DR. T. RAMBABU PROFESSOR OF

ANAESTHESIOLOGYMIMS, Ghanpur

Bioterrorism - role of Anaesthesiologist

LECTURE OBJECTIVES

• To create awareness about CBRN,trauma.

• Problems about treating the pt,containing the

hazard,self protection of medical responders.

• Training medical personnel & civilians.

• Main problem in CBW- treating pt, while

protecting ourselves

“Sadly the world has changed. the threat of bioterrorism is real and growing.”

Margaret Hamburg MD – Oct 12, 1999 Assistant Secretary Department of Health and Human Services

(2009 FDA Commissioner)

----- New York Times – 9/23/01

The nation is "woefully unprepared to deal with bioterrorism,“ Jerome M. Hauer

• IF YOU DON’T SWEAT DURING PEACE TIME YOU WILL BLEED DURING WAR.

- ARMY ADAGE

• So,please Train yourself before event.

No more a topic of Military concern alone but an Emerging Global threat

After 9/11 & recent reports on terrorism: Probability of a

successful terrorist incident with commonly available

CBRN agents high

Bioterrorism

"Bioterrorism” - The unlawful use, or threatened use, of microorganisms or toxins derived from living organisms to produce death or disease in humans,

animals, or plants. The act is intended to create fear and intimidate governments

or societies in the pursuit of political, religious, or ideological goals.

Note: There is no single, universally accepted definition of bioterrorism.

• “ARMIS BELLA NON VENESIS GERI”

• Means war is waged with weapons and not with poisons.

BRIEF HISTORY

• Before cultivation of bacteria, bags containing poisonous snakes, dead animals infected materials used to be thrown into enemy areas.

• I world war due to immobility in trench wars poisonous gasses like Cl2, phosgene were used

• II world war mustard gas organo phosphates sarin etc were prepared by Germans (Schrader). Tabun was used 1942, later sarin,soman & Vx were used

• During cold war, former USSR developed CBW agents

• Post cold war, terrorist groups , rogue nations , religious groups cults , disgruntled persons use & threaten societies .

• HAZMAT hazardous materials can be accidentally released.This is governed by UN laws.

• 1972 – UN biological warfare convention,1993- Chem warfare conv

WHAT’S A HAZARD?

• Accidental release of hazmat is a hazard

• Biowarfare state sponsored

• Bioterrorism disgruntled groups

• Biospectrum inascending order of mol.Wt chemicals (nerve gasses)

• Toxins & neuropeptides then viruses bact. Fungi etc (replicating)

Warning signs

• 1984 - Bhopal - tragedy toll 2,500

• 1994 – Aum SARIN

• 2001 – Anthrax attack in USA

• 2006 – Polonium used in London

• CBW – Is not a WMD but creates panic &

tremendous financial burden particularly

hoax calls

• THREAT=

HAZARD+CAPABILITY+INTENTION

Biological Weapon Advantages

Inexpensive / relatively easy to produce

Cost: (1970 Study - Cost of 50% casualties over a 1sq/km area)

Conventional weapons - $2,000

Nuclear - $800

Chemical - $600

Anthrax - $1

Threat alone may create panic Large attack areas may be covered Detection may be difficult Odorless, Colorless, Tasteless First Sign of Attack is Human Illness Some pathogens are contagious Perpetrators may protect themselves

and escape before effects are felt

Biological Weapon Advantages

Biological Weapon Disadvantages

i. Controllability

ii. Effective dispersion is difficult

iii. Perpetrators may become infected

iv. Results may be so “effective” that retribution towards those responsible may be enormous

Common Characteristics• Can be a liquid or powder• Successfully dispersed as aerosols when

particle sizes are 1 to 5 microns• Can be released from a “Line Source” or

“Point Source”• Weather is a key factor - Inversions are

needed for successful aerosol delivery.• May also be delivered orally through food or

water contamination

Ideal CBW agent• Simple & cheap to mass produce

• Capable of being dispersed as aerosol

• Low dose infection, virulent, robust

• No vaccine, no antidote available

• Stable in harsh climates

• Availability of procurement

• Difficult to detect

• User controller

Bioterrorism Agents

• Category A Diseases–Anthrax (Bacillus anthracis)

–Smallpox (Variola virus)

–Plague (Yersinia pestis)

–Tularemia (Francisella tularensis)

–Botulism (botulinum toxin)

–Viral Hemorrhagic Fever

Bioweapon-related Diseases

• anthrax• botulism• brucellosis• cholera• food poisoning• glanders• hemorrhagic

fever• lassa fever• melioidosis• plague

• psittacosis• Q-fever

• salmonellosis• shigellosis

• smallpox

• tularemia

• typhoid fever

• typhus• viral encephalitis

Delivery Mechanisms

• Aerosol route

– Easiest to disperse

– Highest number of people exposed

– Most infectious

– Undetectable to humans

• Food / Waterborne less likely

– Larger volumes required

– Technically more difficult

28

Biological agent Delivery Methods

• Food / Water

• Aircraft sprayers

• Vehicle sprayers

• Hand sprayers

• Mail

• Air handling

systems

• Human Vector

• Animal Vector

• Hazard – accidental release of CBW

eg: Bhopal gas tragedy

• Threat is a military perception

Threat = Hazard + Capability + Intent

• Haber’s lethality coeff. = Conc x Time of exp

causing death in 50% of people exposed

• Median lethal dose=reffd. To injected drug

• COMPONENTS OF CBW ATTACK

FOUR Toxicity, latency (victim

related)

persistency & transmissibility

(incident management)

AnthraxBacillus anthracis

History

• Sporadic disease in 20th century U.S.

• Experience as biological weapon

–U.S., 2001

• Most letter-associated

• 22 cases (18 confirmed), 5 deaths

–Sverdlovsk, Russia, 1979

• Accidental release from weapons facility

• ≥77 cases, 66 deaths

Epidemiology

• Forms of disease– Inhalational (<5% cases; 45-89%

mortality)–Cutaneous (95%; <1-20% mortality)–Gastrointestinal (<5%; >50% mortality)

• Risk Factors–Exposure to infected animals –Exposure to aerosolized spores

Clinical Features - Inhalational

• Incubation

– Range 2-43, median 4-7 days

• Prodrome

– “flu-like” - fever, malaise, dry cough

– Nausea, vomiting, diarrhea

– Lack of nasal symptoms

• Fulminant

– Respiratory failure, shock, toxemia

Treatment

• Hospitalization

• IV antibiotics– Empiric until sensitivities known

• Intensive supportive care– Electrolyte and acid-base imbalances

– Mechanical ventilation

– Hemodynamic support

• Steroids– Consider for severe disease

Treatment

• Empiric therapy for inhalational (Adults)–Ciprofloxacin 400 mg IV q12° OR

Doxycycline 100 mg IV q12° AND

One or two other antibiotics

- clindamycin - penicillin

- vancomycin - chloramphenicol

- rifampin - imipenem

–Avoid macrolides, cephalosporins, sulfa

Treatment

• Antibiotic therapy – all forms

– Adjust per sensitivities

– Duration

• 60 days - delayed spore germination

• Follow closely after cessation

– Switch to oral

• Clinical improvement, able to tolerate po

• 1 or 2 drugs including cipro or doxy initially

• Children can complete course with amoxicillin

– No role for vaccine in treatment

Post-Exposure Prophylaxis

• Indications– Exposure to anthrax spores

– Not for contacts of cases

• Oral antibiotics– Ciprofloxacin 500 mg po bid OR

– Doxycycline 100 mg po bid

– Duration 60-100 days

• +/- Vaccination

Vaccination

• Inactivated, cell-free vaccine

• Effective– >95% animals vs. inhalational

– Protective for humans vs. cutaneous

• Well-tolerated– Uncommon adverse effects

– No reported deaths

• Limited supply

• Most doctors have never seen

a case of plague or anthrax--it

could be days before we

realize what we have.

SmallpoxVariola Virus

Smallpox Variola major

• Orthopox virus

• DNA virus

• Brick-shaped structure 200 nm in diameter

• Incubation 8-16 days

• Mortality 30%

• Clinical symptoms– Acute

• Fever• Headache• Vomiting• Backache

Smallpox

• Spread by infected droplets

• Most infectious after onset of rash

• Contagious until the last scab falls off

• Vaccine given within 4 days of exposure can prevent disease or lessen symptoms

• 70% recovery rate

• Chicken pox vs. Smallpox

History

• Ancient scourge – many millions killed

• Global eradication in 1977

• Bioweapon potential– Prior use in French-Indian War

– Produced by USSR

• Stocks still exist

Courtesy of National Archives

PlagueYersinia pestis

History

• 3 Pandemics– Justinian - 6th century Africa/Asia

– Black Death – 14th century Europe

– Worldwide – 19th/20th century

• Potential for use as bioweapon– Unit 731 Manchuria

– Former USSR production

Epidemiology

• Distribution– Global – ~1700 cases/yr

– Southwestern U.S. – 5-10 cases/yr

• Routes of transmission– Flea bites

– Animal contact

– Inhalation – animals, people, BT aerosol

Epidemiology

• Forms of Disease– Pneumonic (2-12% of cases)

• Inhalation (1°) or hematogenous (2°)• Mortality 57% (>90% if treatment delayed)• Most likely route for bioterrorism

– Bubonic (84%)• Flea bite or animal handling• Mortality <5% (40-60% untreated)

– Septicemic (13%)• Mortality 30-50% (>90% untreated)

Clinical Features

• Bubonic Plague– Constitutional symptoms

– Lymphadenopathy• “bubo”• May drain

• Septicemic Plague– Same flu-like illness progressing to sepsis

– No discernible adenopathy

Treatment

• Parenteral antibiotics– Aminoglycosides – 1st choice

• Streptomycin 1 g IM bid (adults)• Gentamicin 5 mg/kg IV q24°

– Tetracyclines • Doxycycline 100 mg IV q12°

– Fluoroquinolones• Ciprofloxacin 400 mg IV q12° (adults)

– Chloramphenicol – for meningitis

TularemiaFrancisella tularensis

History

• Discovered early 20th century– Tulare county, California

– “deerfly” fever

• Bioweapon potential– Incapacitating

– Former US and USSR production

– Prior use • Unit 731, Manchuria

CDC/Emory University/Dr. Sellers. PHIL1344

Treatment

• Supportive care

• Parenteral antibiotics ASAP– Aminoglycosides

• Streptomycin 1 g IM q12°• Gentamicin

– Once-daily or traditional dosing

– Tetracyclines – higher relapse rate• Doxycycline 100 mg IV q12°• Tetracycline - oral

BotulismBotulinum toxin

History

• Neurologic disease from botulinum toxin

– Most lethal substance known

• History as bioweapon

– Japanese in WWII (Unit 731)

– Former US and USSR programs

– Iraqi deployed weapons

– Japanese cult in early 1990’s

Microbiology

• Clostridium botulinum– Large, anaerobic Gram positive bacillus

– Spore-forming

– Rarely infects humans

– Produces potent neurotoxin• 7 types (A-G)• Types A,E,B most common in U.S.• Same general mechanism

Viral Hemorrhagic Fevers

History

• Variety of viral illnesses–Similar syndrome with fevers and

bleeding

• No known use as bioweapon

• Great potential for fear –High mortality/morbidity

–Attention in media, entertainment

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

Role of Clinicians

• For specific Bioterrorism (BT) diseases– Recognize typical BT disease syndromes

– Perform appropriate diagnostic testing

– Initiate appropriate treatment/prophylaxis

– Report suspected cases to proper authorities

1) Local health department

2) Hospital epidemiologist

3) Infectious Disease consultants

ROLE OF ANAESTHESIOLOGIST

• In addition to the above,anaesthesiologists with

their special training play a key role in triaging &

initial resuscitation,decontamination,transport

and ICU management of victims.

• Pt resuscitation takes priority over

decontamination.

Removal from exposure

Early suspicion

& Diagnosis

Triage

Evacuation

Essentials of Management of Nerve Agent Casualties

Preparing medical responders

Decontamination

Ventilation

• Foremost requirement -NBC Compliant equipment• Most have respiratory symptoms • Panic sets in fast , Detail team mambers in advance• Rehearse drills • NBC Compliant ventilatorNBC Compliant ventilator• Portable, light weight,

* Easy operations * Excellent Battery backup

Indian Army

Decontamination equipment

EQPT VEHICLE DECONTAMINATION

“Preparing for CBRN disaster is like playing a 20: 20 match ……. You can make a brilliant 20 ball fifty but the only shot that people remember is the one that denies you a win ”

What We Need To Prepare for Bioterrorism

• More trained epidemiologists to speed detection

• Increased laboratory capacity

• Health Alert Network

• Medical professionals “back to school”

• National Pharmaceutical Stockpile

SUMMARY

1. CBW weapons are cheap to produce & procure. Not WMD but create panic & cause economic burden.

2. Most widely used & studied is Anthrax in bio. Agents & Sarin in Chem. Agents.

3. Except armed forces civilians poorly informed & trained hence more casualties

4. Anaesthesiologists most imp. Member of all

trauma teams as airway Physician, for triaging,

onfield resuscitation , decontamination and ICU

management.

5. Training , acquiring knowledge about most

likely agents helps in quick definitive treatment.

REFERENCES

• Miiler’s Anaesthesia – 7th edtn

• The internet journal of anaesthesiology ISSN : 1092-4066

• CTLS guidelines

• Foodgard training programme

• Review article BJA - 2002

Other Resources

• Web sites– www.bioterrorism.slu.edu (SLU-CSBEI)

– www.bt.cdc.gov (CDC)

– www.hopkins-biodefense.org/ (JH-CCB)

– www.apic.org (APIC)

– www.usamriid.army.mil (USAMRIID)

THANK YOU