chapter 109
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Chapter 109. Potential Weapons of Biologic, Radiologic, and Chemical Terrorism. Potential Weapons of Terrorism. Bacteria Viruses Biotoxins Chemical weapons Nerve agents and mustard gas Radiologic weapons. Bacteria and Viruses. Anthrax Bacillus anthracis - PowerPoint PPT PresentationTRANSCRIPT
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Chapter 109Chapter 109
Potential Weapons of Potential Weapons of Biologic, Radiologic, and Chemical Biologic, Radiologic, and Chemical
TerrorismTerrorism
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Potential Weapons of TerrorismPotential Weapons of Terrorism BacteriaBacteria VirusesViruses BiotoxinsBiotoxins Chemical weapons Chemical weapons
Nerve agents and mustard gasNerve agents and mustard gas Radiologic weaponsRadiologic weapons
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Bacteria and VirusesBacteria and Viruses AnthraxAnthrax
Bacillus anthracisBacillus anthracis • Aerobic gram-positive bacteriumAerobic gram-positive bacterium
Dormant form viable for decadesDormant form viable for decades Inhalational, cutaneous, gastrointestinal Inhalational, cutaneous, gastrointestinal Enters the body via the skin or mucous Enters the body via the skin or mucous
membranes of the respiratory tractmembranes of the respiratory tract Not transmitted person to person Not transmitted person to person
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Inhalational AnthraxInhalational Anthrax Anthrax spores deposit in alveolar spaceAnthrax spores deposit in alveolar space Even with treatment, mortality can be highEven with treatment, mortality can be high Clinical latency 2 days-4 weeksClinical latency 2 days-4 weeks
Mature bacilli release toxinsMature bacilli release toxins• Hemorrhage, edema, and necrosisHemorrhage, edema, and necrosis• If toxins reach critical level, antibiotics cannot prevent deathIf toxins reach critical level, antibiotics cannot prevent death
Initial symptomsInitial symptoms Fever, cough, malaise, weaknessFever, cough, malaise, weakness
Second stage (2-3 days later)Second stage (2-3 days later) Sudden increase in fever, severe respiratory distress, Sudden increase in fever, severe respiratory distress,
septicemia, hemorrhagic meningitis, and shocksepticemia, hemorrhagic meningitis, and shock
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Cutaneous AnthraxCutaneous Anthrax Symptoms 1-7 days after exposure to sporesSymptoms 1-7 days after exposure to spores
Broken skin most vulnerableBroken skin most vulnerable Injury can develop anywhere spores landInjury can develop anywhere spores land Initial lesion Initial lesion –– small papule or vesicle associated with local small papule or vesicle associated with local
itchingitching• 2 days – lesion enlarges into painless ulcer with necrotic core2 days – lesion enlarges into painless ulcer with necrotic core• 7-10 days after symptoms – black eschar forms, then dries, 7-10 days after symptoms – black eschar forms, then dries,
loosens, and sloughs off by days 12-14loosens, and sloughs off by days 12-14 In most cases lesions resolve without complications In most cases lesions resolve without complications
or scarringor scarring Treatment is usually successful, but 20% die without Treatment is usually successful, but 20% die without
antibiotic treatmentantibiotic treatment
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Treatment of Anthrax Infection Treatment of Anthrax Infection RespiratoryRespiratory
IV ciprofloxacin IV ciprofloxacin IV doxycycline IV doxycycline
CutaneousCutaneous Oral ciprofloxacin Oral ciprofloxacin Oral doxycyclineOral doxycycline
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Pre-Exposure VaccinationPre-Exposure Vaccination BioThrax (formerly known as Anthrax Vaccine BioThrax (formerly known as Anthrax Vaccine
Adsorbed, or AVA)Adsorbed, or AVA) Licensed for use in U.S.Licensed for use in U.S. Inactivated cell-free preparationInactivated cell-free preparation 3 subQ injections 2 weeks apart, then at 6, 12, 3 subQ injections 2 weeks apart, then at 6, 12,
and 18 monthsand 18 months Persons at high risk should be vaccinatedPersons at high risk should be vaccinated
• Military personnel, those who handle animal products Military personnel, those who handle animal products from anthrax-endemic areas, including veterinarians, lab from anthrax-endemic areas, including veterinarians, lab workers, othersworkers, others
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Postexposure ProphylaxisPostexposure Prophylaxis Oral antibiotics + anthrax vaccineOral antibiotics + anthrax vaccine Vaccine at 0, 2, and 4 weeksVaccine at 0, 2, and 4 weeks BioThrax not currently licensed for BioThrax not currently licensed for
postexposurepostexposure
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Francisella tularensisFrancisella tularensis (Tularemia) (Tularemia) “Rabbit Fever” and “Deer Fly Fever”“Rabbit Fever” and “Deer Fly Fever”
Potentially fatalPotentially fatal Skin, mucous membranes, GI tract, or lungsSkin, mucous membranes, GI tract, or lungs Acute flu-like symptoms initiallyAcute flu-like symptoms initially Pneumonia and pleuritis can developPneumonia and pleuritis can develop TreatmentTreatment
IM streptomycin, gentamicinIM streptomycin, gentamicin Mass outbreak – oral doxycycline or ciprofloxacinMass outbreak – oral doxycycline or ciprofloxacin
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Pneumonic PlaguePneumonic Plague Transmitted person to personTransmitted person to person Acquired by inhaling aerosolized Acquired by inhaling aerosolized Yersinia Yersinia
pestispestis With no treatment, rapidly progresses to With no treatment, rapidly progresses to
respiratory failure and death respiratory failure and death Treatment is streptomycin (IM) and Treatment is streptomycin (IM) and
gentamicin (IM or IV)gentamicin (IM or IV)
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SmallpoxSmallpox No proven treatmentNo proven treatment Highly contagious; fatality rate 30% Highly contagious; fatality rate 30% ACAM2000 approved vaccineACAM2000 approved vaccine Imvamune (in clinical trials)Imvamune (in clinical trials) Vaccine produces high level of immunity for 5 Vaccine produces high level of immunity for 5
to 10 years (before exposure or within a few to 10 years (before exposure or within a few days of exposure)days of exposure)
Pathogenesis and clinical manifestationsPathogenesis and clinical manifestations TransmissionTransmission
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Smallpox Vaccine Smallpox Vaccine Adverse effectsAdverse effects
Mild effectsMild effects• Local inflammation, along with swelling and tenderness in Local inflammation, along with swelling and tenderness in
regional lymph nodesregional lymph nodes• Transient symptoms (fever, headache, muscle aches, fatigue)Transient symptoms (fever, headache, muscle aches, fatigue)
Moderate to severeModerate to severe• Eczema vaccinatum, generalized vaccinia, progressive Eczema vaccinatum, generalized vaccinia, progressive
vaccinia, postvaccinial encephalitis, fetal vaccinia, possible vaccinia, postvaccinial encephalitis, fetal vaccinia, possible cardiac effectscardiac effects
Who should not be vaccinated?Who should not be vaccinated? Persons with eczema, atopic dermatitis, immunodeficiency, Persons with eczema, atopic dermatitis, immunodeficiency,
pregnancypregnancy Persons living with someone elsePersons living with someone else
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BiotoxinsBiotoxins Botulinum toxinBotulinum toxin
Clostridium botulinumClostridium botulinum Blocks release of acetylcholine from cholinergic Blocks release of acetylcholine from cholinergic
neuronsneurons With no treatment, rapidly progresses to paralysis With no treatment, rapidly progresses to paralysis
and respiratory failure and death and respiratory failure and death Classic symptoms – double vision, blurred vision, Classic symptoms – double vision, blurred vision,
drooping eyelids, slurred speech, dry mouth, drooping eyelids, slurred speech, dry mouth, dysphagia, muscle weakness, descending flaccid dysphagia, muscle weakness, descending flaccid paralysisparalysis
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Botulinum ToxinBotulinum Toxin TreatmentTreatment
Prolonged supportive careProlonged supportive care• Fluid/nutritional supportFluid/nutritional support• Mechanical ventilationMechanical ventilation
Immediate infusion of botulinum antitoxinImmediate infusion of botulinum antitoxin
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RicinRicin Toxin present in castor beansToxin present in castor beans
Extraction from the “mash” when beans are Extraction from the “mash” when beans are processed to make castor oilprocessed to make castor oil
Powder, pellet, mist, or dissolved in water or a Powder, pellet, mist, or dissolved in water or a weak acidweak acid
Inhibits protein synthesisInhibits protein synthesis Treatment is purely supportiveTreatment is purely supportive
No antidote for ricinNo antidote for ricin Vaccine in developmentVaccine in development
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Ricin: Clinical ManifestationsRicin: Clinical Manifestations InhalationInhalation
Few hours – coughing, chest tightness, difficulty breathing, Few hours – coughing, chest tightness, difficulty breathing, nausea, muscle aches nausea, muscle aches
Later – severely inflamed/edematous airway; cyanosis and Later – severely inflamed/edematous airway; cyanosis and death can followdeath can follow
Ingestion Ingestion Intestinal and gastric hemorrhage, vomiting, diarrhea; then Intestinal and gastric hemorrhage, vomiting, diarrhea; then
liver, spleen, kidneys may fail; death within 10-12 days of liver, spleen, kidneys may fail; death within 10-12 days of ingestioningestion
InjectionInjection Severe symptoms and death; impractical route for terrorismSevere symptoms and death; impractical route for terrorism
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Chemical WeaponsChemical Weapons Nerve agentsNerve agents
Produce a state of cholinergic crisis, characterized Produce a state of cholinergic crisis, characterized by excessive muscarinic stimulation and by excessive muscarinic stimulation and depolarizing neuromuscular blockade depolarizing neuromuscular blockade
Treatment – mechanical ventilation, atropine, and Treatment – mechanical ventilation, atropine, and diazepam diazepam
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Chemical WeaponsChemical Weapons Sulfur mustard (mustard gas)Sulfur mustard (mustard gas)
Alkylating agent and vesicantAlkylating agent and vesicant Can be vaporized into air or released into water Can be vaporized into air or released into water
supplysupply Injuries severe, but fatality rate is lowInjuries severe, but fatality rate is low During WWI – killed less than 5% of victimsDuring WWI – killed less than 5% of victims
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Radiologic WeaponsRadiologic Weapons Nuclear bombsNuclear bombs
Immediate and delayed impactImmediate and delayed impact Nuclear power plant attackNuclear power plant attack
Radiation exposure in areaRadiation exposure in area Dirty bombs (radiologic dispersion devices)Dirty bombs (radiologic dispersion devices)
Radioactive material formulated into powder or Radioactive material formulated into powder or pelletspellets
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Drugs for Radiation EmergenciesDrugs for Radiation Emergencies Potassium iodidePotassium iodide
Prompt treatment necessaryPrompt treatment necessary Penetrate zinc trisodium and penetrate Penetrate zinc trisodium and penetrate
calcium trisodiumcalcium trisodium Treatment within 24 hours most effectiveTreatment within 24 hours most effective
Prussian blue (Radiogardase)Prussian blue (Radiogardase)