Biological Terrorism

Transcription

1 Biological Terrorism Prof. Renaat A. A. M. Peleman Chief Medical Officer Ghent University Hospital, Belgium Norbert Fraeyman Superior Health council Biological Terrorism Definition, situate biological terrorism within terrorism History Agents, Disease, Diagnosis, Treatment Detection, Response, Surveillance The future, some myths Summary 1

2 Categories of Weapons Used by Terrorists Conventional Biological Chemical Nuclear Cyber Definition of Biological Warfare Biological warfare is the deliberate spreading of (infectious) diseases among humans, animals, and plants in order to cause incapacitation or death of the target population. Hon. Prof. Graham S. Pearson CB Former Director General Chemical & Biological Defence Establishment Porton Down, Salisbury, England 2

3 Definition of Biological Warfare Some history Year Event 1155 Emperor Barbarossa poisons water wells with human bodies, Tortona, Italy 1346 Mongols catapult bodies of plague victims over the city walls of Caffa, Crimean Peninsula 1495 Spanish mix wine with blood of leprosy patients to sell to their French foes, Naples, Italy 1650 Polish fire saliva from rabid dogs towards their enemies 1675 First deal between German and French forces not to use 'poison bullets' 1763 British distribute blankets from smallpox patients to native Americans 1797 Napoleon floods the plains around Mantua, Italy, to enhance the spread of malaria 1863 Confederates sell clothing from yellow fever and smallpox patients to Union troops, USA 3

4 Features of Bioterrorism Weapon: Microbe or Toxin Premeditation Goals: Political, Religious, Ideological Motivation: Fear, Disruption, Instability Desirable Features of Biological Agents as Weapon Inexpensive Available Easily transported/concealed and dispersed Incubation period Hides Tracks of perpetrator Modifiable (resistance, virulence) 4

5 Biological Warfare: tier 1 Botulinum neurotoxins Botulinum neurotoxin-producing species of Clostridium Ebola virus Francisella tularensis Marburg virus Bacillus anthracis Burkholderia mallei Burkholderia pseudomallei Variola major virus (smallpox) Yersinia pestis Foot-and-mouth disease virus (aphthovirus) 5

6 Highest Concern CDC designated A List of Biologic Agents Anthrax Plague Smallpox Botulism Tularemia Viral Hemorrhagic Fever 6

7 Anthrax (Bacillus antracis) Inhalation anthrax : aerosol Symptoms : initially non-specific influenza-like ; progress into pneumonia, meningitis Mortality : high : 45% in Amerithrax, 90 % when complicated with meningitis Diagnosis : cultures, lung scans (long incubation time between 1 day up to 6 weeks) Treatment : ABC-procedures, fluoroquinolone (e.g. ciprofloxacin) PEP : vaccine lowers the burden (accidental release of anthrax from a military installation in Sverdlovsk (Russia) with 64 deaths) 7

8 Small pox (varialo major) The world has been declared free from small pox by the WHO in 1982! Spread by aerosol ; high transmission person to person Diagnosis : cultures, lung scans (long incubation time, days) Treatment : no licensed treatments available. Vaccines stockpiled by the military Lethality : 3% in recently vaccinated victims ; 40 % in non-vaccinated persons Vaccination after exposure is advisable Benefit of Vaccine Following Exposure Within 3 days-prevent or significantly lessen severity of symptoms 4-7 days after exposure-some protection, may modify severity 8

9 Pneumonic plague (Pest) Bacterial disease ; Yersinia Pestis Diagnosis : initially difficult to distinguish from ordinary influenza (incubation time 1-3 days) Lethality : when untreated : nearly 100 % Treatment : aminoglycosides (streptomycin ) No vaccine available (1300 s : e6 deaths in Asia and Europe) Botulism Toxin of Clostridium botulinum Spread during attack by aerosol Diagnosis : paralysis within hours after exposure, lethality is very high Treatment : no specific treatment available ; ABCprocedures No vaccine available 9

10 Tularemia Toxin of Francisella Turalensis Diagnosis : difficult to distinguish from pneumonia, cultures, PCR, staining Treatment : 10 day treatment with aminoglycosides (streptomycin, gentamycin ) PEP : 7 day with doxicyclin, ciprofloxacin Na vaccine available. (Very rare, last case in The Netherlands in 1953) Nominal lethality/1,000 kgs of different biological weapens 10

11 Clues to Bioterrorism Severe disease manifestations in previously healthy people Higher than normal number of patients with fever and respiratory/g.i. Complaints Multiple people with similar complaints from a common location An endemic disease appearing during an unusual time of year Clues to Bioterrorism Unusual number of rapid fatal cases Greater number of ill/dead animals Rapid rising and falling epidemic curve Greater numbers of patients with: 1) Severe pneumonia 2) Sepsis 3) Sepsis with coagulopathy 4) Fever with rash 5) Diplopia with progressive weakness 11

12 Keep Alert Early detection High index of suspicion Immediate reporting of suspected cases to authorithies Standard Infection Control (I.C.) Precautions (for all bio-terrorist threats) Wash hands and Wear gloves Wear face shield Wear cap/gown Process contaminated equipment and linen Clean and disinfect environmental surfaces Adhere to occupational health and blood-borne pathogen requirements Place patients at risk for environmental contamination in private or cohort location 12

13 Airborne Infection Control (I.C.) Precautions (Smallpox and Hemmorhagic Fever) Place patient in negative pressure room, when possible Apply high-intensity air filter respiratory protection Limit patient transport Place tight sealing mask on patient when transporting The future.. Biotechnology allows to construct new bacteria, new toxins. CRISPR/Cas9 as targeted genome editing This could lead to new compounds/bacteries : Modification of the resistance to antibiotics Enhancement of transmission Completely new and dangerous microorganisms without any known treatment 13

14 The future.. The future.. Wolfgang Rudischhauser, Director of the Weapons of Mass Destruction Non-Proliferation Centre at NATO said: 'ISIS actually has already acquired the knowledge, and in some cases the human expertise, that would allow it to use CBRN materials as weapons of terror.' 14

15 Myths of Deterrence Against Bioterrorism Morally Repugnant Effective Treaties Consequences too numerous or terrible Science too difficult Not easily weaponized Knowledge required to Manufacture Biological Weapons The infective dose of the potential biological agent The method of attack on the target population (e.g., inhalation, ingestion, or by an insect vector) The means of dispersion of the biological agent The ability of the biological agent to survive until it reaches the target The time to effect or cause disease in the target population The biological agent needs to be producible 30 15

16 The Capability to Make Biological Weapons The methods for making aerosols stay airborne are widely available. The tools for making pathogens in high quantities in fermenters are on ebay. The recipes for making stable formulations of pathogens are on the internet. The equipment for disseminating these weapons is in hardware or agricultural supply stores. This information and technology is almost entirely dual use - in the sense that it has both legitimate and dangerous uses in the world

17 Bioterrorism: summary No events have occurred since the anthrax outbreak in 2001 Technically difficult to disseminate an infectious agent or toxin, but possible Smallpox and anthrax are considered the greatest threats. Smallpox vaccine now stockpiled Response process requires a team approach Recognition may be challenging New computerized surveillance systems offer promise for early detection 17

18 History 6 century 10 century 1346 : siege of Caffa : dead bodies from plague ; spread of black death in Europe? 1763 : British trying to kill native Americans near fort Pitt WWII : Churchill commands the weaponisation of antrax, tularemia , Afghanistan (53 death), 2006, Iraq (7 death), 2001, USA (5 death), 1987, Philippines (19 death), 1978, Georgetown (913 death), 18

19 Smallpox (Variola virus) Characteristics Bio-warfare Mode: Incubation Period: Onset: Duration: Lethality: Transmission: Aerosol 17d (10-12d) Abrupt 4 weeks Moderate (20-40% in unvaccinated; 3% in recently vaccinated) High (person to person) Anthrax Case 4 / October 19,

20 Smallpox (Variola virus) Disease progression Aerosolized release over densely populated area Anthrax meningitis in 50% pat with inhalation anthrax 20

21 Rationale for Syndromic Surveillance Symptom Onset Severe Illness Number of Cases Release Source: Marcy Layton, NYC DOH Syndromic Surveillance: NYC EID

22 Uniqueness of Biological Attacks Biological Onset - incubation, primary cases Secondary Cases contagion, contamination Responders - medical Response System - untested Medical System may be a target Syndromic surveillance during the Paris terrorist attacksstephanie Vandentorren, Annie-Claude Paty, Elsa Baffert, Pascal Chansard, Celine Caserio-Schönemann The Lancet, Volume 387, Issue 10021, Pages (February 2016) 22

23 Do Not Act on rumor Give antibiotics on demand - without medical indication Order nasal cultures - without medical indication 23