Beyond Anthrax - The Weaponization of Infectious Diseases

Beyond Anthrax

Preface

References

Contents

Contributors

The History of Bioterrorism: Old Idea, New Word, Continuing Taboo

1.1 Definitions

1.2 Acts of God

1.3 Poisoning Water Supplies

1.4 Ballistic Biological Weapons

1.5 Fomites

1.6 Living Human Carriers

1.7 Economic Sabotage Through Biological Weapons

1.8 Biological Warfare and Terrorism by Established Powers Since the Geneva Protocol

1.8.1 Japan

1.8.2 Germany

1.8.3 Allied Forces

1.8.4 Postwar Stockpiling, Psychology, and Propaganda

1.9 Biological and Toxins Weapons Convention, 1972

1.10 Non-state-Sponsored Bioterrorism

1.11 Continuing Bioterror?

References

Smallpox and Bioterrorism

2.1 Introduction

2.2 Smallpox: A Persisting Bioterrorist Threat

2.2.1 Genetic and Immunologic Scenarios

2.3 The Two Viruses: Vaccinia virus (Smallpox Vaccine) and Variola virus (Smallpox)

2.4 Myopericarditis and other adverse events after vaccination: 2002-2004

2.5 HIV/AIDS and Smallpox Vaccination

2.6 Hemorrhagic Smallpox

2.7 International Preparedness for Smallpox

2.8 The Centers for Disease Control and Prevention: Smallpox algorithm for generalized vesicular or pustular rash

2.9 Smallpox Vaccines 2004: First, Second, and Third Generations

2.10 Vaccinia Immune Globulin and Antiviral Drug Development

2.11 Smallpox Preparedness in Hospitals and Public Health Partners

2.11.1 Vaccination Coverage

2.12 Monkeypox: An Emerging Disease in the United States in 2003 and in Sudan in 2005

References

Plague

3.1 Outbreak Scenarios

3.1.3 India 2002 - Spread in an Endemic Area

3.1.3 New York City 2002 - Importation to a Nonendemic Area

3.2 The Organism

3.2.1 History of Plague

3.2.2 Yersinia pestis

3.2.3 Virulence Factors

3.3 Natural Infection

3.3.1 Epidemiology

3.3.2 Life Cycle of Plague

3.4 Diagnosis

3.4.1 Clinical Presentation

3.4.2 Clinical Presentation of Biowarfare Plague

3.4.3 Radiographic Diagnosis

3.4.4 Laboratory Diagnosis

3.5 Therapeutic Interventions

3.6 Preventive Measures

3.6.1 Infection Control

3.6.2 Immunization

3.6.3 Rodent Control

References

Tularemia

4.1 Outbreak Scenario

4.2 The Organism

4.3 Epidemiology and Modes of Transmission

4.4 Clinical Presentation

4.5 Bioterrorism Presentations and How They may Differ from Natural Disease

4.6 Therapy

4.6.1 Preventative Measures (Infection Control, Antimicrobials, Vaccines)

References

Botulism

5.1 Documented Aerosol Exposure Through Laboratory Accident

5.2 Clostridium botulinum

5.2.1 Vegetative Forms

5.2.2 The Spore

5.2.3 The Toxins

5.3 Modes of Transmission

5.4 Diagnosis

5.4.1 Clinical Presentation

5.4.2 Epidemiology

5.4.2.1 Foodborne Botulism

5.4.2.2 Wound Botulism

5.4.2.3 Infant Botulism

5.4.2.4 Adult Intestinal Toxemia Botulism

5.4.3 Laboratory Diagnosis and Confirmation

5.4.4 Botulism as a Biowarfare Event

5.4.4.1 The Threat

5.4.4.2 The Potential Role of Commercial Botulinum Toxin

5.4.4.3 Recognizing the Intentional Nature of an Outbreak of Botulism

5.4.4.4 Responding to an Outbreak of Botulism of Intentional Origin

5.5 Therapeutic Interventions

5.5.1 Supportive Intensive Care

5.5.2 Antitoxin Therapy

5.6 Preventative Measures

5.6.1 Isolation and Infection Control

5.6.2 Prophylactic Treatment

5.6.3 Immunization

5.7 Preparedness and Research Agenda

References

The Viral Hemorrhagic Fevers

6.1 Disease Outbreak Scenario

6.2 Introduction

6.3 History of the Weaponization of HF Viruses

6.3.1 The Viruses

6.3.1.1 Natural Maintenance and Transmission

6.3.1.2 Infectious Dose and Route of Infection

6.4 Possible Strategies for the Dissemination of HF Viruses as Bioweapons

6.4.1 ‘‘Implantation’’ of Infected Humans in the Community or Hospitals to Initiate Person-to-Person Transmission

6.4.2 Release of an Infected Reservoir or Vector

6.4.3 Direct Dissemination Through Artificially Produced Aerosols or Fomites

6.5 Clinical Presentation

6.5.1 The Illness

6.5.2 Bioterrorism Presentation

6.5.3 Differential Diagnosis

6.5.4 Laboratory Diagnosis

6.6 Therapeutic Interventions

6.6.1 Supportive Measures

6.6.2 Antiviral Drugs

6.6.3 Convalescent Immune Plasma

6.6.4 Immunomodulating Drugs

6.7 Preventative Measures and Infection Control

6.7.1 Prophylaxis

6.7.2 Patient Isolation

6.7.3 Contact Tracing

6.7.4 Vaccines

6.7.5 Environmental Clean-up

6.8 Surveillance

6.8.1 Human Disease

6.8.2 Environmental Sampling

6.9 How Likely is a Bioterrorist Attack with a HF Virus?

References

Melioidosis

7.1 Clinical Scenarios

7.1.2 Acute Fulminant Disease

7.1.2 Reactivation Fatal Disease

7.2 The Organism

7.2.1 The History of Melioidosis

7.2.2 Burkholderia pseudomallei

7.3 Natural Infection

7.3.1 Epidemiology

7.3.2 Modes of Transmission

7.4 Diagnosis

7.4.1 Clinical Presentation

7.4.2 Clinical Presentation of Biowarfare Melioidosis

7.4.3 Radiographic Diagnosis

7.4.4 Laboratory Diagnosis

7.4.4.1 Microbiology

7.4.4.2 Serology

7.5 Therapeutic Interventions

7.6 Preventative Measures

7.6.1 Infection Control

7.6.2 Immunization

References

Epidemic Typhus Fever

8.1 Clinical Scenarios

8.1.2 Imported Acute Epidemic Typhus [1]

8.1.2 Imported Latent Epidemic Typhus [2]

8.2 The Organism

8.2.1 The History of Epidemic Typhus

8.2.2 The Pathogen: Rickettsia prowazekii

8.2.3 The Vector: Pediculus humanus humanus

8.3 Natural Disease

8.3.1 Epidemiology

8.3.2 Modes of Transmission

8.3.3 Pathogenesis

8.4 Diagnosis

8.4.1 Clinical Presentation

8.4.1.1 Acute R. prowazekii Infection

8.4.1.2 Brill-Zinsser Disease

8.4.1.3 Latency in Rickettsial Infections

8.4.1.4 Bioterrorism-Associated R. prowazekii Infection

8.4.2 Laboratory Diagnosis

8.4.2.1 Laboratory Abnormalities

8.4.2.2 Serology

8.4.2.3 Molecular

8.4.2.4 Culture

8.5 Therapeutic Intervention

8.6 Preventive Measures

8.6.1 Infection Control

8.6.2 Immunization

References

Category B Biotoxins

9.1 Ricin

9.1.5 Scenarios

9.1.1.1 The Assassination of Georgi Markov [1]

9.1.1.2 In the Mail and Elsewhere

9.1.1 The Toxin

9.1.1 Ricin Disease

9.1.3.1 Natural Disease

9.1.3.2 Biowarfare Ricin Use

9.1.3.3 Diagnosis of Ricin Exposure

9.1.3 Therapeutic Measures

9.1.3 Preventive Measures

9.1.5.1 Environmental

9.1.5.2 Passive and Active Immunization

9.2 Staphylococcal Enterotoxin B (SEB)

9.2.1 Scenario [45]

9.2.2 The Toxin

9.2.3 SEB Disease

9.2.3.1 Natural Disease

9.2.3.2 Biowarfare Disease

9.2.3.3 Diagnosis

9.2.4 Therapeutic Measures

9.2.5 Preventive Measures

9.2.5.1 Environmental

9.2.5.2 Passive and Active Protection

9.3 Clostridium Perfringens Epsilon Toxin

9.3.1 Human C. Perfringens Toxin (non-epsiv) Scenario [96]

9.3.2 The Toxin

9.3.3 Epsilon Toxin Disease

9.3.3.1 Natural Disease

9.3.3.2 Epsilon Biowarfare Disease

9.3.3.3 Diagnosis of Epsilon Disease

9.3.4 Therapeutic Interventions

9.3.5 Preventive Measures

9.3.5.1 Environmental

9.3.5.2 Passive and Active Immunization

References

Intentional Terrorist Contamination of Food and Water

10.1 Introduction

10.2 Vulnerability of the Food Supply

10.3 Vulnerability of the Water Supply

10.4 Potential Threat Agents for Food and Water

10.5 Detecting an Attack on Food or Water

10.6 Recognition of a Foodborne or Waterborne Disease Event as a Terrorist or a Criminal Act

10.7 Diagnosis of the Agent in Suspected Foodborne and Waterborne Terrorism

10.8 Response

10.9 Communications

10.10 Conclusions

References

Resources

Public Health Infrastructure

11.1 Lessons Learned

11.2 Funding for BT Preparedness

11.3 Organizational Issues

11.4 Surveillance

11.5 Communication

11.6 Workforce Development and Needs

11.7 Laboratory Services

11.8 Environmental Issues and Bioterrorism

11.9 Medical and Hospital Preparedness

11.10 Delivery of Prophylaxis

11.11 Crisis Management

11.12 Current and Future Challenges

References

Public Health Law and Biological Terrorism

12.1 Introduction

12.2 Restrictions on Personal Liberty: Quarantine, Isolation, Travel Restrictions, and Privacy

12.2.1 Quarantine and Isolation

12.2.1.1 State and Local Quarantine and Isolation Laws

12.2.1.2 Federal Quarantine and Isolation Law

12.2.1.3 Key Quarantine Considerations

12.2.2 Restrictions on Privacy

12.3 Restrictions on Property

12.4 Conclusion

References

Public Health Surveillance for Bioterrorism

13.1 Consequences of Bioterrorism

13.2 Surveillance

13.2.1 Fundamental Surveillance

13.2.2 Information Technology Impact

13.2.3 Surveillance and the Public Health Infrastructure

13.2.4 Indirect Benefits

13.3 Reporting and Collection of Data

13.3.1 Reporting

13.3.2 Confirmation

13.3.3 Adequacy of Collection

13.3.4 Passive versus Active Systems

13.3.5 Personnel and Electronics

13.4 Syndromic Surveillance Methodology

13.4.1 Syndrome Classifications

13.4.2 Evaluation of Syndromic Surveillance

13.4.3 Electronically-Based Syndromic Surveillance

13.4.4 Role of Syndromic Surveillance

13.5 Data Analysis and Interpretation

13.5.1 Sentinel Health Events

13.5.2 Aberration Detection in Surveillance Data

13.6 Information Dissemination and Communication

13.6.1 Appropriate Reporting of Information

13.6.2 Feedback to Surveillance Participants

13.6.3 Interorganizational Communications

13.7 Confidentiality

13.8 Conclusion

References

Psychosocial Management of Bioterrorism Events

14.1 Introduction

14.2 Primary and Secondary Prevention

14.2.1 Primary Prevention

14.2.2 Secondary Prevention

14.3 Bioterrorism and Phases of the Traumatic Stress Response

14.4 Psychiatric Syndromes and Behavioral Changes in the Aftermath of Bioterrorism

14.4.1 Initial Behavioral Changes

14.4.2 Acute Stress Disease and Posttraumatic Stress Disorder

14.5 Therapeutic Interventions

14.5.1 Effect of Biological Agents and Therapeutic Responses

14.5.2 Use of Separate Location for Psychiatric Treatment

14.5.3 Interventions

14.6 Appraisal, Attribution, Risk Communication, and the Media

14.7 Planning for Mental Health Response

14.8 Summary

References

The Role of the Media in Bioterrorism

15.1 Introduction

15.2 Reporting Science

15.2.1 The Priniciple of Parsimony

15.2.2 The Bell-Shaped Curve

15.2.3 Integrating Parsimony and Bell-Shaped Curve

15.3 US Anthrax Attacks - The Media and HHS

15.4 US Anthrax Attacks - The Media and the CDC

15.5 Getting It Right

15.6 The Potential for Public Panic

15.7 Is There a Correct Answer?

15.8 Lessons

References

Rapid Detection of Bioterrorism Pathogens

16.1 Introduction

16.2 Limitation of Conventional Diagnostics

16.3 Rapid Identification Methods

16.3.1 Serologies: Antigen-Antibody Interactions

16.3.2 Antigen-Non-Antibody Target Interactions

16.3.3 Genetics: Exploiting Genomic Differences

16.3.3.1 Attributes of a Comprehensive Diagnostic Test

16.3.3.2 DNA Microarrays

16.3.3.3 Real-Time Probes

16.3.3.4 Multiplex Assays

16.3.3.5 Target Selection

16.3.3.6 Sample Processing

16.3.4 Validation of Diagnostic Assays

16.4 In Place and on the Horizon

References

Plant Pathogens as Biological Weapons Against Agriculture

17.1 Introduction

17.1.5 Background

17.1.5 Needs Assessment

17.2 Weaponization of Plant Pathogens

17.2.1 Food Supply as a Target for Biological Weapons

17.2.2 The U.S. Agricultural Economy as a Target for Biological Weapons

17.2.2.1 Karnal Bunt of Wheat

17.2.2.2 Citrus Canker

17.2.2.3 Potato Cyst Nematode

17.2.2.4 Citrus Greening

17.2.3 Loss of Consumer Confidence in a Safe and Affordable Food Supply

17.2.4 The Use of Plant and Human Pathogens as Biological Weapons to Adversely Affect Human/Animal Health

17.2.5 The Use of Plant Pathogens as Weapons to Instill Fear and Mistrust of the U.S. Food Supply

17.3 Use of Plant Pathogens as Biological Weapons in the War on Drugs

17.4 Generating Disease Epidemics

17.4.1 Model Selection

17.4.2 Varying the Effectiveness of Initial Inoculum

17.4.3 Time of Inoculation

17.4.4 Choice of Plant Pathogens Based upon Disease Intensity:Yield Relationships

17.4.5 Use of Geographic Information Systems to Identify Target Areas Favorable for Optimum Pathogen Introduction and Establishment

17.4.5.1 Post-Introduction Forensics Protocols

17.5 Conclusions

References

Index