biologic agent final

8/13/2019 Biologic Agent Final

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Biological Warfare


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So whats the ISSU withBIOLOGICAL 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


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History of Issue- Biological Weapons are NOT new!!

- The first Biological Weapon incident:6thCentury B.C.

- 3 Major forms of BW before 20thCentury

- 1925 Geneva Protocol

- 19451950 THE UNITED STATES BW PROGRAM- 1966 A SIMULATED BW ATTACK

- 1969 Thats What they said

A REPORT FROM THE WORLD HEALTHORGANIZATION

- 1966-1971 THE UNITED STATES REACTS- 1972 Biological Weapons Convention

- BW In Recent Times

- CLOSE to HOME

- EASY ACCESS FOR ALL!


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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


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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.


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Have they been used?


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Why think about

Biological Warfare?

Our future enemies strategiesOur future enemies resources

Our blind spots


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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
http://images.google.com/imgres?imgurl=http://www.zyz.com/survivalcenter/images/GasMaskAdv1000.jpg&imgrefurl=http://www.zyz.com/survivalcenter/BioPage.html&h=388&w=325&sz=13&hl=en&start=20&tbnid=t81_DASvbl-hMM:&tbnh=123&tbnw=103&prev=/images?q=biological+warfare&gbv=2&svnum=10&hl=en&safe=active


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Are there an unusual number of patientspresenting 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 infectiousdisease?

Disease outbreak with zoonotic impact

Index of Suspicion


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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 (Viralhemorrhagic fevers)Report ALL suspected or confirmed illness due tothese agents to health authorities immediately


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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


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Nominal lethality/1,000 kgs of differentbiological weapens


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Motivation

Number of

casualties

Level of panic

Capabilities

Group size

Technicalproficiency

Financial

resources

Agents

Availability

Ease of growth

Morbidity & mortality

Dissemination

Ease of dissemination

Efficacy of disseminationtechnique

Target

Number exposed attarget

Target vulnerability

The bioterrorism pathways matrix


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Covert vs. Overt Event

Overt Covert

Recognition Early Delayed

Response Early Delayed

Treatment Early Delayed

Responders Traditional First Health Care

Responders Workers


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Diagnostic matrix:

chemical and biological casualties

I h l l A h Pl T l


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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)


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Inhaled BWF bacteria

Treatment

Fluoroquinolones (all)

Vibramycin

PenicillinAminoglycosides

Prophylaxis

Fluoroquinolones (all) Vibramycin


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Anthrax Disease Complex Summary

GI

Papulevesicle

edema + eschar

ResolveToxic shock

and

Death

Hemorrhagic

Meningitis

Cutaneous

Inhalational

Tracheobronchial

Lymphadenitis

Mediastinitis, cyanosis,

stridor, pulmonary

edema

1 - 6

days

ABRUPT

ONSET

50%

20%

24 - 36 hours

B


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Bacteria

Bacillus Anthracis Disease: anthrax

Incubation: 160 days

Length of illness:1 to 2 days

Mortality rate: extremely high, deathtypically occurs within 2436 hours after

onset of severe symptoms Effective dosage: 8.000-50.000 spores

casualties/50 kg/city/5*106: 250.000


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Chest Radiograph

Inhalation Anthrax

Note:

widened mediastinum

diminished air space

I h l ti l A th E l ti


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Inhalational Anthrax: Evolution


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Anthrax Case 3 / October, 2001


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Anthrax Case 3/ October, 2001


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Anthrax Case 4 / October 19, 2001


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A h C 4 / O b 19 2001


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A th C 4 / O t b 19 2001


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A th C 4 / O t b 19 2001


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Specimen Collection: B. anthracis

Site Specimen CommentsVesicular stage Collect fluid from a previously unopened vesicle with dry sterile

Eschar stage Roll swabs beneath the edge of the eschar without removing

Feces Provides minimal recovery of agent

Blood culturesUseful in later stages of disease. Collect prior to antibiotic use,

if possible.

Nasal swab Collect only within 24 h of exposure

SputumCollect if respiratory symptoms occur and sputum is being

produced. Provides minimal recovery of agent.

Blood cultures

Cultures collected 2-8 days post-exposure may yield the

organism. Collect prior to antibiotic use.

Cutaneous

Anthrax

GastrointestinalAnthrax

Inhalation

Anthrax

C taneo s Anthra


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Cutaneous Anthrax

Arm Neck

black eschar

(anthracis,Greek for

coal)

typical redareola


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Cutaneous anthrax, stemming from wear of infected wool scarf


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

Hemorrhagic Meningitis


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Pneumonic Plague: Prevention of

Secondary Infection

Secondary transmissionis possible and likely

Standard, contact, anddroplet precautions for atleast 48 hrs until sputum

cultures are negative orpneumonic plague isexcluded


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Plague: Specimen Collection

Site Specimen CommentsLymph node

aspirate

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,

bronchial or

tracheal

Minimal recovery from sputum. Bronchial or tracheal aspirate

preferred because of fewer contaminating organisms

Blood cultures


Lymphoid

tissue

Bone marrow

Lung tissue

Postmortem

Examinations

Bubonic

Plague

Pneumonic

Plague


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Clinical clues

Anthrax Plague Brucella

Incubation 160 d 210 d 56 d

Duration of

illness

12 d 12 d Variabel

Major S&S High fever, diff

breathing

pneumonia &

death in 23 d

High T,

tender LN,

pneumonia

Flu-like, aching

joints, myalgia

Minor S&S T & fatigue GI symptoms,skin lesions

GI symptoms

Specific Widened

mediastinum

Gram-neg

pneumonia +

hemoptysis

Low WBC and

platelets

Pl


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Plague:Differential Diagnosis

Bubonic Staph/streptococcal

adenitis

Glandular tularemia Cat scratch disease

Septicemic

Other gram-negativesepsis

Meningococcemia

RMSF

TTP

Pneumonic

Bioterrorism threats

Anthrax

Tularemia

Melioidosis

Other pneumonias

(CAP, influenza, HPS)

Hemorrhagic

Leptospirosis

T l i Di C l


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Primary

pulmonary

+ 2 wks

duration

Conjunctiva

Tularemia Disease Complex

Summary

Inhalational

Fever, chills

headaches

Abrupt

onset

Infiltrates, rales

Lower nephrotic

syndrome

Mild liver

enzyme

Rhabdomyolysis

Alveolar septa

Necrosis & cavitation

Papuleulcer

cutaneous

lesions

Oropharyngeal

pseudomembrane

50% Secondary

pleuropulmonary

7 - 10 days

2 - 10days


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Specimen Collection: F. tularensis

Specimen Comments

Serum for

serology

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.)


Blood

SputumCollect or induce specimen from symptomatic patients. Bronchial or

tracheal wash may produce better yield.Ulcer Collect swab specimen from ulcer on skin or throat

Eye Collect swab specimen if eyes affected

Q F


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Q Fever

Clinical Course SummaryInhalation

Fever (100 - 104 3 - 6 days),

malaise, anorexia + headache

Sudden onset

CNS symptoms

and

neck stiffness

Meningitis

Mild

LFT

Mild primary

atypical pneumonia

ground glass

Late complications

Osteomyelitis

Chronicinfective

endocarditis

(aortic valve)

2 - 14 day

course


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Q fever: Clinical Features

AT

PRESENTATION

3 DAYS

LATER


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Specimen Collection: Q. Fever

Specimen Comments

Serum for

serology

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)


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Clinical clues

Tularemia Q-fever Influenza

Incubation 1

10 d 2

14 d

Duration of

illness

13 wks 214 d

Major S&S T, headache, Flu-like Cough, T,

Catarrh, loss of

appetite

Weariness

Aching limbs

Minor S&S weightloss

Specific irritating cough Elevated LFT

Rickettsiae


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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 812 dayspost exposure. If started too early,prophylaxis prolongs the disease

Treatment: Doxycycline 100 mg bid for 5 - 7

days

S ll Cl l C


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Smallpox - Clinical Course

SummaryInhalational

Replication in regional node of airways12 day incubation

ViremiaAcute malaise, fever,

rigors, headache

Exanthema on

face, arms, hands

Maculespapules

pustular vesicles

Scabs separate

+ pt non-infective

Flat Smallpox

Hemorrhagic

Smallpox

rapid death before

typical lesions

8 - 10 days

2 - 3 days

variants

+ mental status changes


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S ll Cli i l F t


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Smallpox: Clinical Features

USAMRICD


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Incubation 7-17 days 14-21 days

Prodrome 2- 4 days minimal/noneDistribution centrifugal centripetal

Progression synchronous asynchronous

Scab formation 10-14 d p rash 4-7 d p

rash

Scab separation 14-28 d p rash


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Smallpox:Medical Management

Strict airborne precautions and contactisolation of patient

Patient infectious until all scabs haveseparated

Notify public health authorities

immediately for suspected case

Identification of contacts within 17 daysof the onset of cases symptoms


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Specimen Collection: Smallpox

Specimen Comments

Do not collect or ship any specimens without consultation from

MDCH or CDC

Vesicles

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.

Scabs

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.

Biopsy

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.

Autopsy

Specimens

Place into sterile, freezable, leakproof container. Store frozen at 20 to 70C.

VEE


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VEE

Clinical Course Summary

?? Inhalational

Mosquito born

Weakness for

1 - 2 weeks

Recovery

Mild CNS symptoms

for 3 days

liver enzymesMore severe

CNS signs

10 - 37% mortality

20% Children

4% Adult

cases

1 to 5 day

incubation

Febrile

syndrome

lasting 3 days

100- 104 fever

chills, headache,

photophobia,

sore throat


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The VHF RNA VirusesAcute onsetfebrile illness

High fever, myalgia,

GI disturbances

Severe systemic illnesscoagulation abnormalities

Rapid progression into

shock and death

Renal

failure

Pulmonary

Syndrome

Major

organ

necrosis

Four Corners Agent

Ebola

Marburg

Hantaan

Oropharyngeallesions

Severe bleeding

ecchymosis

Jaundice

Syndrome

Lassa

Machupo

Congo fever

Yellow fever

Dengue (2x)

Rift Valley

7 days


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VHF: Patient Isolation

Single room w/ adjoining anteroom (ifavailable)

Handwashing facility withdecontamination solution

Negative air pressure

Strict barrier precautions includingprotective eyewear/faceshield

Disposable equipment /sharps in rigidcontainers with disinfectant then autoclaveor incinerate

All body fluids disinfected

Specimen Collection: Viral


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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


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Clinical clues: viruses

Variola Venezuelan

equine enc

Yellow

fever

Incubation Approx 12 d 15 d 36 d

Duration of

illness

severa1 wks 12 wks 12 wks

Major S&S Malaise, T,

chills, Lesions

after 2-3 d

Sudden T,

headache+,

musclepain

T, myalgia,

prostration.

Easy bleeding

Minor S&S Nausea, sorethroat,diarrea

Specific Highly

contagious

vasculitis

Clinical clues: toxins


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Clinical clues: toxins

Botulinum Ricin SEB

Time to effect 12

36 hrs Few hrs 3

12 hrs

Duration of

illness

2472 hrs 3 d Up to 4 wks

Major S&S Cranial nervepalsy, desc

flaccid

paralysis

Sudden T,weakness,

cough, APE

T, chills,headache,

nausea, cough

Minor S&S Convulsions,liver failure

Specific Latent period

of 312 hrs

on exposure


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Summary: important differentials


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Summary: important differentials

Conclusions


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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


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Thank you!!For notsleeping D

biologic agent final

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