This document discusses bioterrorism and bioterrorist agents. It defines bioterrorism and provides examples of historical bioterrorism incidents. It describes the three categories of bioterrorism agents according to the CDC based on their ease of transmission and potential for mortality. Priority agents are characterized by their ability to infect via aerosol and cause high morbidity and mortality. Sources of potential bioterrorism and impacts on direct infection, the environment and economy are reviewed. The anthrax attacks in the US in 2001 are summarized.

1. BIOTERRORISM ANDBIOTERRORISM AND
VETERINARY PUBLICVETERINARY PUBLIC
HEALTHHEALTH
Dr. Shahnawaz ahmadDr. Shahnawaz ahmad
I.V.R.II.V.R.I
Div. Of SurgeryDiv. Of Surgery

2. Definition of BioterrorismDefinition of Bioterrorism
Bioterrorism is the threat of use of biologicalBioterrorism is the threat of use of biological
agents by individuals or groups motivated byagents by individuals or groups motivated by
political, religious, ecological, social or for otherpolitical, religious, ecological, social or for other
ideological objectives to inculcate fear or causeideological objectives to inculcate fear or cause
illness or death in order to achieve theirillness or death in order to achieve their
objectivesobjectives
(Carus 1998).(Carus 1998).

3.  According to the United States Centers forAccording to the United States Centers for
Disease Control and Prevention (CDC)Disease Control and Prevention (CDC) aa
bioterrorism attack is the deliberate release ofbioterrorism attack is the deliberate release of
viruses, bacteria or other germs (agents) orviruses, bacteria or other germs (agents) or
toxins used to cause illness or death in people,toxins used to cause illness or death in people,
animals or plantsanimals or plants..

4. BIOLOGIC WARFARE: HISTORY
 1414THTH
century, Caffa: Attacking Tatar force catapulted cadavers of plaguecentury, Caffa: Attacking Tatar force catapulted cadavers of plague
victims into city – outbreak of plague led to defeatvictims into city – outbreak of plague led to defeat
 1818thth
century, Fort Pitt, North America: Blankets from smallpox hospitalcentury, Fort Pitt, North America: Blankets from smallpox hospital
provided to Native Americans – resulted in epidemic of smallpox amongprovided to Native Americans – resulted in epidemic of smallpox among
tribes in Ohio River valleytribes in Ohio River valley
Gen. Jeffrey
Amherst, in a letter
dated 16 Jully 1763,
approved the plan to
spread smallpox
to Delaware Indians

5.  1932-45, Manchuria: Japanese military physicians infected1932-45, Manchuria: Japanese military physicians infected
10,000 prisoners with biological agents (10,000 prisoners with biological agents (B. anthracis, N.B. anthracis, N.
meningitidis, Y. pestis, V. choleraemeningitidis, Y. pestis, V. cholerae) –) – 11 Chinese cities11 Chinese cities
attacked via food/water contamination, spraying via aircraftattacked via food/water contamination, spraying via aircraft
The Japanese army used Chinese
prisoners to test bioweapons.

6. Reported cases of bioterrorism
World war II – Polish resistance organizations used
biological agents against German
forces
1952 – Mau Mau, an independence movement in
Kenya, used a plant toxin to poison
livestock
1966 – Dr. M. Suzuki, a Japanese physician,

7. 1981 – Dark harvest groups got anthrax
contaminated soil from Gruinard Island and
damped it on Porton Down.
1984 – Rajaneesh in Portland, Oregon (USA) used
S. thphimurium to contaminate restaurants salad
bars
1995 – AUM Shinrikyo used sarin nerve gas in the
Tokyo subway in Japan.
2001- Anthrax contaminated mails sent to various
people in USA

8. CasualtiesCasualties
Incident Number of cases Number of deaths
Polish
resistance
Not reported 200 Germans
Mau Mau Not reported 33 head of cattle
Dark Harvest None None
Rajaneesh 751 (45 Hospitalized No deaths
AUM Shrinkyo 5500 (641 seen at SJIH on day
I & 349 following week
106 hospitalized at SLIH, 12
deaths ( 2 at SLIH)
Dr. Suzuki 200 4 deaths
Anthrax (USA) 22 4 deaths

9. Motive for Bioterrorism
Incident Motive
Polish resistance Resistance against foreign occupation
Mau Mau Resistance against colonialism
Dark Harvest Send a political message
Rajneesh Win a local election by incapacitating the non-
Rajneeshees voters
AUM Shrinkyo Seize control of Japan through mass murder
causing fear and apprehension
Dr. Suzuki Revenge for unfair treatment he received at the
medical training
Anthrax (USA) Inculcate fear

10. BIOTERRORISM: WHY NOW?BIOTERRORISM: WHY NOW?
 Nuclear arms have great killing capacity but areNuclear arms have great killing capacity but are
hard to get.hard to get.
 chemical weapons are easy to get but lack suchchemical weapons are easy to get but lack such
killing capacitykilling capacity
 Biological agents have both qualitiesBiological agents have both qualities..

11. TRENDSTRENDS FAVORING BIOLOGICALFAVORING BIOLOGICAL
WEAPONSWEAPONS
 Biological weapons have an unmatched destructive potentialBiological weapons have an unmatched destructive potential
 Technology for dispersing biologic agents is becoming more sophisticated.Technology for dispersing biologic agents is becoming more sophisticated.
 The lag time between infection and appearance of symptoms generally isThe lag time between infection and appearance of symptoms generally is
longer for biological agents than with chemical exposures.longer for biological agents than with chemical exposures.
 Lethal biological agents can be produced easily and cheaply.Lethal biological agents can be produced easily and cheaply.
 Biological agents are easier to produce clandestinely than are either chemicalBiological agents are easier to produce clandestinely than are either chemical
or nuclear weapons.or nuclear weapons.

12. TRENDS FAVORING BIOLOGICAL WEAPONSTRENDS FAVORING BIOLOGICAL WEAPONS
 Global transportation links facilitate the potential forGlobal transportation links facilitate the potential for
biological terrorist strikes to inflict mass casualtiesbiological terrorist strikes to inflict mass casualties
 Urbanization provides terrorists with a wide array ofUrbanization provides terrorists with a wide array of
lucrative targetslucrative targets
The emergence of global, real-time media coverage increasesThe emergence of global, real-time media coverage increases
the likelihood that a major biological incident will inducethe likelihood that a major biological incident will induce
panicpanic

14. CENTERS FOR DISEASE CONTROLCENTERS FOR DISEASE CONTROL
BIOTERRORIST AGENTS: CATEGORY ABIOTERRORIST AGENTS: CATEGORY A
 Easily disseminated or transmittedEasily disseminated or transmitted
person-to-personperson-to-person
 High mortality, with potential for publicHigh mortality, with potential for public
health impacthealth impact
 Require special action for public health preparedness .Require special action for public health preparedness .
 Viruses:Viruses: Variola major (smallpox),Variola major (smallpox),
Filoviruses (Ebola, Marburg),Filoviruses (Ebola, Marburg),
Arenaviruses (Lassa, Junin)Arenaviruses (Lassa, Junin)
 BacteriaBacteria:: Bacillus anthracisBacillus anthracis (anthrax),(anthrax), Yersinia pestisYersinia pestis (plague),(plague), FrancisellaFrancisella
tularensistularensis (tularemia)(tularemia)
 ToxinsToxins:: Clostridium botulinumClostridium botulinum toxin (botulism)toxin (botulism)

15. CENTERS FOR DISEASE CONTROLCENTERS FOR DISEASE CONTROL
BIOTERRORIST AGENTS: CATEGORY BBIOTERRORIST AGENTS: CATEGORY B
 Moderately easy to disseminateModerately easy to disseminate
 Moderate morbidity and low mortalityModerate morbidity and low mortality
 Require improved diagnostic capacity & enhanced surveillance .Require improved diagnostic capacity & enhanced surveillance .
 VirusesViruses: Alphaviruses (VEE, EEE, WEE): Alphaviruses (VEE, EEE, WEE)
 BacteriaBacteria:: Coxiella burnetiiCoxiella burnetii (Q fever),(Q fever), Brucella sppBrucella spp. (brucellosis),. (brucellosis), BurkholderiaBurkholderia
malleimallei (glanders)(glanders)
 Toxins:Toxins: Rinus communisRinus communis (caster beans) ricin toxin,(caster beans) ricin toxin, Clostridium perfringensClostridium perfringens
episolon toxin,episolon toxin, StaphylococcusStaphylococcus enterotoxin Benterotoxin B
 Food/waterborne pathogensFood/waterborne pathogens:: Salmonella sppSalmonella spp.,., Vibrio choleraeVibrio cholerae,, ShigellaShigella
dyseneriaedyseneriae,, E. coliE. coli O157:H7,O157:H7, Cryptosporidium parvumCryptosporidium parvum, etc., etc.

16. CENTERS FOR DISEASE CONTROLCENTERS FOR DISEASE CONTROL
BIOTERRORIST AGENTS: CATEGORY CBIOTERRORIST AGENTS: CATEGORY C
 AvailabilityAvailability
 Ease of production and disseminationEase of production and dissemination
 Potential for high morbidity and mortality and major publicPotential for high morbidity and mortality and major public
healthhealth impactimpact
 Viruses:Viruses: Nipah, hantaviruses, tick borne hemorrhagic feverNipah, hantaviruses, tick borne hemorrhagic fever
viruses, tick borne encephalitis viruses, yellow feverviruses, tick borne encephalitis viruses, yellow fever
 BacteriaBacteria: Multi-drug resistant: Multi-drug resistant Mycobacterium tuberculosisMycobacterium tuberculosis

17. CHARACTERISTICS* OF PRIORITY AGENTSCHARACTERISTICS* OF PRIORITY AGENTS
 Infectious via aerosolInfectious via aerosol
 Organisms fairly stable in aerosolOrganisms fairly stable in aerosol
 Susceptible civilian populationsSusceptible civilian populations
 High morbidity and mortalityHigh morbidity and mortality
 Person-to-person transmissionPerson-to-person transmission
 Difficult to diagnose and/or treatDifficult to diagnose and/or treat
 Previous development for BWPrevious development for BW
** * Priority agents may exhibit all or some of the above characteristics* Priority agents may exhibit all or some of the above characteristics

18. SOURCES OF BIOTERRORISMSOURCES OF BIOTERRORISM
 Biological warfareBiological warfare
 State sponsored terrorismState sponsored terrorism
 International terrorist groupsInternational terrorist groups
 National cultsNational cults
 The deranged “loner”The deranged “loner”

19. BIOTERRORISM: IMPACTBIOTERRORISM: IMPACT
 Direct infection: Mortality, morbidityDirect infection: Mortality, morbidity
 Indirect infection: Person-to-person transmission, fomite transmissionIndirect infection: Person-to-person transmission, fomite transmission
 Environmental impact: Environmental survival, animal infectionEnvironmental impact: Environmental survival, animal infection
 Other: Social, political, economicOther: Social, political, economic

20. The terrorists have an option to use exotic
organisms to spread disease in animals and plants.
Imagine somebody spread Foot and Mouth disease,
Glanders, VEE, Rinderpest, Brucellosis, Swine fever, Fowl
plague, Rabies and so on.
THREAT TO ECONOMYTHREAT TO ECONOMY

21.  Similarly Rice blast, Stem Rust, Late blight of potato, Black Rust
and Maize Rust and so on would destroy all the crops and shatter
the economy of the country.
 Eg:-Irish Potato Famine in 1940 due to Potato Blast
 Half a million people died of starvation and half a million people
migrated. It took one century for the country’s economy to
recover.

22. BIOLOGICAL WARFARE: IMPACTBIOLOGICAL WARFARE: IMPACT
[[release of 50 kg agent by aircraft along a 2 km line upwind of arelease of 50 kg agent by aircraft along a 2 km line upwind of a
population center of 500,000 – Christopher et al., JAMA 278;1997:412population center of 500,000 – Christopher et al., JAMA 278;1997:412
AgentAgent Downwind No. deadDownwind No. dead No.No.
reach, kmreach, km incapacitatedincapacitated
Rift Valley feverRift Valley fever 11 400400 35,00035,000
Tick-borne encephalitisTick-borne encephalitis 11 9,5009,500 35,00035,000
TyphusTyphus 55 19,000 85,00019,000 85,000
BrucellosisBrucellosis 1010 500500 125,000125,000
Q feverQ fever >20>20 150150 125,000125,000
TularemiaTularemia >20>20 30,00030,000 125,000125,000
AnthraxAnthrax >20>20 95,00095,000 125,000125,000

23. Biological Delivery Methods
• Food / Water
• Aircraft sprayers
• Vehicle sprayers
• Hand sprayers
• Mail
• Air handling
systems
• Human Vector
• Animal Vector

24. CHARACTERISTICS OF BIOWARFARE
Potential for massive numbers of casualties
Ability to produce lengthy illnesses requiring prolonged and intensive care
Ability of certain agents to spread via contagion
Paucity of adequate detection systems
Presence of an incubation period, enabling victims to disperse widely
Ability to produce non-specific symptoms, complicating diagnosis
Ability to mimic endemic infectious diseases, further complicating diagnosis

25. FOMITE ACQUISITIONFOMITE ACQUISITION
 Agents acquired from contaminated clothesAgents acquired from contaminated clothes
Variola major (smallpox)Variola major (smallpox)
• Bacillus anthracisBacillus anthracis (anthrax)(anthrax)
• Coxiella burnetiiCoxiella burnetii (Q fever)(Q fever)
• Yersinia pestisYersinia pestis (plague)(plague)
ManagementManagement
•Remove clothing, have patient showerRemove clothing, have patient shower
•Place contaminated clothes in impervious bag, wear PPEPlace contaminated clothes in impervious bag, wear PPE
•Decontaminate environmental surfaces with EPA approvedDecontaminate environmental surfaces with EPA approved
germicidal agent or 0.5% bleach (1:10 dilution)germicidal agent or 0.5% bleach (1:10 dilution)

26. Bioterrorism agents: Laboratory riskBioterrorism agents: Laboratory risk
AgentAgent BSLBSL Laboratory RiskLaboratory Risk
B. anthracisB. anthracis 22 lowlow
Y. pestisY. pestis 22 mediummedium
F. tularensisF. tularensis 2/32/3 highhigh
Brucella sppBrucella spp.. 2/32/3 highhigh
Botulinum toxinBotulinum toxin 22 mediummedium
SmallpoxSmallpox 44 highhigh
Viral Hemorrhagic feverViral Hemorrhagic fever 44 highhigh

27. ANTHRAX IN THE US, 2001ANTHRAX IN THE US, 2001
 Locations: FL, NY, DC, NJ, CT, VALocations: FL, NY, DC, NJ, CT, VA
 Mechanism: Via the mail (4 letters positive)Mechanism: Via the mail (4 letters positive)
 Infections: 22 casesInfections: 22 cases
 Cutaneous anthrax: 11 (fatality rate = 0)Cutaneous anthrax: 11 (fatality rate = 0)
 Inhalation anthrax: 11 (fatality rate = 45%)Inhalation anthrax: 11 (fatality rate = 45%)
 ProphylaxisProphylaxis
 Initiated: ~32,000Initiated: ~32,000
 60 day course recommended: ~5,00060 day course recommended: ~5,000

28. UNEXPECTED FEATURES OFUNEXPECTED FEATURES OF
ATTACKATTACK
Targets (news media)Targets (news media)
Vehicle (US mail)Vehicle (US mail)
Source of strain (US, probably weaponized)Source of strain (US, probably weaponized)
Translocation of spore through envelopeTranslocation of spore through envelope
Airborne acquisition in mail facilitiesAirborne acquisition in mail facilities
Wide spread contamination in mail facilitiesWide spread contamination in mail facilities
Transmission via mail-to-mail contaminationTransmission via mail-to-mail contamination
No person or group has claimed responsibilityNo person or group has claimed responsibility

29. ANTHRAX: EPIDEMIOLOGYANTHRAX: EPIDEMIOLOGY
 Agent:Agent: Bacillus anthracisBacillus anthracis, a Gram-positive,, a Gram-positive,
 spore forming non-motile bacillusspore forming non-motile bacillus
 (straightforward lab identification)(straightforward lab identification)
 ReservoirReservoir: Herbivores (cattle, goats,: Herbivores (cattle, goats,
sheep),sheep),
 capable of surviving in the environment forcapable of surviving in the environment for
prolonged periodsprolonged periods
 TransmissionTransmission
 Contact, ingestion, orContact, ingestion, or inhalation of infectiveinhalation of infective
sporesspores
 Sources of infection: Contaminated hides,Sources of infection: Contaminated hides,
wool, hair, bone, meat, or other animalwool, hair, bone, meat, or other animal
productsproducts

30. SVERDLOVSK ANTHRAX OUTBREAKSVERDLOVSK ANTHRAX OUTBREAK
 Site: Sverdlovsk, USSRSite: Sverdlovsk, USSR
 Year: 1979Year: 1979
 Cause: Accidental release fromCause: Accidental release from
military microbiologic facility –military microbiologic facility –
Military report noted: “FilterMilitary report noted: “Filter
clogged so I’ve removed it.clogged so I’ve removed it.
Replacement necessary”Replacement necessary”
 Transmission: AirborneTransmission: Airborne
 Impact: 68 human deaths, 79Impact: 68 human deaths, 79
human cases, multiple animalhuman cases, multiple animal
deaths (sheep, cowsdeaths (sheep, cows))

31. ANTHRAX: CLINICAL FEATURESANTHRAX: CLINICAL FEATURES
 Incubation period:Incubation period: 1-7 days1-7 days (1-60 days)(1-60 days)
 Clinical syndrome(s): Cutaneous ulcer,Clinical syndrome(s): Cutaneous ulcer, respiratoryrespiratory, gastrointestinal,, gastrointestinal,
oropharyngealoropharyngeal
 Inhalation anthrax = main threatInhalation anthrax = main threat
 Spores may germinate up to 60 days after exposureSpores may germinate up to 60 days after exposure
 LDLD5050 (human): 2,500 to 55,000 spores(human): 2,500 to 55,000 spores
 Bronchopneumonia not a component (hemorrhagic lymphadenitis andBronchopneumonia not a component (hemorrhagic lymphadenitis and
mediastinitis)mediastinitis)
 Early diagnosis difficultEarly diagnosis difficult

36. Anthrax: Cutaneous
Healing after treatment

37. Gastrointestinal Anthrax
Hemorrhagic meningitis at
autopsy. Photo courtesy of
USAMRIID

38. B. ANTHRACISB. ANTHRACIS MENINGITISMENINGITIS
Lesion on chin
CSF

39. INHALATION ANTHRAX: DIAGNOSISINHALATION ANTHRAX: DIAGNOSIS
 EpidemiologyEpidemiology
 Sudden appearance of multiple cases of severe flu illness with fulminantSudden appearance of multiple cases of severe flu illness with fulminant
course and high mortalitycourse and high mortality
 Clinical symptomsClinical symptoms
 Non-specific prodrome of flu-like symptomsNon-specific prodrome of flu-like symptoms
 Possible brief interim improvementPossible brief interim improvement
 Abrupt onset of respiratory failure and hemodynamic collapse 2-4 days afterAbrupt onset of respiratory failure and hemodynamic collapse 2-4 days after
initial symptoms, possibly accompanied by thoracic edema and a widenedinitial symptoms, possibly accompanied by thoracic edema and a widened
mediastinum on CxRmediastinum on CxR

40. INHALATION ANTHRAX: DIAGNOSISINHALATION ANTHRAX: DIAGNOSIS
 Diagnostic studiesDiagnostic studies
 Chest radiograph with widened mediastinumChest radiograph with widened mediastinum
 Peripheral blood smear with gram (+) bacilli onPeripheral blood smear with gram (+) bacilli on
unspun smearunspun smear
 MicrobiologyMicrobiology
 Blood culture growth of large gram (+) bacilliBlood culture growth of large gram (+) bacilli
with preliminary identification ofwith preliminary identification of Bacillus sppBacillus spp..
 PLET mediumPLET medium
 PathologyPathology
 Hemorrhagic mediastinitis, hemorrhagicHemorrhagic mediastinitis, hemorrhagic
thoracic lymphadenitis, hemorrhagic meningitisthoracic lymphadenitis, hemorrhagic meningitis
INHALATION ANTHRAX: CxRINHALATION ANTHRAX: CxR
Inhalational anthrax: CT scan

41. INHALATION ANTHRAX, US
Prominent superior mediastinum,
?small left pleural effusion
B. ANTHRACISB. ANTHRACIS: PERIPHERAL: PERIPHERAL
BLOOD SMEARBLOOD SMEAR

42. Cutaneous Anthrax, USCutaneous Anthrax, US
7 mo male infant hospitalized with 2 day7 mo male infant hospitalized with 2 day
history of swelling left arm and weepinghistory of swelling left arm and weeping
lesion at left elbow. Patient had been atlesion at left elbow. Patient had been at
his mother’s office at a TV network.his mother’s office at a TV network.
Biopsies yieldedBiopsies yielded B. anthracis.B. anthracis.

43. PlaguePlague
Public Health and ClinicalPublic Health and Clinical
FeaturesFeatures

44. IntroductionIntroduction
 Due to infection with theDue to infection with the
bacteriumbacterium
Yersinia pestisYersinia pestis
Several forms:Several forms:
 ––BubonicBubonic
 ––Primary septicemia/Primary septicemia/
secondarysecondary
pneumonicpneumonic
 ––Primary pneumonicPrimary pneumonic
PERIPHERAL BLOOD SMEARPERIPHERAL BLOOD SMEAR

47. Public Health FeaturesPublic Health Features
 Most cases in U.S. occur in southwestMost cases in U.S. occur in southwest
 Pneumonic plague can be transmittedPneumonic plague can be transmitted person toperson to
person via respiratory dropletsperson via respiratory droplets

48. PLAGUE: CLINICAL FEATURESPLAGUE: CLINICAL FEATURES
 Incubation period: 1-4 days (pneumonia), 1-7 days (bubonic orIncubation period: 1-4 days (pneumonia), 1-7 days (bubonic or
septicaemic)septicaemic)
 Clinical syndrome(s)Clinical syndrome(s)
 Bubonic, septicemic, pneumonic, cutaneous, meningitisBubonic, septicemic, pneumonic, cutaneous, meningitis
 Epidemiology and symptomsEpidemiology and symptoms
 Sudden onset fever, shortness of breath, hemoptysis, chest painSudden onset fever, shortness of breath, hemoptysis, chest pain
 Gastrointestinal symptoms common (N, V, diarrhea)Gastrointestinal symptoms common (N, V, diarrhea)
Fulminant course and high mortalityFulminant course and high mortality

49. Inguinal buboInguinal bubo Bubo – rupturedBubo – ruptured
inguinal lymph nodeinguinal lymph node

50. Axillary buboAxillary bubo
Femoral buboFemoral bubo

51. PLAGUE: CLINICAL MANIFESTATIONSPLAGUE: CLINICAL MANIFESTATIONS
Cervical
bubo
Ecchymosis,
septicemia
Gangrene, septicemia

52. PNEUMONIC PLAGUE: CxRPNEUMONIC PLAGUE: CxR

53. PLAGUE: CONTROLPLAGUE: CONTROL
 Laboratory precautions: BSL 2 (potentially infective clinical material), BSLLaboratory precautions: BSL 2 (potentially infective clinical material), BSL
3 (activities with high potential for droplet or aerosol production)3 (activities with high potential for droplet or aerosol production)
 Prophylaxis:Prophylaxis:
 Post-exposure: Doxycycline (alternatives ciprofloxacin or TMP-SMX)Post-exposure: Doxycycline (alternatives ciprofloxacin or TMP-SMX)
 CDC isolation guidelinesCDC isolation guidelines
 Bubonic: StandardBubonic: Standard
 Pneumonic: Droplet (until patient treated for 3 days)Pneumonic: Droplet (until patient treated for 3 days)

54. SMALLPOX: HISTORYSMALLPOX: HISTORY
 1754-67: Biological weapon French and Indian wars1754-67: Biological weapon French and Indian wars
 1796: Edward Jenner uses vaccinia for immunization1796: Edward Jenner uses vaccinia for immunization
 1967: WHO global eradication campaign1967: WHO global eradication campaign
 1972: US ceases routine vaccination1972: US ceases routine vaccination
 1977: Last case endemic smallpox (Somalia)1977: Last case endemic smallpox (Somalia)
 1978: Last laboratory acquired case (England)1978: Last laboratory acquired case (England)
 1982: Worldwide cessation of vaccination1982: Worldwide cessation of vaccination

55. SMALLPOX: VIROLOGYSMALLPOX: VIROLOGY
 Agent: Variola (family poxviridae)Agent: Variola (family poxviridae)
 8 genera in family8 genera in family
 Human infectious agentsHuman infectious agents
 Orthopoxviruses: Variola, varicella (chickenpox)Orthopoxviruses: Variola, varicella (chickenpox)
 Mullucipoxvirus: Mulluscum contagiosum virusMullucipoxvirus: Mulluscum contagiosum virus
 Nonhuman orthopoxviruses: Monkeypox, cowpox,Nonhuman orthopoxviruses: Monkeypox, cowpox,
canarypox, rabbitpox, etc.canarypox, rabbitpox, etc.

56. VARIOLA (SMALLPOX)VARIOLA (SMALLPOX)
 Large DNA VirusLarge DNA Virus
 Dumb bell shaped virusDumb bell shaped virus
 Complex membranesComplex membranes

58. SMALLPOX: EPIDEMIOLOGYSMALLPOX: EPIDEMIOLOGY
 Agent: Variola virusAgent: Variola virus
 Reservoir: HumansReservoir: Humans
 TransmissionTransmission
 Contact, droplet, and airborneContact, droplet, and airborne
 Transmission does not occur until the onset rashTransmission does not occur until the onset rash
 Maximum infectiousness, days 7-10 of rashMaximum infectiousness, days 7-10 of rash
 Increased infectiousness if patient coughing or has a hemorrhagicIncreased infectiousness if patient coughing or has a hemorrhagic
form of smallpoxform of smallpox

59. SMALLPOX: CLINICAL FEATURESSMALLPOX: CLINICAL FEATURES
 Incubation period: 12 days (7-17 days)Incubation period: 12 days (7-17 days)
 Clinical featuresClinical features
 Non-specific prodrome (2-4 days) of fever, mylagiasNon-specific prodrome (2-4 days) of fever, mylagias
 Rash most prominent on face and extremities (including palms andRash most prominent on face and extremities (including palms and
soles) in contrast to truncal distribution of varicellasoles) in contrast to truncal distribution of varicella
 Rash scabs over in 1-2 weeksRash scabs over in 1-2 weeks
 Variola rash has a synchronous onset (in contrast to the rash ofVariola rash has a synchronous onset (in contrast to the rash of
varicella which arises in crops)varicella which arises in crops)

60. SMALLPOX IN A CHILDSMALLPOX IN A CHILD

61. Classic Centrifugal Rash of Smallpox Involving Face
and Extremities. Photo courtesy of National
Archives

62. Smallpox in an adult
Nigeria, 1970
27 yo female
Lesions have a
peripheral distribution,
Facial edema, and
Uniform in terms of
Stage of development

63. SMALLPOX: DIAGNOSISSMALLPOX: DIAGNOSIS
 Appearance of rashAppearance of rash
 Hemorrhagic smallpox may be mistaken for meningococcemia orHemorrhagic smallpox may be mistaken for meningococcemia or
severe acute leukemiasevere acute leukemia
 Culture of lesionsCulture of lesions
 Should be obtained by immunized person; place specimen inShould be obtained by immunized person; place specimen in
vacutainer tube, tape juncture of stopper and tube, place in secondvacutainer tube, tape juncture of stopper and tube, place in second
durable, watertight containerdurable, watertight container
 Alert labAlert lab

64. SMALLPOX: CONTROLSMALLPOX: CONTROL
 Laboratory precautions: BSL 4Laboratory precautions: BSL 4
 Clothing/fomites: DecontaminateClothing/fomites: Decontaminate
 ProphylaxisProphylaxis
 Pre-exposure: VaccinePre-exposure: Vaccine
 Post-exposure: Vaccine (within 4 days) or vaccine plus VIG (>4Post-exposure: Vaccine (within 4 days) or vaccine plus VIG (>4
days); potential role for cidofovirdays); potential role for cidofovir
 Isolation: Contact plus airborneIsolation: Contact plus airborne

65. Vaccination With the Bifurcated NeedleVaccination With the Bifurcated Needle

66. EVOLVING PRIMARY VACCINATIONEVOLVING PRIMARY VACCINATION

68. Photo courtesy of CDC
Fatal case of Vaccinia necrosum
at inoculation site Accidental auto-inoculation of theAccidental auto-inoculation of the
eye witheye with VacciniaVaccinia virusvirus

69. VACCINIA VACCINE:VACCINIA VACCINE:
PRECAUTONS AND CONTRAINDICATIONSPRECAUTONS AND CONTRAINDICATIONS
 Severe allergic reaction to prior dose of vaccineSevere allergic reaction to prior dose of vaccine
 History or presence of eczema, other skin conditionsHistory or presence of eczema, other skin conditions
 Pregnancy (children in the household is not a contraindication)Pregnancy (children in the household is not a contraindication)
 Altered immocompetenceAltered immocompetence
 HIV, Leukemia, lymphoma, generalized malignancyHIV, Leukemia, lymphoma, generalized malignancy
 Solid organ transplant, BMTSolid organ transplant, BMT
 Corticosteroids, alkylating agents, antimetabolites, radiationCorticosteroids, alkylating agents, antimetabolites, radiation
 Cardiac diseaseCardiac disease
 AllergiesAllergies
 Neomycin, polymyxin b, tetracyclines, streptomycinNeomycin, polymyxin b, tetracyclines, streptomycin

70. VACCINIA VACCINE:VACCINIA VACCINE:
PREVENTION OF CONTACT TRANSMISSIONPREVENTION OF CONTACT TRANSMISSION
 Vaccinia virus can be cultured from primary vaccination site beginning at theVaccinia virus can be cultured from primary vaccination site beginning at the
time of development papule (2-5d after vaccination)time of development papule (2-5d after vaccination)
 Transmission via direct skin contact may occurTransmission via direct skin contact may occur
 Vaccination site should be covered with a porous bandage until scab hasVaccination site should be covered with a porous bandage until scab has
separated and underlying skin has healed (do not use an occlusive dressing)separated and underlying skin has healed (do not use an occlusive dressing)
 Use impermeable bandage when bathingUse impermeable bandage when bathing
 Vaccinated HCWs may continue to work (vaccination site covered withVaccinated HCWs may continue to work (vaccination site covered with
sterile gauze and semipermeable dressing, and practice of goodsterile gauze and semipermeable dressing, and practice of good
handwashing)handwashing)

72. Botulism ToxinBotulism Toxin
A major bioweapons threat because ofA major bioweapons threat because of
its extreme potency and lethalityits extreme potency and lethality
• The single most poisonous substance known.The single most poisonous substance known.
 Easy to produce, transport and misuseEasy to produce, transport and misuse
 The average incubation period is 12-72 hours afterThe average incubation period is 12-72 hours after
ingestion.ingestion.
Neurotoxin produced by
Clostridium botulinum
Most lethal substance known

73. Modes of transmissionModes of transmission
 No person-to-person transmissionNo person-to-person transmission
 Exposure typesExposure types
 Foodborne - Ingestion of toxinFoodborne - Ingestion of toxin
 Infant – Ingestion ofInfant – Ingestion of C. botulinumC. botulinum
 Wound – Infection withWound – Infection with C. botulinumC. botulinum
 Inhalation of aerosolized toxinInhalation of aerosolized toxin
 As BT agent may be aerosolized or added toAs BT agent may be aerosolized or added to
food or waterfood or water

74. • Patients with botulism typicallyPatients with botulism typically
present with difficulty speaking,present with difficulty speaking,
seeing and/or swallowing.seeing and/or swallowing.
 Prominent neurologic findings includeProminent neurologic findings include
ptsosis, diplopia, blurred vision,ptsosis, diplopia, blurred vision,
dysarthria and dysphagia.dysarthria and dysphagia.
 Patients typically are afebrile and doPatients typically are afebrile and do
not have an altered level ofnot have an altered level of
consciousness.consciousness.
 Patients may initially presentPatients may initially present withwith
gastrointestinal distress,gastrointestinal distress,
nausea, and vomiting preceding neurologicalnausea, and vomiting preceding neurological
symptoms.symptoms.
Six-week old infant with
botulism.

75. BotulismBotulism

76. BotulismBotulism
Symptoms:Symptoms:
 Acute, afebrile, symmetric, decending paralysis of facialAcute, afebrile, symmetric, decending paralysis of facial
musculature, multiple cranial nerve palsiesmusculature, multiple cranial nerve palsies
 Onset and severity dependent on amount of toxin absorbedOnset and severity dependent on amount of toxin absorbed
 Incubation variable 2 hrs to 8 days after ingestionIncubation variable 2 hrs to 8 days after ingestion
 Neurologic symptoms:Neurologic symptoms:
 Ptosis, diplopia, blurred vision, loss of head controlPtosis, diplopia, blurred vision, loss of head control
 Deep tendon reflexes diminishDeep tendon reflexes diminish
 Death results from airway obstruction;Death results from airway obstruction;
 Respiratory and diaphragmatic muscle paralysisRespiratory and diaphragmatic muscle paralysis
 Diagnosis:Diagnosis:
 Index of suspicion for botulism; clusters of casesIndex of suspicion for botulism; clusters of cases
 Treatment:Treatment:
 Supportive care and administration of passive equine antitoxinSupportive care and administration of passive equine antitoxin

77. Botulinum Toxin as a BioweaponBotulinum Toxin as a Bioweapon
 Aum Shinrikyo 1990, 1993, 1995: attempted aerosol dispersionAum Shinrikyo 1990, 1993, 1995: attempted aerosol dispersion
in Japanin Japan
 Japan WW II (Unit 731): fed cultures to prisoners in ChinaJapan WW II (Unit 731): fed cultures to prisoners in China
 US bioweapons programUS bioweapons program
 Soviet Union program: gene splicingSoviet Union program: gene splicing
 Iraq 19,000 liters weaponizedIraq 19,000 liters weaponized
 ? Iran, North Korea, Syria? Iran, North Korea, Syria

78. Viral Hemorrhagic FeversViral Hemorrhagic Fevers
 Arena VirusesArena Viruses
Lassa feverLassa fever
Argentine hemorrhagic feverArgentine hemorrhagic fever
Bolivian hemorrhagic feverBolivian hemorrhagic fever
 FlaviviridaeFlaviviridae
Yellow feverYellow fever
DengueDengue
 BunyaviridaeBunyaviridae
Crimean-Congo feverCrimean-Congo fever
 FilovirusesFiloviruses
Marburg Ebola hemorrhagic feversMarburg Ebola hemorrhagic fevers

79. Ebola and Marburg –Ebola and Marburg –
Etiologic agentsEtiologic agents
 FlioviridaeFlioviridae family virusesfamily viruses
 Among the most virulent viruses (25-90%Among the most virulent viruses (25-90%
case fatality depending on strain)case fatality depending on strain)
 ZoonoticZoonotic
 Humans are incidental hostsHumans are incidental hosts Marburg
Ebola

81. Clinical features - VHFClinical features - VHF
Severe multisystem syndromeSevere multisystem syndrome
 Overall vascular system damageOverall vascular system damage
 Body’s ability to regulate itself is impairedBody’s ability to regulate itself is impaired
 Often accompanied by hemorrhagic (in itself notOften accompanied by hemorrhagic (in itself not
usually life threatening)usually life threatening)

82. Ebola & Marburg Viruses -Ebola & Marburg Viruses -
clinical courseclinical course
 Sudden onset of flu-like illnessSudden onset of flu-like illness
 May progress to nausea, vomiting, diarrhea,May progress to nausea, vomiting, diarrhea,
abdominal pain, photophobia, maculopapularabdominal pain, photophobia, maculopapular
rash, DIC, internal and external hemorrhage,rash, DIC, internal and external hemorrhage,
multiorgan failure with jaundice and renalmultiorgan failure with jaundice and renal
insufficiencyinsufficiency

83. Atlanta, Georgia: Electron Micrograph: Ebola virus causing African
Hemorrhagic Fever. (Courtesy of the National Archives, 82-424)

84. Marburg & Ebola –Marburg & Ebola –
OccurrenceOccurrence
 Naturally occurring sporadic outbreaks in AfricaNaturally occurring sporadic outbreaks in Africa
 Cases have occurred in West as a result of exposure toCases have occurred in West as a result of exposure to
animal reservoirsanimal reservoirs
 BT potentialBT potential
 Russian biowarfare programRussian biowarfare program
 Iraq is believe to have triedIraq is believe to have tried

85. Ebola and Marburg - transmissionEbola and Marburg - transmission
 Direct contact with infected tissue and bodyDirect contact with infected tissue and body
fluids or contaminated objectsfluids or contaminated objects
 Probably aerosol inhalationProbably aerosol inhalation

86. Borio, et al JAMA consensus statement 2002
Maculopapular Rash in Marburg Disease
Ocular Manifestations in Bolivian Hemorrhagic Fever

87. Psychological and Social FactorsPsychological and Social Factors
during bioterrorismduring bioterrorism
1.1. HorrorHorror
2.2. AngerAnger
3.3. PanicPanic
4.4. Magical thinking about microbesMagical thinking about microbes
5.5. Fear of invisible agents Fear of contagionFear of invisible agents Fear of contagion
6.6. Anger at Terrorist/GovernmentAnger at Terrorist/Government
7.7. ScapegoatScapegoat
8.8. ParanoiaParanoia
9.9. Social isolationSocial isolation
10. Demoralization10. Demoralization
11. Loss of faith in social institutions11. Loss of faith in social institutions
12. Attribution of arousal symptoms to infection12. Attribution of arousal symptoms to infection

88. MANAGEMENT OF PEOPLE WITHMANAGEMENT OF PEOPLE WITH
PSYCHOLOGICAL PROBLEMSPSYCHOLOGICAL PROBLEMS
1.1. care of health workerscare of health workers
2.2. Critical incidence stress management (CISM) for rescue workersCritical incidence stress management (CISM) for rescue workers
3.3. Prevention of public fleeingPrevention of public fleeing
4.4. Confidence building by the medical workersConfidence building by the medical workers
5.5. Dealing with emotional and psychological problems while dealing with theDealing with emotional and psychological problems while dealing with the
dead.dead.
6.6. Care of emergency workers, medical and paramedical workersCare of emergency workers, medical and paramedical workers
7.7. Critical incidence of stress debriefing(CSID)Critical incidence of stress debriefing(CSID)

89. 8.Prevention of group panic8.Prevention of group panic
9. Avoidance of emotion based responses (Knee jerk9. Avoidance of emotion based responses (Knee jerk
quarantine)quarantine)
10. Effective risk communication10. Effective risk communication
11. Control of symptoms secondary to hyper arousal11. Control of symptoms secondary to hyper arousal
12. Reassurance12. Reassurance
13. Management of anger fear (Diazepam and other13. Management of anger fear (Diazepam and other
anxiolytic drugs)anxiolytic drugs)
14. Provision of respite as required14. Provision of respite as required
15. Social support of the community15. Social support of the community

90. Role of CliniciansRole of Clinicians
 Be prepared to diagnose and treat BTBe prepared to diagnose and treat BT
diseasesdiseases
 Keep alert to unusual disease patternsKeep alert to unusual disease patterns
 Use reportable disease system toUse reportable disease system to
alert public health officials of aalert public health officials of a
potential problempotential problem
 Get involved in disaster planningGet involved in disaster planning
processprocess

91. Clusters of patients with the sameClusters of patients with the same
disease or syndromedisease or syndrome
Especially when:Especially when:
 there is more cases than would be expectedthere is more cases than would be expected
 cases are geographically or temporally clusteredcases are geographically or temporally clustered
 the illness is unexplainedthe illness is unexplained
 there are multiple atypical presentations of the diseasethere are multiple atypical presentations of the disease
 the mortality or morbidity is higher than expectedthe mortality or morbidity is higher than expected

92. Even a single case may be a signalEven a single case may be a signal
 Caused by an uncommon agentCaused by an uncommon agent
 Unusual for region, age group or seasonUnusual for region, age group or season
 Fulminant disease in otherwise healthy patientFulminant disease in otherwise healthy patient
 Atypical presentationAtypical presentation

93. Other cluesOther clues
Similar genetic type of agent from distinctSimilar genetic type of agent from distinct
sourcessources
 Unusual, atypical, genetically engineered, orUnusual, atypical, genetically engineered, or
antiquated strainantiquated strain
Atypical aerosol, food, or water transmissionAtypical aerosol, food, or water transmission
Concurrent animal diseaseConcurrent animal disease

94. DETECTION OFDETECTION OF
OUTBREAKSOUTBREAKS
 RecognitionRecognition
• Syndrome criteriaSyndrome criteria
• Epidemiological featuresEpidemiological features
 CommunicationCommunication
 MedicalMedical
•Triage, psychological aspects, lab support, public informationTriage, psychological aspects, lab support, public information
•Patient isolation (Follow CDC guidelines), decontaminationPatient isolation (Follow CDC guidelines), decontamination
•Post-exposure prophylaxis, treatment of infected personsPost-exposure prophylaxis, treatment of infected persons

95. DETECTION OFDETECTION OF
OUTBREAKSOUTBREAKS
Epidemiologic featuresEpidemiologic features
 A rapidly increasing disease incidenceA rapidly increasing disease incidence
 An unusual increase in the number of people seeking care, esp. withAn unusual increase in the number of people seeking care, esp. with
fever, respiratory, or gastrointestinal symptomsfever, respiratory, or gastrointestinal symptoms
 An endemic disease rapidly emerging at an uncharacteristic time or inAn endemic disease rapidly emerging at an uncharacteristic time or in
an usual patternan usual pattern
 Lower attack rate among persons who had been indoorsLower attack rate among persons who had been indoors
 Clusters of patients arriving from a single localClusters of patients arriving from a single local
 Large numbers of rapidly fatal casesLarge numbers of rapidly fatal cases
 Any patient presenting with a disease that is relatively uncommon andAny patient presenting with a disease that is relatively uncommon and
has bioterrorism potentialhas bioterrorism potential

96. DETECTION AND IDENTIFICATIONDETECTION AND IDENTIFICATION
OF BIOWEAPON AGENTOF BIOWEAPON AGENT
1.1. The conventional microbiological methods viz., culture,The conventional microbiological methods viz., culture,
immunodetection, serology, molecular identification take longimmunodetection, serology, molecular identification take long
time (hours to days)time (hours to days)
2.2. Several biodetectors (bioluminometer) based on the principlesSeveral biodetectors (bioluminometer) based on the principles
of bioluminescence and biofluorescence are being developedof bioluminescence and biofluorescence are being developed
__ Fire fly luciferage geneFire fly luciferage gene..
3.3. There are various types ofThere are various types of biosensors such as immunosensors,biosensors such as immunosensors,
nucleic acid sensors, tissue based sensors and laser sensorsnucleic acid sensors, tissue based sensors and laser sensors

97. EMERGINGEMERGING INFECTIONS ANDINFECTIONS AND
BIOTERRORISMBIOTERRORISM
 New diseases have also appeared within the developed nations includingNew diseases have also appeared within the developed nations including
United States. Some of these include:United States. Some of these include:
 Lyme diseaseLyme disease
 Legionnaires’ diseaseLegionnaires’ disease
 New variant of Creutzfeldt -Jakob diseaseNew variant of Creutzfeldt -Jakob disease
 West-Nile virus diseaseWest-Nile virus disease
 Hantavirus pulmonary syndrome (HPS)Hantavirus pulmonary syndrome (HPS)
 Multi-drug resistant TB,Multi-drug resistant TB,
 Antibiotic resistant staphylococcal, enterococcal and pneumococcalAntibiotic resistant staphylococcal, enterococcal and pneumococcal
infectionsinfections
 Diarrhoeal diseases caused by the parasiteDiarrhoeal diseases caused by the parasite Cryptosporidium parvumCryptosporidium parvum andand
then certain strains ofthen certain strains of Escherichia coliEscherichia coli bacteria.bacteria.

98. Factors contribute to the emergence and re-Factors contribute to the emergence and re-
emergence of infectious diseasesemergence of infectious diseases
1. Unprecedented worldwide population growth draining the natu1. Unprecedented worldwide population growth draining the naturalral
resourcesresources
2. Overcrowding in cities with poor sanitation2. Overcrowding in cities with poor sanitation
3. Rapid and increased international travel3. Rapid and increased international travel
4. Increased international trade in animals and food products4. Increased international trade in animals and food products
5. Mass distribution of food and unhygienic food preparation5. Mass distribution of food and unhygienic food preparation practicespractices
6. Increased exposure of humans to disease vectors and reservoirs in nature6. Increased exposure of humans to disease vectors and reservoirs in nature
7. Man-made changes to the environment and climatic changes which have7. Man-made changes to the environment and climatic changes which have
a direct impact on the population of insect vectors and animala direct impact on the population of insect vectors and animal
reservoirs.reservoirs.
7. Misuse of antibiotics leading to the evolution of resistant microbes.7. Misuse of antibiotics leading to the evolution of resistant microbes.

99. Impact of biological agents on nationalImpact of biological agents on national
economieseconomies
 Highly pathogenic avian influenza, Hong KongHighly pathogenic avian influenza, Hong Kong
The outbreak of highly pathogenic avian influenzaThe outbreak of highly pathogenic avian influenza
(HPAI) type A (H5N1) in live market chickens in Hong(HPAI) type A (H5N1) in live market chickens in Hong
Kong resulted in 6 million deaths and killing of 1.4Kong resulted in 6 million deaths and killing of 1.4
million birds.million birds.

100. Nipah virus, MalaysiaNipah virus, Malaysia
 Nipah virus, a previously un known virus wasNipah virus, a previously un known virus was
identified in 1998, primarily inidentified in 1998, primarily in pigs and in humanspigs and in humans inin
Malaysia.Malaysia.
 The virus caused over 250 human cases resulting in 100The virus caused over 250 human cases resulting in 100
deaths. Approximately 1 million pigs were killed. Otherdeaths. Approximately 1 million pigs were killed. Other
countries in the region banned he importation of porkcountries in the region banned he importation of pork
products.products.
 Malaysia authorities blamed the disease on a deliberateMalaysia authorities blamed the disease on a deliberate
attack by rival Asian countries trying to slowdownattack by rival Asian countries trying to slowdown
Malaysia’s recovery from the Asian Economic Crisis ofMalaysia’s recovery from the Asian Economic Crisis of
the 1997.the 1997.

101. Foot and Mouth disease, TaiwanFoot and Mouth disease, Taiwan
 The 1997 Foot and mouth disease outbreak in Taiwan had aThe 1997 Foot and mouth disease outbreak in Taiwan had a
devasting effect on export oriented pork industry.devasting effect on export oriented pork industry.
 The virus is believed to have been brought into TaiwanThe virus is believed to have been brought into Taiwan
through smuggled animals, meat products or illegalthrough smuggled animals, meat products or illegal
immigrants from mainland China.immigrants from mainland China.
 The epizootic resulted in the depopulation of 3.8 million pigs.The epizootic resulted in the depopulation of 3.8 million pigs.
 At one point the outbreak it was blamed asAt one point the outbreak it was blamed as deliberate introduction ofdeliberate introduction of
FMD into Taiwan by mainland China. The economic impact on TaiwanFMD into Taiwan by mainland China. The economic impact on Taiwan
has been estimated in the billions of dollars.has been estimated in the billions of dollars.

103. ConclusionsConclusions
 Less developed nations can produce biological weapons that are as lethal asLess developed nations can produce biological weapons that are as lethal as
nuclear weapons include: Iran, Iraq, Israel, North Korea, China, Libya, Syrianuclear weapons include: Iran, Iraq, Israel, North Korea, China, Libya, Syria
and Taiwan.and Taiwan.
 Recent terrorist activities in India underscores it’s vulnerability toRecent terrorist activities in India underscores it’s vulnerability to
bioterrorism and the need for a comprehensive plan to defend against anbioterrorism and the need for a comprehensive plan to defend against an
attack.attack.
 Currently, it does not have the infrastructure to quickly detect and identifyCurrently, it does not have the infrastructure to quickly detect and identify
many pests and pathogens nor is the country able to respond to even small-many pests and pathogens nor is the country able to respond to even small-
scale attack.scale attack.

104. TERRORISM TODAY