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

Week 16: 2011-06-30

I’m completing the chapter in my book on bioterrorism and would like to ask everyone: how concerned are you?

Have you done anything to prepare in the event of a bioterrorist attack?  Do you worry about receiving a letter with a suspicious powdery substance? 

Is bioterrorism really worth worrying about on an individual level?

Comments, questions, and suggestions are all appreciated.  Submit your response in the block below.

 – Doc Cindy

 Image:  Anthrax targets

Graphical depiction of 2001 anthrax mailing (s...

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About Cynthia J. Koelker, MD

CYNTHIA J KOELKER , MD is a board-certified family physician with over twenty years of clinical experience. A member of American Mensa, Dr. Koelker holds degrees in biology, humanities, medicine, and music from M.I.T., Case Western Reserve University School of Medicine, and the University of Akron. She served in the National Health Service Corps to finance her medical education.
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3 Responses to Week 16 – Question of the Week: Bioterrorism – Worth worrying about or not?

  1. Mike M, APRN says:

    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.

  2. KF says:

    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

  3. KF says:

    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

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