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NURSING IN THE ERA OF NURSING IN THE ERA OF BIOTERRORISMBIOTERRORISM
Accurate informationAccurate information
is the best defense againstis the best defense against
panic and confusionpanic and confusion
in the event of a crisis.in the event of a crisis.
Definition of Definition of BioterrorismBioterrorism
Premeditated Premeditated threatthreat or actual use of or actual use of biological weapons to produce disease or biological weapons to produce disease or death in people, animals, or plants.death in people, animals, or plants.
Biological weapons: microbes or their toxins.Biological weapons: microbes or their toxins.
Biological WeaponsBiological Weapons
Bioterrorism OverviewBioterrorism Overview
Microorganisms or their toxins can be in liquid Microorganisms or their toxins can be in liquid or powder form.or powder form.
Various delivery methods are possible:Various delivery methods are possible: aerosolaerosol envelope or packageenvelope or package food or water contaminationfood or water contamination
Exposure can be isolated to a single area or Exposure can be isolated to a single area or can be more widespread.can be more widespread.
BioterrorismBioterrorism
Microorganisms as biologic weapons Microorganisms as biologic weapons would most likely result in illness would most likely result in illness occurring days to weeks after attack occurring days to weeks after attack and would affect persons dispersed and would affect persons dispersed from the site.from the site.
Biological Agents:Biological Agents:Types and Types and
CharacteristicsCharacteristics
BacteriaBacteria
VirusesViruses
Biological ToxinsBiological Toxins
CDC CategoriesCDC Categories
Category A:Category A: easily disseminated OR transmitted easily disseminated OR transmitted
person to personperson to person susceptible populationsusceptible population potential for panic / disruptionpotential for panic / disruption requires special action for treatmentrequires special action for treatment high morbidity and mortalityhigh morbidity and mortality examples: examples: anthraxanthrax, , smallpoxsmallpox, , plagueplague, ,
botulismbotulism, , viral hemorrhagic feversviral hemorrhagic fevers
CDC CategoriesCDC Categories Category B:Category B: moderately easy to disseminatemoderately easy to disseminate
moderate morbidity, low mortalitymoderate morbidity, low mortality examples: Q fever, brucellosis, glanders, examples: Q fever, brucellosis, glanders,
some toxinssome toxins
Category C:Category C: emerging pathogens that could be engineered emerging pathogens that could be engineered
for mass dissemination in the futurefor mass dissemination in the future potential for high morbidity and mortalitypotential for high morbidity and mortality examples: hantavirus, tickborne viruses, MDR examples: hantavirus, tickborne viruses, MDR
TBTB
Isolation PrecautionsIsolation Precautions
StandardStandard (“blood and body fluid”): (“blood and body fluid”): glovesgloves mask with face shieldmask with face shield gowngown
Airborne:Airborne: standard plus negative pressure room and N95 mask standard plus negative pressure room and N95 mask
(“duckbill mask”)(“duckbill mask”)
HANDWASHINGHANDWASHING
Gram positive bacillus that forms Gram positive bacillus that forms sporesspores
Spores found in soil worldwideSpores found in soil worldwide Humans usually infected by Humans usually infected by
contact with infected animals or contact with infected animals or contaminated animal productscontaminated animal products
No person-to-person No person-to-person transmission of inhalation transmission of inhalation anthraxanthrax
Anthrax: OverviewAnthrax: Overview
Anthrax: CutaneousAnthrax: Cutaneous
Most common form (95%)Most common form (95%)
Inoculation of spores in skinInoculation of spores in skin
Incubation: hours to daysIncubation: hours to days
Progression:Progression:11. small papule. small papule2. ulcer surrounded by vesicles2. ulcer surrounded by vesicles3. painless eschar with edema3. painless eschar with edema
Death:Death:• untreated – 20%untreated – 20%• treated – raretreated – rare
Anthrax: Anthrax: GastrointestinalGastrointestinal
Ingestion of contaminated meatIngestion of contaminated meat
Fever, vomiting, bloody diarrheaFever, vomiting, bloody diarrhea
Intestinal eschar similar to Intestinal eschar similar to cutaneous anthrax lesioncutaneous anthrax lesion
Progression to general toxemiaProgression to general toxemia
Mortality 50% despite treatmentMortality 50% despite treatment
Anthrax TestingAnthrax Testing Nasal Swab:Nasal Swab:
A tool for epidemiology, not diagnosisA tool for epidemiology, not diagnosis Limitations:Limitations:
positive test indicates exposure, not infectionpositive test indicates exposure, not infection false positives have been seen (positive test does not false positives have been seen (positive test does not
prove infection)prove infection) false negatives (negative test does not rule out false negatives (negative test does not rule out
anthrax infection)anthrax infection)
Anthrax TestingAnthrax Testing Nasal Swab:Nasal Swab:
A tool for epidemiology, A tool for epidemiology, not diagnosisnot diagnosis Limitations:Limitations:
positive test indicates exposure, not infectionpositive test indicates exposure, not infection false positives have been seen (positive test false positives have been seen (positive test
does not prove infection)does not prove infection) false negatives (negative test does not rule out false negatives (negative test does not rule out
anthrax infection)anthrax infection)
Serologic tests:Serologic tests: Available at special labs but not used for routine Available at special labs but not used for routine
screeningscreening
Anthrax TestingAnthrax Testing Nasal Swab:Nasal Swab:
A tool for epidemiology, not diagnosisA tool for epidemiology, not diagnosis Limitations:Limitations:
positive test indicates exposure, not infectionpositive test indicates exposure, not infection false positives have been seenfalse positives have been seen negative test does not rule out anthrax infectionnegative test does not rule out anthrax infection
Serologic tests:Serologic tests: Available at special labs but not used for routine screeningAvailable at special labs but not used for routine screening
Blood cultures:Blood cultures: Probably best test for symptomatic individual at riskProbably best test for symptomatic individual at risk
ANTHRAX: TreatmentANTHRAX: Treatment Inhalation anthrax Inhalation anthrax oror cutaneous anthrax with systemic cutaneous anthrax with systemic
involvement:involvement:
ciprofloxacin (400mg, IV, q12h) ciprofloxacin (400mg, IV, q12h) oror doxycycline (100 mg, doxycycline (100 mg, IV, q12h)IV, q12h)
combine with one of the following:combine with one of the following:
rifampin, vancomycin, penicillin, ampicillin, clindamycin, rifampin, vancomycin, penicillin, ampicillin, clindamycin, clarithromycinclarithromycin
Treat for 60 daysTreat for 60 days
Anthrax: Other TreatmentAnthrax: Other Treatment
Uncomplicated cutaneous anthrax:Uncomplicated cutaneous anthrax: Cipro (500 mg, po, bid) or doxycycline (100 Cipro (500 mg, po, bid) or doxycycline (100
mg, po,mg, po, bid) bid)
Prophylaxis for exposure:Prophylaxis for exposure: Cipro (500 mg, po, bid) or doxycycline (100 Cipro (500 mg, po, bid) or doxycycline (100
mg, po, bid)mg, po, bid) Children or breastfeeding mothers: Children or breastfeeding mothers:
amoxicillinamoxicillin Levoquin- adults 18 and olderLevoquin- adults 18 and older
Treat for 60 daysTreat for 60 days
2.2 KG’S OF ANTHRAX SPRINKLED 2.2 KG’S OF ANTHRAX SPRINKLED FROM A 20FROM A 20THTH FLOOR HIGH RISE IN FLOOR HIGH RISE IN NEW YORK CITY WOULD KILL / NEW YORK CITY WOULD KILL / INFECT OVER 120,000 PEOPLEINFECT OVER 120,000 PEOPLE
Plague: OverviewPlague: Overview
Yersinia pestis (gram-Yersinia pestis (gram-
negative coccobacillus)negative coccobacillus)
About 10 U.S. cases/yr (SW)About 10 U.S. cases/yr (SW)
Two major formsTwo major forms
Very contagious via Very contagious via
respiratory dropletsrespiratory droplets
Plague EpidemicsPlague Epidemics
3 major recorded epidemics:3 major recorded epidemics: 550, 1350 (Black Death), 1850 (China)550, 1350 (Black Death), 1850 (China)
30% - 60% mortality in infected 30% - 60% mortality in infected continentscontinents
PlaguePlague
GOOD NEWS:GOOD NEWS: future epidemics unlikely due to sanitation, future epidemics unlikely due to sanitation,
public health practices, and antibiotics.public health practices, and antibiotics.
BAD NEWS:BAD NEWS: US and Russia and other countries have US and Russia and other countries have
developed techniques to aerosolize plague, developed techniques to aerosolize plague, eliminating need for fleas to spread the infection.eliminating need for fleas to spread the infection.
Plague as a BioweaponPlague as a Bioweapon
Infected fleas could spread bubonic form (less Infected fleas could spread bubonic form (less likely scenario)likely scenario)
Aerosolized organisms would spread Aerosolized organisms would spread pneumonic form (more likely scenario)pneumonic form (more likely scenario)
Plague: BubonicPlague: Bubonic
Bite from infected fleaBite from infected flea Sudden onset flu-like syndromeSudden onset flu-like syndrome
Buboes:Buboes: tender, enlarged lymph nodes tender, enlarged lymph nodes
(inguinal, axillary, cervical)(inguinal, axillary, cervical)
Can spread to lungs Can spread to lungs (hematogenous)(hematogenous)
Can also lead to endotoxic Can also lead to endotoxic septicemic phasesepticemic phase
Plague: PneumonicPlague: Pneumonic
Inhalation of organisms Inhalation of organisms (aerosol)(aerosol)
Incubation: 1-3 daysIncubation: 1-3 days
Sudden onset flu-like syndrome Sudden onset flu-like syndrome
Pneumonia progresses rapidly Pneumonia progresses rapidly to hypoxemia, cyanosis, to hypoxemia, cyanosis, hemoptysishemoptysis
Endotoxin: septic shock with Endotoxin: septic shock with DIC, ARDS, deathDIC, ARDS, death
Plague Disease Plague Disease ComplexComplex
Inhalational of plague organisms
Flu-likeSyndrome
Sudden onset
2 -3 days
Plague Disease Plague Disease ComplexComplex
Fulminant Pneumonia
Flu-likeSyndrome
Sudden onset
productive coughbilateral infiltratescyanosis
2 -3 days
24 hrs
Inhalational of plague organisms
Plague Disease Plague Disease ComplexComplex
ARDS DIC
Fulminant Pneumonia
Flu-likeSyndrome
Sudden onset
2 -3 days
24 hrs
Inhalational of plague organisms
Plague Disease Plague Disease ComplexComplex
ARDS DIC
Fulminant Pneumonia
Flu-likeSyndrome
Sudden onset
2 -3 days
24 hrs
Inhalational of plague organisms
Endotoxemia
Respiratory failureCirculatory collapse
Plague Disease Plague Disease ComplexComplex
ARDS DIC
Fulminant Pneumonia
Flu-likeSyndrome
Sudden onset
2 -3 days
24 hrs
Inhalational of plague organisms
Endotoxemia
Respiratory failureCirculatory collapse
Flu-like syndrome
Tender buboes
2 - 10 days
Pneumonic Plague:Pneumonic Plague:Isolation precautionsIsolation precautions
SECONDARY SECONDARY TRANSMISSION IS TRANSMISSION IS POSSIBLE - EASILY POSSIBLE - EASILY
USE STANDARD AND USE STANDARD AND AIRBORNE AIRBORNE PRECAUTIONSPRECAUTIONS
Management / Management / ProphylaxisProphylaxis
Antibiotic therapy Antibiotic therapy IV amino glycoside and IV doxycyclineIV amino glycoside and IV doxycycline Ciprofloxacin Ciprofloxacin
Antibiotic resistant strains existAntibiotic resistant strains exist
Supportive measuresSupportive measures
Prophylaxis for respiratory droplet Prophylaxis for respiratory droplet exposure:exposure: oral doxycycline or oral ciprofloxacin for 7-10 oral doxycycline or oral ciprofloxacin for 7-10
daysdays vaccine - no longer manufactured in U.S.vaccine - no longer manufactured in U.S.
Plague:Plague:Diagnostic TestsDiagnostic Tests
No widely available rapid testsNo widely available rapid tests
Gram stain of body fluids or lymph node Gram stain of body fluids or lymph node aspirate may reveal gram-negative organismsaspirate may reveal gram-negative organisms
Blood cultures should be positive within 2 days.Blood cultures should be positive within 2 days.
Confirmatory testing via government labs Confirmatory testing via government labs (antigen detection, immunoassays, and PCR)(antigen detection, immunoassays, and PCR)
Viruses as BioweaponsViruses as Bioweapons
Viral Hemorrhagic Viral Hemorrhagic
Fevers:Fevers: EbolaEbola
LassaLassa
MarburgMarburg
SmallpoxSmallpox
Viral Hemorrhagic FeversViral Hemorrhagic Fevers
Group of illnesses caused by several RNA Group of illnesses caused by several RNA virusesviruses
All can be used as bioweaponsAll can be used as bioweapons
Examples: Ebola, Marburg, LassaExamples: Ebola, Marburg, Lassa
Mortality can be very high (90% for Ebola)Mortality can be very high (90% for Ebola)
VHF: OccurrenceVHF: Occurrence Naturally occurring infections can occur via Naturally occurring infections can occur via
transmission from infected rodents and transmission from infected rodents and arthropodsarthropods
Readily transmissible from person to person Readily transmissible from person to person via body fluids:via body fluids: great risk for healthcare workersgreat risk for healthcare workers
VHF very rare in US:VHF very rare in US: usually travelers to endemic areasusually travelers to endemic areas
CURRENT OUTBREAKCURRENT OUTBREAK
Current outbreak in AfricaCurrent outbreak in Africa
80-89% MORTALITY80-89% MORTALITY
VHF: PathophysiologyVHF: Pathophysiology Variable incubation (2-21 days)Variable incubation (2-21 days)
Flu-like symptoms with high feverFlu-like symptoms with high fever
Increased vascular permeability causes:Increased vascular permeability causes: hemorrhage in GI tract and mucous membraneshemorrhage in GI tract and mucous membranes petechial or ecchymotic rashpetechial or ecchymotic rash edemaedema hypotensionhypotension
Rapid progression to shock and deathRapid progression to shock and death
VHF: Lab TestingVHF: Lab Testing
No widely available rapid testsNo widely available rapid tests
Government labs can provide nucleic acid Government labs can provide nucleic acid assaysassays
Routine labs reveal clotting abnormalities:Routine labs reveal clotting abnormalities: elevated PT and PTT, decreased plateletselevated PT and PTT, decreased platelets
VHF: TreatmentVHF: Treatment Supportive treatmentSupportive treatment IV ribavirin used occasionally for Lassa IV ribavirin used occasionally for Lassa
fever.fever. Vaccines under developmentVaccines under development Postexposure prophylaxis with oral Postexposure prophylaxis with oral
ribavirin may be usefulribavirin may be useful
Contact and respiratory Contact and respiratory precautions necessaryprecautions necessary
SmallpoxSmallpox Variola virusVariola virus
Characteristic skin lesionsCharacteristic skin lesions
About 30% mortality in unvaccinatedAbout 30% mortality in unvaccinated
Last known natural case: Somalia in 1977Last known natural case: Somalia in 1977
Smallpox as a Smallpox as a BioweaponBioweapon
Can be aerosolizedCan be aerosolized Highly contagiousHighly contagious No effective treatmentNo effective treatment Vaccination ceased in 70’sVaccination ceased in 70’s Stable in the environment (contamination Stable in the environment (contamination
for months)for months)
Smallpox: PathophysiologySmallpox: Pathophysiology
Virus inhaled or deposited on mucous Virus inhaled or deposited on mucous membranesmembranes
Goes to lymph nodes, incubates for 7-17 daysGoes to lymph nodes, incubates for 7-17 days Release into blood causes flu-like symptomsRelease into blood causes flu-like symptoms Rash begins 2-3 days laterRash begins 2-3 days later Death due to toxemia of viral antigens and Death due to toxemia of viral antigens and
circulating immune complexescirculating immune complexes
Smallpox: Skin lesionsSmallpox: Skin lesions Macular (flat, red) rash 2-3 days after flu Macular (flat, red) rash 2-3 days after flu
symptomssymptoms Starts on face, forearms, hands (+ palms Starts on face, forearms, hands (+ palms
and soles)and soles) Rash evolves synchronously in an areaRash evolves synchronously in an area Evolves into tense vesiclesEvolves into tense vesicles Scabs form in 7-10 days if patient livesScabs form in 7-10 days if patient lives Infectious until all scabs are shed.Infectious until all scabs are shed.
Day 3 Day 5 Day 7Day 3 Day 5 Day 7
Chickenpox with characteristic rose-colored macules, papules, vesicles, pustules, necrotic pustules, and crusted lesions occurring simultaneously.
Herpes zoster (varicella virus) withcharacteristic grouping of vesicles
Herpes zoster showing dermatomal distribution of lesions
ProdromeProdrome yesyes minimal or minimal or nonenone
Smallpox vs. ChickenpoxSmallpox vs. Chickenpox
Smallpox Chickenpox
ProdromeProdrome yesyes minimal or minimal or nonenone
Distribution Distribution out to inout to in in to outin to out
Smallpox vs. ChickenpoxSmallpox vs. Chickenpox
Smallpox Chickenpox
ProdromeProdrome yesyes minimal or noneminimal or none
Distribution Distribution out to inout to in in to outin to out
LesionsLesions painfulpainful / deep / deep pruritic / superficialpruritic / superficial
ProgressionProgression synchronoussynchronous asynchronousasynchronous
Palms / SolesPalms / Soles yesyes nono
Smallpox vs. ChickenpoxSmallpox vs. Chickenpox
Smallpox Chickenpox
Smallpox vs. Smallpox vs. ChickenpoxChickenpox
Smallpox: DiagnosisSmallpox: Diagnosis
CLINICAL PRESENTATION AND PATIENT CLINICAL PRESENTATION AND PATIENT HISTORY IS THE KEY TO DIAGNOSISHISTORY IS THE KEY TO DIAGNOSIS
No widely available rapid testNo widely available rapid test Electron microscopy to confirm presence of Electron microscopy to confirm presence of
variola virus particlesvariola virus particles
Smallpox:Smallpox:Treatment and ProphylaxisTreatment and Prophylaxis
No effective treatmentNo effective treatment Animal trials with cidofovir are promisingAnimal trials with cidofovir are promising Vaccinia immune globulin may be usefulVaccinia immune globulin may be useful Vaccination within 3-4 days of Vaccination within 3-4 days of ALLALL potential potential
contacts may prevent or lessen diseasecontacts may prevent or lessen disease
Smallpox: PrecautionsSmallpox: Precautions Airborne and Contact IsolationAirborne and Contact Isolation
Airborne Isolation:Airborne Isolation: negative pressure roomnegative pressure room anteroomanteroom closed ventilation systemclosed ventilation system N95 mask (Duckbill mask)N95 mask (Duckbill mask)
Contact Isolation:Contact Isolation: strict use of PPE and handwashingstrict use of PPE and handwashing
Smallpox: PrecautionsSmallpox: Precautions
Patients may be cohortedPatients may be cohorted
Laundry kept separate and in Red BagLaundry kept separate and in Red Bag Limit number of personnel in contactLimit number of personnel in contact Mask patient if in-hospital transportMask patient if in-hospital transport Contacts placed under 18 day fever Contacts placed under 18 day fever
surveillance (>100.5 reportable)surveillance (>100.5 reportable)
Smallpox VaccineSmallpox Vaccine
Vaccination in U.S. ended in 1972 except Vaccination in U.S. ended in 1972 except military personnelmilitary personnel
Not known if previous vaccination is Not known if previous vaccination is protective nowprotective now
Not a benign vaccine: side effects and Not a benign vaccine: side effects and fatalitiesfatalities
Possibly MANY deaths if given to all in USPossibly MANY deaths if given to all in US
Smallpox VaccineSmallpox Vaccine Vaccine is for vaccinia, a closely related and more Vaccine is for vaccinia, a closely related and more
benign virusbenign virus Vaccine contraindicated in some, Vaccine contraindicated in some, unless exposure unless exposure
has occurredhas occurred: : Immunosuppressed (hiv / cancer/transplant patientsImmunosuppressed (hiv / cancer/transplant patients chronic steroid usage (eyedrops)chronic steroid usage (eyedrops) eczema or chronic exfoliative skin disorderseczema or chronic exfoliative skin disorders pregnancypregnancy age under 18age under 18 CARDIAC DISEASE- Mi’s / Myopathy / AnginaCARDIAC DISEASE- Mi’s / Myopathy / Angina
Smallpox VaccineSmallpox Vaccine Virus sheds from vaccine site for up Virus sheds from vaccine site for up
to 6 weeksto 6 weeks Shedding can infect household Shedding can infect household
contacts with vacciniacontacts with vaccinia Some serious vaccine reactions:Some serious vaccine reactions:
encephalitis, severe vaccinia, encephalitis, severe vaccinia, anaphylaxis, Stevens-Johnsonanaphylaxis, Stevens-Johnson
Auto-inoculation of orifices can occurAuto-inoculation of orifices can occur
AUTO-INNOCULATIONAUTO-INNOCULATION
NEW JERSEY CLINICSNEW JERSEY CLINICS
NORTHWESTNORTHWEST- - Sussex/Passaic/Warren/MorrisSussex/Passaic/Warren/Morris St Joe’sSt Joe’s and ID Associatesand ID Associates
NORTHEASTNORTHEAST- Bergen/Essex/Hudson- Bergen/Essex/Hudson Hackensack / UMDNJ- NewarkHackensack / UMDNJ- Newark
CENTRALEAST- CENTRALEAST- Middlesex/Union/Monmouth/OceanMiddlesex/Union/Monmouth/Ocean Raritan Bay Medical CenterRaritan Bay Medical Center
CENTRALWESTCENTRALWEST- - Somerset/Mercer/ HunterdonSomerset/Mercer/ Hunterdon Hunterdon HospitalHunterdon Hospital
South- South- Camden/Burlington/Atlantic/SalemCamden/Burlington/Atlantic/Salem Our Lady of Lourdes and Shore Our Lady of Lourdes and Shore
HospitalsHospitals
VACCINATION REPORTVACCINATION REPORT
HEALTH CARE WORKERS HEALTH CARE WORKERS NEW JERSEY- 619NEW JERSEY- 619 NYC- 138NYC- 138 PENNSYLVANIA- 67PENNSYLVANIA- 67 NEVADA – 0NEVADA – 0 MINNESOTA- 1439MINNESOTA- 1439 TENNESSEE- 2407 TENNESSEE- 2407
VACCINATORSVACCINATORS
NEW JERSEY - 50NEW JERSEY - 50
FEDERAL VACCINATION PROGRAM FEDERAL VACCINATION PROGRAM IS NOW ON “HOLD”IS NOW ON “HOLD”
BIOLOGICAL TOXINSBIOLOGICAL TOXINS
BOTULINUM – BO-TOXBOTULINUM – BO-TOX
RICINRICIN
STAPHYLOOCCAL ENTEROTOXIN B (not STAPHYLOOCCAL ENTEROTOXIN B (not
reviewed)reviewed)
T-2 MYCOTOXINS (not reviewed)T-2 MYCOTOXINS (not reviewed)
RICINRICIN
Botulinum ToxinBotulinum Toxin 7 neurotoxins produced by Clostridium botulinum7 neurotoxins produced by Clostridium botulinum Among the most toxic substances knownAmong the most toxic substances known May be found in naturally contaminated foodMay be found in naturally contaminated food As a bioweapon, likely to be delivered by aerosolAs a bioweapon, likely to be delivered by aerosol
No person-to-person transmissionNo person-to-person transmission Multiple cases without common food source Multiple cases without common food source
suggests bioterrorismsuggests bioterrorism
Botulinum Toxin:Botulinum Toxin:Mechanism of ActionMechanism of Action
Site: neuromuscular junction (pre-synaptic)Site: neuromuscular junction (pre-synaptic)
Action: binds at acetylcholine release sites to Action: binds at acetylcholine release sites to prevent releaseprevent release
Effect: muscle weakness (skeletal and cranial Effect: muscle weakness (skeletal and cranial nerve distribution)nerve distribution)
Does not cross the blood-brain barrier:Does not cross the blood-brain barrier: patients remain alert and afebrilepatients remain alert and afebrile
Botulinum Toxin:Botulinum Toxin:Clinical FindingsClinical Findings
Botulism onset: about 1-3 daysBotulism onset: about 1-3 days
Cranial nerve palsies early:Cranial nerve palsies early: Eye: blurred vision, photophobia, diplopia, ptosisEye: blurred vision, photophobia, diplopia, ptosis Throat: dysarthria, dysphagiaThroat: dysarthria, dysphagia
Skeletal muscle weakness later:Skeletal muscle weakness later: symmetrical, descending, progressivesymmetrical, descending, progressive abrupt respiratory failureabrupt respiratory failure
Botulinum Toxin:Botulinum Toxin:Differential DiagnosisDifferential Diagnosis
Differential Diagnosis:Differential Diagnosis: tetanus, myasthenia gravis, Guillain-tetanus, myasthenia gravis, Guillain-
BarreBarre
Botulism differentiated by:Botulism differentiated by: more cranial nerve involvementmore cranial nerve involvement facial muscles more involved than facial muscles more involved than
below neckbelow neck lack of sensory changeslack of sensory changes
Botulinum Toxin: LabBotulinum Toxin: Lab
Laboratory testing:Laboratory testing: generally not helpfulgenerally not helpful detection of toxin in serum is detection of toxin in serum is
possiblepossible
Botulinum Toxin: TreatmentBotulinum Toxin: Treatment
Do not wait for lab confirmationDo not wait for lab confirmation Administer antitoxin:Administer antitoxin:
available from CDC but very limited suppliesavailable from CDC but very limited supplies only binds to circulating toxin to prevent progressiononly binds to circulating toxin to prevent progression will not reverse symptoms already presentwill not reverse symptoms already present anaphylaxis and serum sickness may resultanaphylaxis and serum sickness may result do not prophylax exposed but asymptomatic do not prophylax exposed but asymptomatic
patientspatients Respiratory support necessaryRespiratory support necessary Recovery takes weeks to monthsRecovery takes weeks to months
RICINRICIN
RicinRicin
Potent protein toxin derived from castor beansPotent protein toxin derived from castor beans
Easily produced / Recently found in FranceEasily produced / Recently found in France
Inhibits protein synthesisInhibits protein synthesis
Causes necrotizing airway lesions:Causes necrotizing airway lesions: tracheitistracheitis bronchitis and bronchiolitisbronchitis and bronchiolitis interstitial pneumonia with ARDSinterstitial pneumonia with ARDS
RicinRicin
Inhalation as an aerosol produces Inhalation as an aerosol produces severe respiratory symptoms:severe respiratory symptoms: day 1: cough, fever, dyspneaday 1: cough, fever, dyspnea day 2-3: pulmonary edema, resp failure, deathday 2-3: pulmonary edema, resp failure, death
Specific serum test is availableSpecific serum test is available
No treatment available other than No treatment available other than supportivesupportive
Chemical WeaponsChemical Weapons
Chemical WeaponsChemical Weapons
Nerve agentsNerve agents Vessicants (blistering Vessicants (blistering
agents)agents) Pulmonary agentsPulmonary agents Blood agents (cyanide)Blood agents (cyanide) Riot Control agentsRiot Control agents
Nerve AgentsNerve Agents Most toxic of all the synthetic chemical agents.Most toxic of all the synthetic chemical agents. Very similar to organophosphate insecticides.Very similar to organophosphate insecticides. Death within minutes when inhaled or absorbed Death within minutes when inhaled or absorbed
through skin.through skin. Developed in WW2 by Germany but not used.Developed in WW2 by Germany but not used. U.S. completed development after WW2.U.S. completed development after WW2.
Examples:Examples:
SARINSARIN
Nerve Agents: EffectsNerve Agents: Effects
Smooth muscle hyper Smooth muscle hyper stimulationstimulation
Glandular hyper stimulationGlandular hyper stimulation
Skeletal muscle hyper Skeletal muscle hyper stimulationstimulation
Nerve Agents: EffectsNerve Agents: Effects Smooth muscle hyper Smooth muscle hyper
stimulation:stimulation:
vomiting and diarrheavomiting and diarrhea urinationurination bronchospasmbronchospasm small pupils (miosis)small pupils (miosis)
Nerve Agents: EffectsNerve Agents: Effects Glandular hyper stimulation:Glandular hyper stimulation:
salivationsalivation lacrimationlacrimation increased airway secretionsincreased airway secretions increased GI secretionsincreased GI secretions
Nerve Agents: EffectsNerve Agents: Effects
Skeletal muscle hyper stimulation at Skeletal muscle hyper stimulation at first:first: FasciculationsFasciculations
Later, skeletal muscle exhaustion:Later, skeletal muscle exhaustion: weakness followed by flaccid paralysisweakness followed by flaccid paralysis
Nerve Agents: EffectsNerve Agents: Effects
SLUDGESLUDGE reaction: reaction: SSalivationalivation LLacrimationacrimation UUrinationrination DDefecationefecation GGeneralized twitchingeneralized twitching EEmesismesis
Nerve Agents:Nerve Agents:DecontaminationDecontamination
Removal of contaminated clothingRemoval of contaminated clothing Copious irrigation and washing with Copious irrigation and washing with
soap and watersoap and water
BIOSUITS- NO CONTACT WITH BIOSUITS- NO CONTACT WITH AGENTAGENT
Mark 1Mark 1Nerve Agent Nerve Agent Antidote KitAntidote Kit
ATROPINEATROPINEPROTOPAMPROTOPAM
VALIUMVALIUM
Sources ofSources ofRadioactive MaterialRadioactive Material
High-level sources (plutonium, uranium):High-level sources (plutonium, uranium): nuclear power plantsnuclear power plants and weapons sites and weapons sites high security; more difficult to obtain and handlehigh security; more difficult to obtain and handle
Low-level sources (cobalt-60, strontium-90, Low-level sources (cobalt-60, strontium-90, cesium-137, americium-241):cesium-137, americium-241): hospitalshospitals construction sitesconstruction sites food irradiation plantsfood irradiation plants smoke detectorssmoke detectors
Key Point: AvoidanceKey Point: Avoidance
Avoidance prevents or minimizes effects:Avoidance prevents or minimizes effects:
TIME:TIME: decrease time near source of radiationdecrease time near source of radiation
DISTANCE:DISTANCE: increase distance from sourceincrease distance from source
SHIELDING:SHIELDING: increase barriers between you increase barriers between you and sourceand source
DecontaminationDecontamination
Spray light water mist on clothes to Spray light water mist on clothes to decrease radioactive dustdecrease radioactive dust
Remove clothes (up to 90% decrease in Remove clothes (up to 90% decrease in radioactivity exposure)radioactivity exposure)
Washing skin and hair with soapy waterWashing skin and hair with soapy water
TreatmentTreatment
Potassium Iodide:Potassium Iodide:
may prevent thyroid cancer after radiation may prevent thyroid cancer after radiation exposureexposure
NJ dispensed it to those who live within 10 mi. of NJ dispensed it to those who live within 10 mi. of nuclear plantnuclear plant
blocks thyroid uptake of radioactive iodineblocks thyroid uptake of radioactive iodine
TreatmentTreatment Depends on specific radioactive substance and Depends on specific radioactive substance and
mode of exposure (inhaled, ingested, skin).mode of exposure (inhaled, ingested, skin).
Call Poison Control if available.Call Poison Control if available.
Meticulously clean contaminated wounds.Meticulously clean contaminated wounds.
For ingestions, lavage, laxatives, and ion-For ingestions, lavage, laxatives, and ion-exchange resins may be indicated.exchange resins may be indicated.
Bombing FrequencyBombing Frequency
Worldwide, 50% of terrorist attacks are Worldwide, 50% of terrorist attacks are bombings.bombings.
In U.S., over 85% of terrorist attacks are In U.S., over 85% of terrorist attacks are bombings.bombings.
• Dramatic, low risk, draw attentionDramatic, low risk, draw attention• Few skills neededFew skills needed• Can execute attack remotelyCan execute attack remotely• Large groups not requiredLarge groups not required• Components readily availableComponents readily available• Forensic evidence difficult to identify, collect and Forensic evidence difficult to identify, collect and
assembleassemble
Why Use Explosives?Why Use Explosives?
BOMB COOKBOOKBOMB COOKBOOK
HUNDREDS OF SITES ON HUNDREDS OF SITES ON INTERNETINTERNET
BOOKS-BOOKS- “ “Bombs for Dummies”Bombs for Dummies”
Most supplies available in home Most supplies available in home depot and garden shopsdepot and garden shops
““Dirty Bombs”Dirty Bombs” A type of radiological dispersion device.A type of radiological dispersion device.
Combines conventional explosives with Combines conventional explosives with radioactive materials in the form of powder radioactive materials in the form of powder or pellets.or pellets.
Disperses radioactive material.Disperses radioactive material.
Causes fear and contaminates land and Causes fear and contaminates land and buildings for prolonged periodsbuildings for prolonged periods..
““Dirty Bombs”Dirty Bombs”
Dangers of dirty bombs:Dangers of dirty bombs: if low-level radioactive sources used, primary danger is if low-level radioactive sources used, primary danger is
blast itselfblast itself gauging degree of radioactive contamination due to gauging degree of radioactive contamination due to
fallout is difficultfallout is difficult most probable sources would not provide enough most probable sources would not provide enough
radiation to cause acute radiation sicknessradiation to cause acute radiation sickness environmental contaminationenvironmental contamination
REMEMBER-REMEMBER-
REPORT ANY SUSPICIOUS ILLNESSESREPORT ANY SUSPICIOUS ILLNESSES CLUSTERING OF CASESCLUSTERING OF CASES UNUSUAL NUMBERS OF PATIENTS WITH UNUSUAL NUMBERS OF PATIENTS WITH
SAME COMPLAINTSSAME COMPLAINTS
SUSPECTED BIOLOGICAL INCIDENTS- SUSPECTED BIOLOGICAL INCIDENTS- REPORTABLE: FOLLOW HANDOUTREPORTABLE: FOLLOW HANDOUT
1- LOCAL AND / OR STATE DOH1- LOCAL AND / OR STATE DOH 2- LOCAL / STATE POLICE / FBI2- LOCAL / STATE POLICE / FBI 3- BIOTERRORISM TASK FORCE3- BIOTERRORISM TASK FORCE 4- CDC – FEDERAL TASK FORCE- ETC4- CDC – FEDERAL TASK FORCE- ETC