight loss, malaise with continued illness.
   * Inhalation would have the greatest adverse public health consequences … release in a densely populated area would result in an abrupt onset of a sick population (yet, slower progression than anthrax or plague).
   * This is a dangerous bioweapon due to its extreme infectivity, ease of dissemination, and substantial capacity to cause illness and death. Contaminated arthropods, soil, animals, water, and vegetation
   * Humans become infected by direct contact, ingestion, or inhaled infective aerosols Vaccine available, not fully approved for general use No
   Standard precautions Individual treatment drugs of choice:
   Streptomycin
   Gentamycin
   * Mass Casualty treatment drugs of choice:
   Doxycycline
   Ciprofloxin
   * Special considerations for children, pregnant woman, and those w/ immuno-suppression 6 months … these patients are prone to endocarditis. Infected milk, urine, feces, amniotic fluid of animals
   * Humans are infected by inhaling dried, contaminated particles
   * Ingestion of contaminated milk may produce illness yes … although not commercially available in the United States

   rare

   Standard precautions

   Q fever:
   *Tetracycline
   * Doxycycline … started 8-12 days post exposure

   Chronic Q fever:
   * Doxycycline with quinolones for at least 4 years or Doxycycline with hydroychloroquine for 1.5 – 3 years.

   Q fever< 2% mortality rate

   Chronic
   Q fever:
   65%
   mortality rate

   Reply
3. KF says:

   July 7, 2011 at 3:55 pm

   Don’t worry, be proactive! Be prudent and be prepared for any scenario that could be presented to you and your family.

   This is the best reference, in my opinion available on this subject.
   All are downloadable.

   http://www.bordeninstitute.army.mil/published_volumes/chemwarfare/chemwarfare.html
   Medical Aspects of Chemical Warfare

   Published Volumes
   Contents PDF document

   Front Matter

   1. Introduction to the Chemical Threat
   Thomas B. Talbot, Brian Lukey, and Gennady E. Platoff, Jr
   2. History of Chemical Warfare
   Corey J. Hilmas, Jeffery K. Smart, and Benjamin A. Hill, Jr
   3. History of the Medical Management of Chemical Casualties
   Benjamin A. Hill, Jr
   4. History of the Chemical Threat, Chemical Terrorism, and Its Implications for Military Medicine
   Jeffery K. Smart, Al Mauroni, Benjamin A. Hill, Jr, and Allart B. Kok
   5. Nerve Agents
   Frederick R. Sidell, Jonathan Newmark, and John H. McDonough
   6. Neuroprotection as a Treatment for Nerve Agent Survivors
   Gerald P.H. Ballough, Jonathan Newmark, Eric S. Levine, and Margaret G. Filbert
   7. Nerve Agent Bioscavenger: Development of a New Approach to Protect Against Organophosphorus Exposure
   Michelle C. Ross, Clarence A. Broomfield, Douglas M. Cerasoli, Bhupendra P. Doctor, David E. Lenz, Donald M. Maxwell, and Ashima Saxena
   8. Vesicants
   Charles G. Hurst, John P. Petrali, David J. Barillo, John S. Graham, William J. Smith, John S. Urbanetti, and Frederick R. Sidell
   9. Long-Term Health Effects of Chemical Threat Agents
   William J. Smith, Matthew G. Clark, Thomas B. Talbot, Patricia Ann Caple, Frederick R. Sidell, and Charles G. Hurst
   10. Toxic Inhalational Injury and Toxic Industrial Chemicals
   Shirley D. Tuorinsky and Alfred M. Sciuto
   11. Cyanide Poisoning
   Steven I. Baskin, James B. Kelly, Beverly I. Maliner, Gary A. Rockwood, and Csaba K. Zoltani
   12. Incapacitating Agents
   James S. Ketchum and Harry Salem
   13. Riot Control Agents
   Harry Salem, Bradford W. Gutting, Timothy A. Kluchinsky, Jr, Charles H. Boardman, Shirley D. Tuorinsky, and Joseph J. Hout
   14. Field Management of Chemical Casualties
   Charles H. Boardman, Shirley D. Tuorinsky, Duane C. Caneva, John D. Malone, and William L. Jackson
   15. Triage of Chemical Casualties
   Shirley D. Tuorinsky, Duane C. Caneva, and Frederick R. Sidell
   16. Decontamination of Chemical Casualties
   Ernest H. Braue, Jr, Charles H. Boardman, and Charles G. Hurst
   17. Chemical Defense Equipment
   Laukton Y. Rimpel, Daniel E. Boehm, Michael R. O’Hern, Thomas R. Dashiell, and Mary Frances Tracy
   18. Occupational Health and the Chemical Surety Mission
   Claudia L. Henemyre-Harris, Melanie L. Murrow, Thomas P. Logan, Brent R. Gibson, and Robert Gum
   19. Toxins: Established and Emergent Threats
   Patrick Williams, Scott Willens, Jaime Anderson, Michael Adler, and Corey J. Hilmas
   20. Medical Chemical Defense Acquisition Programs
   Keith Vesely and Jonathan Newmark
   21. Medical Management of Chemical Toxicity in Pediatrics
   Elora Hilmas, James Broselow, Robert C. Luten, and Corey J. Hilmas
   22. Medical Diagnostics
   Benedict R. Capacio, J. Richard Smith, Richard K. Gordon, Julian R. Haigh, John R. Barr, and Gennady E. Platoff, Jr
   23. Domestic Preparedness
   Carol A. Bossone, Kenneth Despain, and Shirley D. Tuorinsky

   Reply