Terrorism%20101

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Terror Is Real !
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Terrorism Are We Ready?
Barbara Russell, RN,MPH,CIC,ACRN
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Biological and Chemical TerrorismHow Real is
the Threat?
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What is Terrorism?

• No single definition
• FBI The unlawful use of force or violence
  against persons or property to intimidate or
  coerce a government, the civilian population, or
  any segment thereof, in furtherance of political
  or social objectives.

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Kill 1, Frighten 10,000
Sun Tzu
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Anthrax 2001

• 22 confirmed or suspected cases
• 11 inhalation (confirmed)
• 11 cutaneous (7 confirmed, 4 suspected)

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Inhalation Anthrax (11)
9 confirmed - exposed to mail (other 2
possible) 55 (6) survived
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Types of Terrorism

• Biological
• Nuclear
• Incendiary
• Chemical
• Explosive
• B-NICE

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Target Selection

• SSymbolic target to audience or terrorist
  Economic, political, social or religious value
  Highly visible and photogenic
  Random To create confusion
  Diversionary
  Asymmetrical attack

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Timing

• Anniversary of significant historical event
• Highly visible event in the area
• Increase in international tensions

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Chemical Biological Terrorism
1984 The Dalles, Oregon, Salmonella (salad
bar) 1991 Minnesota, ricin toxin (hoax) 1994
Tokyo, Sarin and attack 1995 Arkansas, ricin
toxin (hoax) 1995 Ohio, Yersinia pestis (sent
in mail) 1997 Washington DC, Anthrax
(hoax) 1998 Nevada , non-lethal strain of B.
anthracis 1998 Multiple Anthrax hoaxes
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Chemical Warfare Agents
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Tokyo Subway Attack

• Odon March 20, 1995, terrorists released sarin,
  an organophosphate (OP) nerve gas at several
  points in the Tokyo subway system, killing 11 and
  injuring more than 5,500 people.
• Concealed in lunch boxes and soft-drink
  containers and placed on subway train floors. It
  was released as terrorists punctured the
  containers with umbrellas before leaving the
  trains.
• .On April 19th, 1995 repeat attack in subway
  which the same terrorist group killed seven and
  injured more than 200 people.

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Chemical Warfare Agents (CWA)

• ? Lethal CWAs
• ? Nerve gas (Sarin, Tabun, soman, and VX)
• ? Organophosphates- anticholinesterase
• ? Colorless, odorless, tasteless
• ? Cyanides
• ? Vesicants (blistering ) agents
• mustard gas

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Nerve Gas Agents

• ? All nerve agents belong chemically to the group
  of
• organo-phosphorus compounds.
• ? Stable and easily dispersed, highly toxic and
  have
• rapid effects both when absorbed through the
  skin
• and via respiration.
• ? Nerve agents can be manufactured by means of
  fairly
• simple chemical techniques. The raw materials
  are
• inexpensive and generally readily available.

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Chemical

• Chemical agents are toxic, but
• - They can be detected
• - You can protect yourself
• - Victims can be decontaminated
• Can be inhaled, absorbed through the skin or
  injected

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Nerve Agent Symptoms

• Salivation
• Lacrimination
• Urination
• Defecation
• Gastrointestinal pain
• Emesis
• SLUDGE

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Decontamination

• Removes the agent from the patient
• Reduces the chance of secondary spread
• Helps the victim psychologically

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Nerve Gas Poisoning

• Eyes excessive lacrimation and pain.
• Skin excessive sweating
• Muscles involuntary twitching
• Respiratory Mucous secretion, dyspnea
• Digestive excessive salivation, abdominal pain

• Symptoms minutes to 2 hours
• Treatment Atropine, 2-PAM (pralidoxime-2-chlorid
  e)
• Decontamination Soap Water, Chlorox

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Sulfur Mustard Poisoning

• Eyes reddening, congestion, pain 1/2 -12 hours
• Skin itching, burning, erythema, large blisters
  (1-12 hours)
• Respiratory burning throat, cough, dsypnea.
  (2-12 hours)
• Digestive abdominal pain, nausea, blood stained
  vomiting and diarrhea

• Treatment none
• Decontamination Soap Water, Chlorox
• Care watch for leukopenia, debride bullae

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Im confident that we can defend against
chemical warfare. The one that really scares me
to death is biological
Colin Powell - 1993
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Potential Biological Weapon Agents
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Characteristics of a Biological Attack

• Civilian Targets Likely.
• Possibility of Large Numbers of Casualties.
• Symptoms May Not Appear For Days.
• Initial Symptoms Likely to be Non-Specific.
• Diagnoses Will Depend Heavily Upon Laboratory
  Tests.
• Complex Epidemiology.
• Ongoing Need to Care for Large Numbers of
  Patients
• Concerns About Availability of Drugs, Supplies,
  Staff Members.
• Legal Considerations.
• Coordination with Local, State, and Federal
  Authorities.

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Potential Bioterrorism Agents

• Bacterial Agents
• Anthrax
• Brucellosis
• Cholera
• Plague, Pneumonic
• Tularemia

• Viruses
• Smallpox
• VEE
• VHF
• Biological Toxins
• Botulinum
• Staph Entero-B
• Ricin
• T-2 Mycotoxins

Source U.S.A.M.R.I.I.D.
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Biological Agents of Highest Concern

• Variola major (Smallpox)
• Bacillus anthracis (Anthrax)
• Yersinia pestis (Plague)
• Francisella tularensis (Tularemia)
• Botulinum toxin (Botulism)
• Filoviruses and Arenaviruses (Viral hemorrhagic
  fevers)
• ALL suspected or confirmed cases should be
  reported to health authorities immediately

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Anthrax - The Weapon

• Bacillus anthracis (coal anthrakis) because of
  black coal like lesions
• Aerobic, gram-positive, spore forming, non-motile
  bacillus species.
• Inhalation Anthrax
• Most morbidity and mortality as aerosolized
  biological weapon.
• Disease occurs 2 to 43 days after exposure.

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Anthrax - The Disease

• Inhalation anthrax
• Hemorrhagic thoracic lymphadenitis
• Hemorrhagic mediastinitis
• Hemorrhagic meningitis
• Two Stages
• 1. Fever, cough, dyspnea, headache, vomiting,
  chills, weakness
• 2. Sudden fever spikes, dyspnea, shock, cyanosis,
  hypotension
• Mortality 89!!!!

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AnthraxDiagnosis, Prevention, Treatment

• CXR widened mediastinum
• Blood culture shows growth after 2-6 hours
• Vaccine Licensed since 1970, 88 effective, not
  available!
• Treatment PNC, Doxycycline, Ciprofloxacin,
  first generation cephalosporin, vacomycin,
  clindamycin

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Anthrax
Cause Bacillus anthracis
Incubation 1-60 days, average 7 days
Mortality (without treatment) Cutaneous 20 Intestinal 25-60 Inhalation Usually fatal
Infectious Dose Varied 8,000-50,000 spores (inhalation)
Treatable? Yes antibiotics and supportive care
Human to Human Transmission? No
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Anthrax (bacillus anthracis)
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What is smallpox?

• Serious, contagious, viral disease that causes a
  fever and distinctive rash
• Treatment supportive
• Historically, 30 of smallpox patients died, many
  developed scars especially on face, some became
  blind
• Prevented by smallpox vaccine (gt95 effective)

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How is smallpox spread?

• By direct, prolonged face-to-face contact
• Less commonly, indirectly by contaminated bedding
  or clothing
• Rarely spread by air
• Transmission prevented by using airborne and
  contact precautions in health care settings

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What is the risk of smallpox?

• 1972 routine smallpox vaccination discontinued
  in U.S.
• 1977 last naturally-acquired case in world
• Deliberate release is possible but risk is
  unknown
• Health care workers at higher risk due to
  exposure to most severely ill patients
• In Europe from 1950-71, 50 of smallpox
  transmission was in hospitals

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How the skin looks with successful vaccine take
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Smallpox
Cause Variola major
Incubation 7-17 days, average 12-14 days
Mortality (without treatment) 30
Infectious Dose Small
Treatable? Supportive care vaccine after exposure
Human to Human Transmission? Yes - Airborne
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Smallpox vs. Chickenpox
Smallpox Chickenpox
Distribution of pox Centrifugal distribution (face, arms, legs) More covered parts of body, trunk
Stage of pox development All at same stage of development Various stages of development
Unique presentation Pox found on palms and soles of feet Uncommon to find pox on palms and soles of feet
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Smallpox (variola major)
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Treatment

• Treatment of smallpox is limited to supportive
  therapy and antibiotics as required for treating
  secondary bacterial infections.
• There are no proven antiviral agents effective in
  treating smallpox.

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Plague

• Found in rodents and their fleas in many parts of
  the world
• Bites from an infected flea
• Bubonic, septicemic, pneumonic
• Seen in rural areas (US 10-15 cases per year)
• Two recent human cases of primary pneumonic
  plague contracted from cats

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Plague (cont)

• US 390 cases from 1947-1996
• - 84 bubonic (standard precautions)
• - 13 septicemic (standard precautions)
• - 2 pneumonic (droplet precautions)
• Patients may present with GI symptoms (N/V, abd
  pain)
• Treated with antibiotics

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Plague (cont)

• BBiological terrorism release clues
• - Pneumonic plague outbreak 1-6 days after
• exposure
• - Initial severe respiratory illness
• - Death occurs quickly after onset of illness
• - Infection in persons with no known risk
• factors

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Plague (cont)

• BBiological terrorism release clues (cont)
• - Occurrence of cases in areas not known to
• have previous cases
• - Absence of prior rodent deaths (which may
• be present after natural disaster)
• Plague vs. Anthrax presentation

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Plague (yersinia pestis)
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Plague
Cause Yersinia pestis
Incubation 2-6 days
Mortality (without treatment) 50 (bubonic) near 100 (pneumonic)
Infectious Dose Small
Treatable? Yes antibiotics and supportive care
Human to Human Transmission? Pneumonic Yes Bubonic No
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Botulism

• Most potent naturally occurring lethal substance
  known to man
• Possible routes of exposure Ingestion (food),
  Inhalation (terrorist), Injection (drug users),
  dirty wound
• In 1999. 174 cases
• 26 food borne
• 107 intestinal / infant
• 41 wound

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Botulism (cont)

• CCardinal Signs
• - Fever is absent (unless infection is present)
• - Neurological symptoms are symmetrical
• - Patient remains responsive
• - Heart rate normal or slow
• - Sensory deficits do not occur (except for
• blurred vision)

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Botulism (cont)

• IIncubation period
• - Food borne 12-36 hours (preformed toxin)
• - Intestinal (Infant) 1-2 weeks
• - Wound 4-14 days

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Botulinum Toxin
Cause Clostridium botulinum
Incubation 2 hours 8days, average 12-72 hours (foodborne)
Mortality High
Lethal Dose 1 ng/kg (about 0.00000009g/200lb person)
Treatable? Yes antitoxin and supportive care
Human to Human Transmission? No
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Tularemia

• Reservoir Numerous wild animals (i.e. rabbits,
  beavers, some ticks)
• Can also be found in contaminated water, soil,
  vegetation
• Infections occur in North America (US 171 cases
  / year) AKA Rabbit Fever, Deer Fly Fever
• Infection caused by handling infectious animal
  tissues or fluids, direct contact with
  contaminated water, food, soil and inhalation of
  aerosols.

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Tularemia (francisella tularensis)
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Tularemia
Cause Francisella tularensis
Incubation 1-14 days, average 3-5 days
Mortality (without treatment) Varies 5-60
Infectious Dose 10 organisms
Treatable? Yes antibiotics and supportive care
Human to Human Transmission? No
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Hemorrhagic Fevers

• Ebola, Marburg, Lassa, Junin related viruses
• Presentation Initially febrile illness,
  malaise,
• myalgias, H/A, vomiting, diarrhea followed
  by
• bleeding, hypo tension, shock
• Mode of Transmission Contact with infected
• blood or other materials, higher risk at
  late stages
• of illness

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Hemorrhagic Fevers (cont)

• Incubation period (days)
• - Ebola 2-21,
• - Marburg 3-9,

• Lassa, commonly 6-21
• - Junin 7-16

• Diagnostic Tests Available
• Significant number of people with
• hemorrhagic fever symptoms
• Intensive supportive care
• Standard and Contact Precautions

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Hemorrhagic Fever
Cause Varies viral
Incubation Varies days to weeks
Mortality (without treatment) Varies high (as much as 80)
Infectious Dose Unknown
Treatable? No supportive care only
Human to Human Transmission? Yes
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Key Points

• Increase Level of Awareness
• Be familiar with Workplace Plan
• Be familiar with County Plan
• Have a Family Plan
• No I in Response Its a Team Effort

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Personal Protective Equipment

• Be sure that it is Appropriate to the hazard(s)

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