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  2. 2. Definition of Bioterrorism"Bioterrorism” - The unlawful use, orthreatened use, of microorganisms ortoxins derived from living organisms toproduce death or disease in humans,animals, or plants. The act is intended tocreate fear and intimidate governmentsor societies in the pursuit of political,religious, or ideological goals. Note: There is no single, universally accepted definition of bioterrorism.2DR.T.V.RAO MD
  3. 3. HISTORY OF BIOLOGICAL WARFARE • 1346 Siege of Kaffa; plague • 1763 French and Indian War; smallpox • WW I German program; anthrax, glanders • 1925 Geneva protocol bans biological weapons • WW II Japanese program; anthrax, plague, cholera, shigellaDR.T.V.RAO MD 3
  4. 4. HISTORY OF BIOLOGICAL WARFARE (CONT.)• 1941 George W. Merck named U.S. civilian head of Chemical Warfare Service later changed to War ResearcService• 1946 U.S. announces its involvement in bioweapons research• 1969 Nixon eliminates offensive biological warfare programDR.T.V.RAO MD 4
  5. 5. History of Biological Warfare (cont.)• 1972 Biological Weapons Convention• 1979 Accidental release of B. anthracis spores at bioweapon research center, Sverdlovsk, U.S.S.R • 1989-92 Scientists from the former U.S.S.R. involved in biological weapons research defect to the West DR.T.V.RAO MD 5
  6. 6. Domestic Biological Terrorism • 1984 Rajneesh cult members contaminate salad bar with Salmonella typhimurium in Oregon • 1992 Ricin attack planned by Minnesota militia • 2001 Anthrax releases in FL, DC, NY, NJDR.T.V.RAO MD 6
  7. 7. BIOLOGICAL TERRORISMThe use of biologicalagents tointentionally produceillness or intoxicationin a susceptiblepopulationDR.T.V.RAO MD 7
  8. 8. BIOLOGICAL AGENTS RANKING SYSTEMPublic Health impact criteria based on:• Morbidity and mortality• Delivery potential• Public perception (fear, civil disruption)• Public health preparedness needs DR.T.V.RAO MD 8
  9. 9. CDC SELECT AGENTS* – BACTERIA • Bacillus anthracis (spores) • Clostridium • Brucella abortus (botulinum- • Brucella melitensis producing species) • Brucella suis • Coxiella burnetii • Burkholderia mallei • Francisella tularensis (aka Pseudomonas mallei) • Rickettsia prowazekii • Burkholderia pseudomallei • Rickettsia rickettsii (aka Pseudomonas pseudomallei) • Yersinia pestis * Not including agents only on USDA lists. n = 12DR.T.V.RAO MD 9
  10. 10. CDC Select Agents* – Fungi • Coccidioides immitis • Coccidioides posadasii n=2 * Not including agents only on USDA lists.DR.T.V.RAO MD 10
  11. 11. CDC Select Agents* – Viruses I • Central European Tick-borne encephalitis • Cercopithecine herpesvirus 1 • Crimean-Congo haemorrhagic fever • Eastern Equine encephalitis • Ebola • Far Eastern Tick-borne encephalitis • Flexal South American haemorrhagic fever • Guanarito South American haemorrhagic fever • Hendra • Junin South American haemorrhagic fever • Kyasanur Forest disease • Lassa fever • Marburg * Not including agents only on USDA lists.DR.T.V.RAO MD 11
  12. 12. CDC Select Agents* – Viruses II • Machupo South American haemorrhagic fever • Monkeypox • Nipah • Omsk haemorrhagic fever • Reconstructed 1918 influenza • Rift Valley fever • Russian Spring and Summer encephalitis • Sabia South American haemorrhagic fever • Variola major (smallpox) • Variola minor (alastrim) • Venezuelan Equine encephalitis n = 24 * Not including agents only on USDA lists.DR.T.V.RAO MD 12
  13. 13. CDC Select Agents* – Toxins • Abrin • Botulinum neurotoxins • Clostridium perfingens epsilon toxin • Conotoxins • Diacetoxyscirpenol • Ricin • Saxitoxin • Shiga-like ribosome-inactivating proteins • Shigatoxin • Staphylococcal enterotoxins • Tetrodotoxin • T-2 toxin n = 12 * Not including agents only on USDA lists.DR.T.V.RAO MD 13
  14. 14. BIOWEAPON-RELATED DISEASES • anthrax • psittacosis • Q-fever • botulism • salmonellosis • brucellosis • shigellosis • cholera • smallpox • tularemia • food poisoning • typhoid fever • glanders • typhus • viral encephalitis • hemorrhagic fever • lassa fever • melioidosis • plagueDR.T.V.RAO MD 14
  15. 15. ADDITIONAL POTENTIAL BIOTERRORISM AGENTS• • Chlamydia psittaci• • Cryptosporidium parvum• • Escherichia coli O157:H7• • hantavirus• • Salmonella species• • Shigella species• • Vibrio choleraeDR.T.V.RAO MD 15
  16. 16. Potential Bioterrorism Agents• Potentially thousands• NATO NBC Handbook lists 31 agents• CDC created Category A, B, & C lists • Based on: – Ease of dissemination – Potential for Public Health Impact – Potential for Public Panic and Social DisruptionDR.T.V.RAO MD 16
  17. 17. BIOTERRORISM AGENT CLASSIFICATION SYSTEM CDC • The Centers for Disease Control (2004) have placed agents in one of three priority categories for initial public health preparedness efforts: A, B, or C. AgentsDR.T.V.RAO MD 17
  18. 18. CLASSIFYING BIOTERROR AGENTSCLASS A• Contagious• High death rates and high health impact on the public• ANTHRAX, BOTULISM, SMALLPOX, TULAREMIA, PLAGUECLASS B• Moderately easy to spread• Some illness & death rates• TYPHUS, WATER SAFETY THREATS, SALMONELL ACLASS C• Easily available• Easily produced and spread• Have potential for high death & illness rates• NIPAH VIRUS Hey look, a llama! Never can be too careful…DR.T.V.RAO MD 18
  19. 19. CRITICAL BIOLOGICAL AGENTS CATEGORY A • Can be easily disseminated or transmitted person-to- person • Cause high mortality, with potential for major public health impact • Might cause public panic and social disruption • Require special action for public health preparedness • MMWR 49;RR-4, April 21, 2000DR.T.V.RAO MD 19
  20. 20. CATEGORY A AGENTS INCLUDE• variola major (smallpox) • Bacillus anthracis (anthrax) • Yersinia pestis (plague) • Clostridium botulinum toxin (botulism) • Francisella tularensis (tularaemia) • filoviruses • Ebola hemorrhagic fever • Marburg hemorrhagic fever • arenaviruses • Lassa (Lassa fever) • Junin (Argentine hemorrhagic fever) and related viruses• MMWR 49;RR-4, April 21, 2000DR.T.V.RAO MD 20
  21. 21. CATEGORY B • Are moderately easy to disseminate • Cause moderate morbidity and low mortality • Require specific enhancements of CDCs diagnostic capacity and enhanced disease surveillance • MMWR 49;RR-4, April 21, 2000DR.T.V.RAO MD 21
  22. 22. CATEGORY B AGENTS• Coxiella burnetti (Q fever); • Brucella species (brucellosis) • Burkholderia mallei (glanders) • alpha viruses • Venezuelan encephalomyelitis • eastern and western equine encephalomyelitis • ricin toxin from Ricinus communis (castor beans) • epsilon toxin of Clostridium perfringens • Staphylococcus enterotoxin B. • MMWR 49;RR-4, April 21, 2000DR.T.V.RAO MD 22
  23. 23. SUBSET OF LIST B AGENTS INCLUDES PATHOGENS THAT ARE FOOD- OR WATERBORNE - THESE PATHOGENS INCLUDE• Salmonella species • Shigella dysenteriae • Escherichia coli O157:H7 • Vibrio cholerae • Cryptosporidium parvumDR.T.V.RAO MD 23
  24. 24. CATEGORY C INCLUDES EMERGING PATHOGENS THAT COULD BE ENGINEERED FOR MASS DISSEMINATION IN THE FUTURE • Nipah virus • Hantaviruses • Fick-borne hemorrhagic fever viruses • Tick-borne encephalitis viruses • Yellow fever • Multidrug-resistant tuberculosisDR.T.V.RAO MD 24
  25. 25. Biological Delivery Methods• Food / Water • Air handling• Aircraft sprayers systems• Vehicle sprayers • Human Vector• Hand sprayers • Animal Vector• MailDR.T.V.RAO MD 25
  26. 26. KEY INDICATORS OF A BIOLOGICAL TERROR EVENT• Occurrence of vector-borne disease where there is no vector• Cluster of sick or dead animals• Atypical seasonality• Geographic Pattern of Illness• More respiratory presentation of diseaseDR.T.V.RAO MD 26
  27. 27. The Ideal Bioterror Weapon Would Be 1. contagious 2. virulent 3. robust 4. difficult to detect 5. drug-resistant 6. user-controllableNo natural agent meets all of these criteria. Thus, sooneror later, terrorists may decide to devise novel weaponsusing the techniques of synthetic biology to enhance orreplace the characteristics of pre-existing organisms ortoxins. Countermeasures must be pursued vigorously –in advance.DR.T.V.RAO MD 27
  28. 28. PREPARATION FOR BT ATTACK • Familiarize medical staff with BT agents • Incorporate into Disaster Planning • Decontamination & Infection Control • Communications with key agencies • Laboratory, Respective health authorities of the Nation. • Contacts to obtain stockpiled supplies: antibiotics, immune sera, vaccines, etc. • Security preparationsDR.T.V.RAO MD 28
  29. 29. WHAT TO DO IF YOU SUSPECT A BIOTERRORIST DISEASEIMMEDIATELY NOTIFY:• Hospital Infection Control • Isolation: Smallpox, plague, hemorrhagic fevers• Laboratory• Hospital Administration• Local Public Health DepartmentDR.T.V.RAO MD 29
  30. 30. WHAT DOES PUBLIC HEALTH DO IN A BIOTERRORIST EVENT? • Assess health impacts in the community • Environmental health assesses water safety and sanitation • Public health nurses coordinate with Shelter Operations • Acute communicable disease tracks infectious diseases • Injury program tracks injuries and fatalities • Health Officer coordinates information for the public and health care providers • Public Health Laboratories identify agents (either in-house or through referral to State governments or health authorities )DR.T.V.RAO MD 30
  31. 31. SPECIAL PROBLEMS WITH BT• Identifying a covert attack• Social disruption• Prophylaxis for large populations• Decontamination• Secondary transmissionDR.T.V.RAO MD 31
  32. 32. TECHNOLOGY AT WORKForensic teams work hard to identify biological agents, their origins and effectsDR.T.V.RAO MD 32
  33. 33. TECHNOLOGY AT WORK • Labs are working on advanced detection systems to detect early attacks, identify at-risk areas, and to give proper treatmentDR.T.V.RAO MD 33
  34. 34. TECHNOLOGY AT WORK• Bio surveillance: Real- Time-Outbreak Disease Surveillance system made its debut in 1999. This collects data from labs, hospitals, and environmental studies in order to detect bioterror attacks as early as possible.DR.T.V.RAO MD 34
  35. 35. BIOTERRORISM BIOAGENT WARNING SYSTEMS• Wyatt-Lorenz was founded as a spin-off of Wyatt Technology Corporation ("WTC") with a unique mission: To provide immediate bioterrorism bioagent warning systems for the protection of people and property from biological and chemical threats. These Bioterrorism threats are often directed toward elements of the private sector long ignored by the Department of Defense and Department of Homeland SecurityDR.T.V.RAO MD 35
  36. 36. SPECIAL PROBLEMS WITH BIOTERRORISM• Specialized labs needed for some agents• Risks to laboratory workers• Limited resources• Communication between agenciesDR.T.V.RAO MD 36
  37. 37. PREPARATION FOR BIOTERRORISM ATTACK • Familiarize medical staff with BT agents • Incorporate into Disaster Planning • Decontamination & Infection Control • Communications with key agencies • Laboratory, CDC, Police, FBI, etc. • Contacts to obtain stockpiled supplies: antibiotics, immune sera, vaccines, etc. • Security preparationsDR.T.V.RAO MD 37
  38. 38. CLASSIFICATION OF BIOTERRORISM LABORATORIES D - High level characterization (seek evidence of molecular chimeras) and secure banking of isolates Safety & proficiency to probe for universe of Level D Lab bio- and chemical agents in non-clinical specimen BSL-4 C - Safety and proficiency sufficient Level C Lab to probe, type, perform toxigenicity testing BSL-3 B - Safety and proficiency adequate to confirm & characterize susceptibility Level B Lab Work at BSL-3 with BT agents A - Adequate safety to rule-out and forward organisms Level-A Labs - Assess Risks for Aerosols and Use Biosafety CabinetDR.T.V.RAO MD 38
  39. 39. WHAT TO DO IF YOU SUSPECT A BIOTERRORIST DISEASEIMMEDIATELY NOTIFY:• Hospital Infection Control • Isolation: Smallpox, plague, hemorrhagic fevers• Laboratory• Hospital Administration• Local Public Health DepartmentDR.T.V.RAO MD 39
  40. 40. PUBLIC HEALTH’S ROLE IN BIOTERRORISM EVENT• Health Officer coordinates information for the public and medical providers• Community Health and PHN‟s provide education, information to the public and to community providers• Treatment and prophylaxis• QuarantineDR.T.V.RAO MD 40
  41. 41. PROJECT BIOSHIELD "We refuse to remain idle when modern technology might be turned against us. We will rally the great promise of American science and innovation to confront the greatest danger of our timeFormer President George W. Bush, at the signing of the Project Bio shield Act of 2004• Authorized spending of $5.6 billion over a span of 10 years in order to pay for vaccines and medical facilities in case of national biological emergency• Gave the National Institute of Health grants to pursue medical research & technology• Emergency Use Authorization – EUA – gave access to best medical responses in case of an emergency as declared by the Secretary of Human Healthy & Services OR Secretary of Homeland Security DR.T.V.RAO MD 41
  42. 42. COORDINATING WITH SYSTEM IS PRIORITY Primary Care Physicians Hospitals Coordinating with the Feedback/Recommendations Public Health Local Labs System Public Health System DR.T.V.RAO MD 42
  43. 43. WHAT WE NEED TO PREPARE FOR BIOTERRORISM• More trained epidemiologists to speed detection• Increased laboratory capacity• Health Alert Network• Medical professionals “back to school”• National Pharmaceutical StockpileDR.T.V.RAO MD 43
  44. 44. HOW CAN HOSPITALS PREPARE?• Familiarize medical staff and lab with bioterrorist threat agents• Incorporate BT planning into disaster planning • Infection control • Notification procedures and contact numbers • Daily surveillance and reporting • Security preparations • Media • Personal Protective Equipment (PPE) DR.T.V.RAO MD 44
  45. 45. IS IT A TRUE TERRORISM ?• Outbreak of rare disease• Seasonal disease at wrong time• Unusual age distribution• Unusual clinical symptoms• Unusual epidemiologic features• Outbreak in region normally not seenDR.T.V.RAO MD 45
  46. 46. STEPS IN PREPARING PUBLIC HEALTH AGENCIES FOR BIOLOGICAL ATTACKS • Enhance epidemiologic capacity to detect and respond to biological attacks. • Supply diagnostic reagents to state and local public health agencies. • Establish communication programs to ensure delivery of accurate information. • Enhance bioterrorism-related education and training for health-care professionals. • MMWR 49;RR-4, April 21, 2000DR.T.V.RAO MD 46
  47. 47. BIOTERRORISM AND THE PUBLIC HEALTH SECTOR • Preparation for a biological mass disaster requires coordination of diverse groups of medical and non-medical personnel • Preparation can not occur without support and participation by all levels of government • Preparation must be a sustained and evolutionary processDR.T.V.RAO MD 47
  48. 48. • Created by Dr.T.V.Rao MD for „e” Learning Resources for Medical and Public Personal on Bioterrorism • Email doctortvrao@gmail.comDR.T.V.RAO MD 48