Identification of Bioterrorism Agents Rashid A. Chotani, M.D., MPH Assistant Professor of Medicine & Public Health Director, Global Infectious Disease

Identification of Bioterrorism Agents

Identification of Bioterrorism Agents

Rashid A. Chotani, M.D., MPHAssistant Professor of Medicine & Public HealthDirector, Global Infectious Disease Surveillance

& Alert SystemJohns Hopkins University

President, Pakistan Public Health [email protected]

GIDSAS

mailto:[email protected]

Chotani, 2003Chotani, 2003

History of Biological WarfareHistory of Biological Warfare

66thth Century BC – Assyrians poison the wells of Century BC – Assyrians poison the wells of their enemies with rye ergottheir enemies with rye ergot

66thth Century BC – Solon of Athens poisons the Century BC – Solon of Athens poisons the water supply with hellebore (skunk cabbage) an water supply with hellebore (skunk cabbage) an herb purgative, during the siege of Krissaherb purgative, during the siege of Krissa

184 BC – Hannibal forces hurled earthen pots 184 BC – Hannibal forces hurled earthen pots filled with serpents upon enemyfilled with serpents upon enemy

1346 – Tatar army hurls its plague ridden dead 1346 – Tatar army hurls its plague ridden dead over the walls of the cityover the walls of the city

1422 – Battle of Carolstein, bodies of plague 1422 – Battle of Carolstein, bodies of plague ridden soldiers plus 2000 cartloads of ridden soldiers plus 2000 cartloads of excrement are hurled into the enemy ranksexcrement are hurled into the enemy ranks



14th Century: Plague at Kaffa14th Century: Plague at Kaffa



1515thth Century – Pizarrio’s army Century – Pizarrio’s army presented South American natives presented South American natives clothing laden with the variola clothing laden with the variola virusvirus

1710 – Russian troops hurl the 1710 – Russian troops hurl the corpses of plague victims over the corpses of plague victims over the city wall (Russian – Sweden war)city wall (Russian – Sweden war)


History of Biological History of Biological Warfare - USWarfare - US 18th Century: Smallpox Blankets18th Century: Smallpox Blankets


History of Biological History of Biological Warfare - USWarfare - US

20th Century:20th Century:– 1943:1943:USA bio program launchedUSA bio program launched

– 1953:1953:BioBio Defensive programDefensive programestablishedestablished

– 1969:1969:Bio Offensive programBio Offensive program

disbandeddisbanded


History of Biological History of Biological Warfare - GloballyWarfare - Globally

19251925 Geneva ProtocolGeneva Protocol 19721972 Biological WeaponsBiological Weapons

ConventionConvention– signed by 103 nationssigned by 103 nations

19751975 Geneva ConventionsGeneva Conventions

RatifiedRatified


Biological Terrorism - Biological Terrorism - A New Trend?A New Trend?Biological Terrorism - Biological Terrorism - A New Trend?A New Trend?

1978:1978: Bulgarian exile injected with ricin in Bulgarian exile injected with ricin in LondonLondon 1979:1979: Sverdlovosk, USSR – accidental anthrax Sverdlovosk, USSR – accidental anthrax released released

– 40 fatalities – 40 fatalities 1984: 1984: Oregon, Oregon, SalmonellaSalmonella – Rajneeshee cult – Rajneeshee cult 1991: 1991: Minnesota, ricin toxinMinnesota, ricin toxin 1994: 1994: Tokyo, Sarin and biological attacksTokyo, Sarin and biological attacks 1995: 1995: Arkansas, ricin toxinArkansas, ricin toxin 1995: 1995: Indiana, Indiana, Y. pestisY. pestis purchase purchase 1997: 1997: Washington DC, ‘Anthrax/plague’ hoaxWashington DC, ‘Anthrax/plague’ hoax 1998: 1998: Nevada , nonlethal strain of Nevada , nonlethal strain of B. anthracisB. anthracis 1998-9: 1998-9: Multiple ‘Anthrax’ hoaxes Multiple ‘Anthrax’ hoaxes 2001:2001: Anthrax Outbreak USAAnthrax Outbreak USA


Bioterrorism BasicsBioterrorism Basics

Definition:Definition: The unlawful use, or The unlawful use, or threatened use, of microorganisms threatened use, of microorganisms or toxins derived from living or toxins derived from living organisms to produce death or organisms to produce death or disease in humans, animals, or disease in humans, animals, or plants. The act is intended to create plants. The act is intended to create fear and/or intimidate governments fear and/or intimidate governments or societies in pursuit of political, or societies in pursuit of political, religious, or ideological goals.religious, or ideological goals.


Bioterrorism BasicsBioterrorism BasicsWhat makes the use of biological agents so attractive to What makes the use of biological agents so attractive to the terrorist?the terrorist?

– Ease of AcquisitionEase of Acquisition Information readily accessible on World Wide WebInformation readily accessible on World Wide Web American Type Culture Collection, other sourcesAmerican Type Culture Collection, other sources

– Ease and Economy of ProductionEase and Economy of Production Only basic microbiology equipment necessaryOnly basic microbiology equipment necessary Small labs require no special licensingSmall labs require no special licensing Investment to cause 50% casualty rate per sq. km:Investment to cause 50% casualty rate per sq. km:

Conventional weapon $2000, nuclear $800, anthrax $1Conventional weapon $2000, nuclear $800, anthrax $1

– LethalityLethality 50 kg aerosolized anthrax = 100,000 mortality50 kg aerosolized anthrax = 100,000 mortality Sverdlovsk experience, former USSRSverdlovsk experience, former USSR



What makes the use of biological agents so What makes the use of biological agents so attractive to the terrorist?attractive to the terrorist?

– StabilityStability– InfectivityInfectivity

Weaponized agents may be easily spreadWeaponized agents may be easily spread Clinical symptoms days to weeks after releaseClinical symptoms days to weeks after release

– Low VisibilityLow Visibility– Ease and Stealth of DeliveryEase and Stealth of Delivery

Remote, delayed, undetectable releaseRemote, delayed, undetectable release Difficult/impossible to trace origin of agentDifficult/impossible to trace origin of agent



Routes of Delivery for Biological AgentsRoutes of Delivery for Biological Agents

Aerosol is most likely method of disseminationAerosol is most likely method of dissemination

Easy, silent dispersalEasy, silent dispersal

Maximum number of victims exposedMaximum number of victims exposed

Inhalation is most efficient and contagious Inhalation is most efficient and contagious route of infectionroute of infection

Food/Water-borne dispersal less likelyFood/Water-borne dispersal less likely

Less stable, ineffective for some agentsLess stable, ineffective for some agents

Inefficient compared to aerosolInefficient compared to aerosol



Events Suggesting the Release of a Events Suggesting the Release of a BioweaponBioweapon

Multiple people ill at the same time Multiple people ill at the same time (epidemic)(epidemic)

Previously healthy persons affectedPreviously healthy persons affected High morbidity and mortality among High morbidity and mortality among

affected individualsaffected individuals Identification of diseases and pathogens Identification of diseases and pathogens

unusual to a particular regionunusual to a particular region Recent terrorist claims or activityRecent terrorist claims or activity Unexplained epizootic of sick or dead Unexplained epizootic of sick or dead

animalsanimals



Events Suggesting the Release of a BioweaponEvents Suggesting the Release of a Bioweapon Severe respiratory disease in a healthy hostSevere respiratory disease in a healthy host An epidemic curve rising and falling rapidlyAn epidemic curve rising and falling rapidly Increase in fever, respiratory, and GI symptomsIncrease in fever, respiratory, and GI symptoms Lower attacks rates in people working indoors vs. Lower attacks rates in people working indoors vs.

outdoorsoutdoors Seasonal disease during a different time of year Known pathogen with unusual antimicrobial

resistance pattern Genetically-identical pathogen in different areas


Bioterrorism BasicsBioterrorism BasicsWhat Can We Do As Medical Professionals?What Can We Do As Medical Professionals? Maintain a high index of suspicion by including Maintain a high index of suspicion by including

biological agents in differential diagnosesbiological agents in differential diagnoses

Learn to recognize historical and physical examination Learn to recognize historical and physical examination findings suggestive of bioweapon exposurefindings suggestive of bioweapon exposure

Stay informed of local, regional and national Stay informed of local, regional and national epidemiologic trendsepidemiologic trends

Be knowledgeable about treatment and prophylaxis of Be knowledgeable about treatment and prophylaxis of patients exposed to biological agentspatients exposed to biological agents

Know whom to report suspected biological agent Know whom to report suspected biological agent exposures and illnesses to (Police, State Intelligence exposures and illnesses to (Police, State Intelligence agency, Infectious Disease Specialists, Local and State agency, Infectious Disease Specialists, Local and State Health Officials)Health Officials)


Agents of BioterrorismAgents of Bioterrorism

Bacterial AgentsBacterial Agents

Bacillus anthracis Bacillus anthracis ((AnthraxAnthrax))

Yersinia pestis Yersinia pestis (Plague)(Plague)

Francisella tularensis Francisella tularensis (Tularemia)(Tularemia)

Brucella spp. Brucella spp. (Brucellosis)(Brucellosis)

Coxiella burnetii Coxiella burnetii (Q Fever)(Q Fever)

Burkholderia mallei Burkholderia mallei (Glanders)(Glanders)

Vibrio cholerae Vibrio cholerae (Cholera)(Cholera)



Viral AgentsViral AgentsVariola virus (Variola virus (SmallpoxSmallpox))Venezuelan Equine Encephalitis Virus Venezuelan Equine Encephalitis Virus (VEE)(VEE)Hemorrhagic Fever Viruses: Ebola, Hemorrhagic Fever Viruses: Ebola, Marburg, Lassa Fever, Argentine and Marburg, Lassa Fever, Argentine and Bolivian Hemorrhagic Fever Viruses, Bolivian Hemorrhagic Fever Viruses, Hantavirus, Congo-Crimean Virus, Rift Hantavirus, Congo-Crimean Virus, Rift Valley Fever Virus, Yellow Fever Virus, Valley Fever Virus, Yellow Fever Virus, Dengue VirusDengue Virus



Biological ToxinsBiological ToxinsBotulinum ToxinsBotulinum Toxins

Staphylococcal Enterotoxin BStaphylococcal Enterotoxin B

RicinRicin

Mycotoxins (T2)Mycotoxins (T2)

Agent TypeMinimum Dose

Incubation period

Initial Symptoms

Duration of illness Lethality

Animal Indicator

Anthrax Bacteria8,000 (spores) 1-6 days Flu-like 3-5 days High 90% Yes

Plague Bacteria100 organisms 2-3 days

Pneumonia / Flu-like 1-6 days High 90-100% Yes

Tuleramia Bacteria 10 organisms2-10 days (avg. 3-5) Flu-like >=2 w eeks

Moderate 5-30% Yes

Brucellosis Bacteria 10 organisms 5-60 days Flu-likeWeeks to months Low 2-10% Yes

Q Fever Rickettsia 1 organisms 10-40 days Flu-like 2-14 days Low 4% Yes

Smallpox Virus 10 organisms7-17 days (avg. 12) Flu-like 4 w eeks High 30%

Animal Varients

Encephalitides VEE, EEE, WEE Virus 10 organisms 2-6 days Flu-like

days to w eeks low Yes

Hemorrhagic Fevers Ebola, Marburg Virus 1 organism 4-21days Flu-like 7-16 days

High Marburg 25% Ebola 50-90% Yes

Botulinum Toxin 100 ng 1-5 daysmuscle w eakness 24-72 hours High 30% Yes

Characteristics of BT AgentsCharacteristics of BT AgentsCharacteristics of BT AgentsCharacteristics of BT Agents



AnthraxAnthrax Caused by contact with spores of Caused by contact with spores of Bacillus Bacillus

anthracisanthracis, a spore-forming, gram-positive rod, a spore-forming, gram-positive rod

Three distinct forms of clinical illness:Three distinct forms of clinical illness:– CutaneousCutaneous by inoculation of skin lesions with by inoculation of skin lesions with

spores; common, easily recognized and treatedspores; common, easily recognized and treated– InhalationInhalation by inhalation of spores into the lower by inhalation of spores into the lower

respiratory tract; rare, difficult to recognize, respiratory tract; rare, difficult to recognize, > > 80% mortality (classic description = 80% mortality (classic description = Woolsorter’s disease)Woolsorter’s disease)

– GastrointestinalGastrointestinal by ingestion of spores in by ingestion of spores in contaminated meat; rarely encountered but contaminated meat; rarely encountered but highly lethalhighly lethal


Cutaneous AnthraxCutaneous Anthrax• A nondescript, painless, pruritic papule A nondescript, painless, pruritic papule

develops develops 3 to 5 days3 to 5 days after introduction of after introduction of B. B. anthracisanthracis endospores endospores

• In In 24 to 36 hours24 to 36 hours, the lesion forms a vesicle , the lesion forms a vesicle that undergoes central necrosis and drying, that undergoes central necrosis and drying, leaving a characteristic black eschar leaving a characteristic black eschar surrounded by edema and a number of surrounded by edema and a number of purplish vesicles: resolves without scarringpurplish vesicles: resolves without scarring

• 80-90% resolve without treatment, but mortality 80-90% resolve without treatment, but mortality can approach 20%, so cases usually treatedcan approach 20%, so cases usually treated


Anthrax: Cutaneous

Day 4Day 6

Day 10

Eschar formation

Vesicle Vesicle developmentdevelopment

Day 2Day 2


Left, Forearm lesion on day 7—vesiculation and ulceration of initial macular or papular anthrax skin lesion. Right, Eschar of the neck on day 15 of illness, typical of the last stage of the lesion. From Binford CH, Connor DH, eds. Pathology of Tropical and Extraordinary Diseases. Vol 1. Washington, DC: AFIP; 1976:119. AFIP negative 71-1290–2.

Anthrax: Cutaneous


NEJM 1999; 341: 815– 826

Anthrax: Cutaneous


Anthrax: Cutaneous

Healing after treatment


Anthrax: Cutaneous

Notice the edema and typical lesions


Cutaneous Anthrax: Diagnosis Cutaneous Anthrax: Diagnosis

Gram stain, polymerase chain Gram stain, polymerase chain reaction (PCR), or culture of vesicular reaction (PCR), or culture of vesicular fluid, exudate, or escharfluid, exudate, or eschar

Blood culture if systemic symptoms Blood culture if systemic symptoms presentpresent

Biopsy for immunohistochemistry, Biopsy for immunohistochemistry, especially if person taking especially if person taking antimicrobialsantimicrobials


Spider biteSpider bite Ecthyma gangrenosumEcthyma gangrenosum Ulceroglandular tularemiaUlceroglandular tularemia PlaguePlague Staphylococcal or streptococcal Staphylococcal or streptococcal

cellulitiscellulitis Herpes simplex virusHerpes simplex virus

Differential DiagnosisDifferential Diagnosisof Cutaneous Anthraxof Cutaneous AnthraxDifferential DiagnosisDifferential Diagnosisof Cutaneous Anthraxof Cutaneous Anthrax


Inhalational AnthraxInhalational Anthrax

PathogenesisPathogenesis• 1-5 micron 1-5 micron Anthrax Anthrax spore size is optimal spore size is optimal

for deposition into alveolifor deposition into alveoli• Inhaled spores are ingested by alveolar Inhaled spores are ingested by alveolar

macrophages and transported to macrophages and transported to mediastinal and peribronchial lymph mediastinal and peribronchial lymph nodes, spores germinating en routenodes, spores germinating en route

• AnthraxAnthrax bacilli multiply in lymph nodes, bacilli multiply in lymph nodes, causing hemorrhagic mediastinitis, and causing hemorrhagic mediastinitis, and spread throughout the body in the bloodspread throughout the body in the blood



Inhalational AnthraxInhalational Anthrax

Clinical PresentationClinical Presentation• 10 days to 6 weeks after inhalation of spores, 10 days to 6 weeks after inhalation of spores,

infected patients develop fever, non-infected patients develop fever, non-productive cough, myalgia and malaiseproductive cough, myalgia and malaise

• Early in the course of the disease, chest Early in the course of the disease, chest radiographs show a widened mediastinum, radiographs show a widened mediastinum, which is evidence of hemorrhagic which is evidence of hemorrhagic mediastinitis, and marked pleural effusionsmediastinitis, and marked pleural effusions

• After 1-3 days, the disease takes a fulminant After 1-3 days, the disease takes a fulminant course with dyspnea, strident cough, and course with dyspnea, strident cough, and chills, culminating in hypotension, shock, and chills, culminating in hypotension, shock, and deathdeath


Mediastinal wideningJAMA 1999;281:1735–1745

Anthrax: Inhalational


Mediastinal Widening and Pleural Effusion on Chest X-Ray in Inhalational Anthrax


Inhaltional Anthrax: Diagnosis Inhaltional Anthrax: Diagnosis

Chest X-ray—widened Chest X-ray—widened mediastinum, pleural effusions, mediastinum, pleural effusions, infiltrates, pulmonary congestioninfiltrates, pulmonary congestion

Affected tissue biopsy for Affected tissue biopsy for immunohistochemistryimmunohistochemistry

Any available sterile site fluidAny available sterile site fluid for for Gram stain, PCR, or cultureGram stain, PCR, or culture

Pleural fluid cell block for Pleural fluid cell block for immunohistochemistryimmunohistochemistry


Mycoplasmal Mycoplasmal pneumoniapneumonia

Legionnaires’ Legionnaires’ diseasedisease

PsittacosisPsittacosis TularemiaTularemia Q feverQ fever

Viral pneumoniaViral pneumonia Histoplasmosis Histoplasmosis

(fibrous (fibrous mediastinitis)mediastinitis)

CoccidioidomycosisCoccidioidomycosis MalignancyMalignancy

Differential Diagnosis of Inhalational AnthraxDifferential Diagnosis of Inhalational Anthrax


Gastrointestinal AnthraxGastrointestinal Anthrax

• Fever and diffuse abdominal pain with Fever and diffuse abdominal pain with rebound tenderness develop 2-5 days rebound tenderness develop 2-5 days after ingestion of spores in after ingestion of spores in contaminated meatcontaminated meat

• Melenic or blood-tinged stools, blood-Melenic or blood-tinged stools, blood-tinged or coffee-ground emesis, and tinged or coffee-ground emesis, and ascites developascites develop

• Death results from fluid and electrolyte Death results from fluid and electrolyte imbalances, blood loss, shock, imbalances, blood loss, shock, intestinal perforation or anthrax toxemiaintestinal perforation or anthrax toxemia


Gastrointestinal AnthraxGastrointestinal Anthrax


Gastrointestinal Anthrax: Gastrointestinal Anthrax: DiagnosisDiagnosis Gastrointestinal Anthrax: Gastrointestinal Anthrax: DiagnosisDiagnosis

Blood cultures Oropharyngeal (OP) swab

collection

Documents

Identification of Bioterrorism Agents Rashid A. Chotani, M.D., MPH Assistant Professor of Medicine & Public Health Director, Global Infectious Disease