1. Playthings of
Bioterrorists
Bioweapons of Mass Destruction
James Chrosniak, MHS, PA-C

2. Overview
 Definition
 Characteristics
 Major Players
 History of BioWarfare
 Indications of a Bioweapons Attack
 What is being done?

3. Definition
 Bioterrorism is the intentional use of
any living organisms, such as bacteria
or viruses, as a weapon

4. Characteristics
What is an effective Bioterror Agent?.
 High mortality rate agents are the best choice
 Designed to kill a large number of people quickly
 More than one route of infection
 High rate of person-to –person transmission
 An aerosol route is the most probable
 Public panic and social disruption

5. Major Players
Biological Agents
 Q Fever
 Anthrax
 Glanders
 Smallpox  Cholera
 Botulism  E.Coli O157:H7
 Plague
Chemical Agents
 Tularemia
 Nerve Agents
 Hemorrhagic Fevers  Vesicants or Blister
Agents

6. History of BioWarfare
 1346 As Tartars launched a siege of Caffa, a port on the Black Sea,
they suffered an outbreak of plague. Tartars sent the infected bodies of
their comrades over the walls of the city.
 1422 At Karlstein in Bohemia, attacking forces launched the decaying
cadavers of men killed in battle over the castle walls.
 1763 During the French and Indian War, British Gen. Jeffery Amherst
ordered that blankets and handkerchiefs be taken from smallpox
patients in the fort's infirmary and given to Delaware Indians at a peace-
making parley.
 (Jenner discovered in 1798 that people could be vaccinated against
smallpox by using the closely-related cowpox)

7. History cont.
 In occupied Manchuria, starting around 1936, Japanese
scientists (Imperial Army Unit 731) used scores of human
subjects to test the lethality of various disease agents, including
anthrax, cholera, typhoid, and plague. As many as 10,000
people were killed
 Japanese airplanes dropped paper bags filled with plague-
infested fleas over the cities of Ningbo and Quzhou in Zhejiang
province
 Iraq is known to have unleashed chemical weapons in the
1980s, both during the Iran-Iraq war and against rebellious
Kurds in northern Iraq.

8. History cont.
 In 1984, the Rajneeshee cult led by the Bhagwan Shree Rajneesh
contaminated with salmonella bacteria several salad bars in restaurants
across Dalles, Ore., sickening 751 people in an attempt to influence the
results of a local election
 In 1995, the apocalyptic religious sect Aum Shinrikyo released sarin
gas in a Tokyo subway, killing 12 commuters and injuring thousands.
The cult also had enlisted Ph.D. scientists to launch biological attacks
 In the fall of 2001, several deadly anthrax terrorist attacks took place in
the U.S. All told, five people died and another 18 became infected,
most from being in the vicinity of anthrax-laced letters, but at least two
from completely unknown means
 Plans for airborne anthrax bombs and for attacks using botulism were
found in houses that had been occupied by Al-Queda leaders in Kabul,
Afghanistan

9. Anthrax
 Bacillus anthracis derives from the Greek word for coal, anthrakis,
because the disease causes black, coal-like skin lesions
 For centuries, anthrax has caused disease in animals and,
uncommonly, serious illness in humans throughout the world (Usually
an occupational disease of farmers, slaughterers, tanners.)
 3 types of anthrax infection occur: inhalational, cutaneous, and
gastrointestinal
 Aerosol spraying is the gravest threat. (No cloud, colorless, tasteless)
 Office of Technology Assessment, estimated that up to 3 million deaths
could occur following the release of 100 kilograms of aerosolized
anthrax over Washington D.C., making such an attack as lethal as a
hydrogen bomb

10. Anthrax cont
 Incubation period is one to six days
 Inhalational Anthrax Symptoms: Rapid progression of fever, malaise,
cough and sub-sternal chest pain is followed by marked respiratory
distress. Shock and death generally occur within 36 hours of symptom
onset
 By the time symptoms develop, it is probably too late.
 Treatment of choice is Doxycycline or Ciprofloxin
 There is a vaccine for anthrax that requires six immunizations over 18
months plus annual boosters. It is currently available only to the military
(Over 2 mil already vaccinated)
 Anthrax does not have person to person transmission , but watch out
what you powder your nose with

11. Small Pox
 Variola major, a virus commonly known as smallpox.
 Through natural epidemics, smallpox has likely claimed more
lives than any other infectious disease
 A 12-14 day incubation period after exposure to the virus
(makes it difficult to track)
 Aerosol spreading is the common means of transmission.
 Symptoms include the onset of generalized rash, oral macular
and papular lesions. The onset of fever, headache, backache
and the oral lesions are usually exhibited within the first two
days of the virus activation.

12. Small Pox con’t
 The distinction of smallpox is
the involvement of the palms of
the hands and soles of the feet.
 Generally the greatest
concentrations of lesions are
located on the face.
 An additional distinction
between smallpox and
chickenpox is the uniform
progression of lesions from
maculae to papules to vesicles
then to scab formations.
 In chicken pox, the lesions are
all at various stages of
development.

13. Smallpox con’t
 Death usually occurs within day 5-7 of lesion progression with
increasing fever, abdominal pain, confusion and delirium due to
toxemia
 Outbreaks of Smallpox usually involve strict quarantine of all individuals
who have come in contact with infected individuals
 Mortality is expected to be about 30% for the unvaccinated. Infants
and the elderly historically succumbing first
 As with all viral agents, treatment is supportive.
 Vaccination given 3-5 days post-exposure can prevent the disease.
 Because most of North America has not been immunized in 25 years,
there is a risk to the entire population

14. Botulism
 Clostridium botulinum is a bacterial agent that occurs in nature,
but is commonly found in spoiled food items
 The bacterium produces a nerve toxin that can be fatal if not
treated immediately.
 Botulism toxin is one of the most poisonous substances known.
A single gram of crystalline toxin could theoretically kill 1 million
people
 Three types: Food borne, wound botulism from contact with an
open wound and infant botulism (from consuming the spores of
botulism in items that may not be considered spoiled like
natural honey)

15. Botulism
 Double vision, blurred vision, drooping eyelids, slurred speech,
difficulty swallowing, dry mouth, and muscle weakness
 May progress to cause paralysis of the arms, legs, trunk and
respiratory muscles
 Therapy for botulism consists of supportive care (i.e.,
mechanical ventilation) and passive immunization with equine
antitoxin (recombinant vaccine is in development)

16. Plague
 The causative agent of pneumonic plague and black (or bubonic)
plague is Yersinia Pestis, a bacteria that is commonly found in the fleas
that reside on rodents like rats.
 In 1346, a bubonic plague pandemic known as the Black Death erupted
in Europe and eventually killed 20-30 million people, a third of the
population
 Techniques to aerosolize plague were developed in the Soviet Union,
and many former Soviet scientists that have this know-how have
disappeared.
 Transmission is by aerosol or person-to-person. Pneumonic plague is
contagious through respiratory droplets.
 Short incubation period of two or three days

17. Plague
 Pneumonic plague symptoms
include progressively worsening
fever, malaise, headache, cough
with bloody sputum. The
pneumonia progresses over 2-4
days, without treatment, can
lead to septic shock and death
from respiratory and circulatory
collapse
 Extremely swollen lymph nodes
known as “bubo”
 Doxycycline and Cipro are the
drugs of choice
 A vaccine was licensed in the
U.S. but discontinued by its
manufacturer in 1999. Does not
prevent the pneumonic form of
plague.

18. Tularemia
 The agent that causes tularemia, Francisella tularensis, is one
of the most infectious bacteria known: inhaling as few as ten
microscopic germs can trigger disease
 It is so infective that examining an open culture plate can cause
infection.
 WHO has estimated that if 110 pounds of a virulent strain of the
bacteria were sprayed over a city of 5 million, it could
incapacitate 250,000 people and kill 19,000.
 Tularemia occurs naturally in small mammals such as mice,
squirrels, and rabbits. Human infection, which is rare, can result
from tick bites or handling infected animals

19. Tularemia
 Symptoms include high fever, malaise, severe headache, sore throat,
myalgias, non-productive cough, and possibly nausea, vomiting and
diarrhea
 Without antibiotics, the clinical course could progress to respiratory
failure, shock and death
 Human to human transmission has not been documented
 The treatment is Doxycycline for 14 to up to 21 days. Ciprofloxin can
also be considered
 No vaccine is available for the general public. The FDA is investigating
a vaccine that is now available for high-risk lab workers.

20. Viral Hemorrhagic Fever
 There are a variety of viruses that cause Hemorrhagic fever,
most common of which include Ebola, Marburg , and Lassa
 Occurs in nature either in the urine and feces of rodents or
certain monkeys
 Hemorrhagic fever is very rare in the United States. Most cases
occur in Sub-Saharan Africa (Lassa virus infections for example,
claim an estimated 300,000 infected with about 5,000 deaths
per year. Marburg virus has a case-fatality rate of 25%.)
 Japanese cult Aum Shinrikyo sent members to Zaire in 1992 to
obtain Ebola for weapons development

21. Viral Hemorrhagic Fever
 Incubation period is about 1-3 weeks after being infected.
Human-to-human transmission can occur by contact with
infected blood or body fluids
 Symptoms are progressively worsening high fever,
malaise, headache, myalgias, together with mucous
membrane bleeding (mouth, nose, eyes) bloody
diarrhea and vomiting
 The only treatment available is the general antiviral
Ribavarin and life supportive measures available in
the ER or ICU

22. Is this the real thing?
Indications of a bioweapon attack
 Case numbers rapidly increase over a period of hours or days
(except food poisoning outbreaks)
 The rapid outbreak of any disease that is not indigenous to the
local area (i.e., vector-borne illness)
 Respiratory presentation of illnesses that usually have non-
pulmonary patterns when contracted in nature (I.e., anthrax
and plague)
 Large numbers of casualties concentrated in a certain area or
with wind direction.

23. What is being done?
 National Pharmaceutical Stockpile Program (NPSP) -- This resource
of medical supplies can be sent anywhere in the country within 12
hours of a biological attack.
 The Health Alert Network (HAN) -- The CDC and other health
organizations are developing a national communication system on the
Internet
 Health department lab preparedness -- The CDC is working with
other officials to ensure that all state health departments are equipped
to test suspicious substances.
 Health advisories -- Recent official health advisories from the CDC,
available on the CDC Web site
 The Joint Commission on Accreditation of Healthcare Organizations
recently changed its guidelines so that all hospitals must demonstrate
bioterrorism preparedness to receive accreditation

24. Any Questions?

25. References
 CDC Bioterrorism Section www.bt.cdc.gov
 Johns Hopkins Center for Civilian Biodefense Studies
www.hopkins-biodefense.org/
 The Maryland Institute for Emergency Medical Services
Systems www.miemss.umaryland.edu
 Nova Online “Bioterrism” www.pbs.org
 “Weapons of Mass Destruction” Capt. Charles W. Reed, USAF,
BSC, PA-C, MEd