Bioterrorism

By: Berlian Isnia Fitrasanti

Weapon of Mass Destruction

(WMP)
Definition:
Any destructive device that is designed or
intended to cause death or seriously bodily
injury through the release, dissemination, or
impact of toxic or poisonous chemicals, or
their precursors; any weapon involving a
disease organism; or any weapon that is
designed to release radiation or radioactivity
at a level dangerous to human life.
Designed for military purposes

WMP
WW II outbreaks of bubonic plague (never
reported) in Chussien, Ningpo & Kinhwa, each
after a Japanese plane dropped a load of wheat
grain and rice admixed w/ numerous fleas
microscopic features of Y.pestis identified
Geneva Protocol 1925 commit the signatory
nations to refraining from the use of biological
weapons disastrous effects to civilian
population too
Though forbidden, some have stockpiles &
production facilities
2000: Reported 9 nations nuclear weapons; 27
chemical weapons; 19 biological weapons

Bioterrorism
Bioterrorism: the use of biological organism
dead or alive, natural or modified, and/or part of
body (blood, toxin)to inflict fear in people
with/without illness/death
Bioweapon needs time to manifest after being
dispersed
Chemical and nuclear weapon cause immediate
maximum damage
Aim of biological warfare: kill/incapacitate the
largest possible number of enemy soldiers
Aim of bioterrorism: cause maximum disruption &
to seed terror
Targets: Agriculture & food

Bioterrorism
Use of bioweapons: contaminate wells, reservoir
& other water resources
300 BC: Greeks polluted the wells & drinking
water supplies w/ animal corpses
In Italy 1155: dead bodies of soldiers & animals
15th century: Spanish conquistadors presented
smallpox contaminated clothing indigenous
people of Central & South America
In 1710: Russian troops threw plague victims
over the city walls of Revat (Swedish)

Why?
Why terrorist choose bioterrorism
cheap (main reason) known as a poor
mans atomic bomb
Conventional weapons: $ 2000/km2
Nuclear weapons: $ 800
Chemical weapons: $ 600
Biological weapons : $1
Unable to detect
High fatality rate
Induce fear, even by mentioning
producible in civilian setting using
equipment for making yoghurt, yeast, or beer

Modern Biological Weapons

Bioweapons have the potential to inflict
deliberate, potentially devastating epidemics of
infectious disease on populations; have
destructive power capable of killing entire
populations
100 kg anthrax released upwind of the city 3
million deaths
After Geneva Protocol:
In 1942, US began an offensive biological
programme
1932-1945, Japan conducted 12 large-scale
field trials of bioweapons (B. anthracis, N.
meningitides, Shigella sp, V. Cholera, Y. Pestis)

Bioweapon System
1. A payload infectious agents/toxin
2. Munitions (carry & keep pathogens virulent)
3. Delivery system (missile, vehicle, artillery shell,
or mail)
4. Dispersion system dissemination of the
payload, in a virulent form, among target
population
Dispersion system: aerosol sprays, explosives, food
& water; explosives are not very effective heat
& physical stress inactivate biological activity
UV, wind speed, wind direction, size & atmospheric
stability effect dispersion

Bioweapon system
1. Microbial agents should have the specific
characteristics:
Must be suitable for mass production, storage,
& weaponization
Should produce desired effects of disease &
death
Should be highly contagious & effective in low
dose
Should have a known short & predictable
incubation time
The disease should be difficult to identify in
the target population overlap w/
common/endemic infections

Bioterrorism Agents
Category A
Can be easily disseminated/transmitted person to person
Cause high morality
Might cause public panic & social disruption
Require special preparedness in the PH community
Category B
Are moderately easy to disseminate
Cause low morality & moderate morbidity
Require specific enhancement of diagnostic capacity
Category C
Ready availability
Ease of production & dissemination
The potential of high morbidity & mortality & major
health impact

Anthrax

Bacillus anthracis
Easy to produce as weapon, very stable & can be stored
with no time limit in the form of powder; can be used in an
explosive device
In case of untreated inhalational anthrax almost 100%
mortality; no effective treatment for advanced forms of
inhalational anthrax
Aum Shinrikyo tried to disperse this agent 3 times failed
(no death)
2001 : 3 letters sent to NBC, New York Post Washington
DC and Florida 22 people infected (5 people died)
actual letter (?)
Clinical Manifestation:
Cutaneous Anthrax (>95%)
Mortality rate is low

Anthrax
Symptoms: flu-like in the beginning fever, headache,
diaphoresis, chills, myalgias, fatigue, malaise, weakness,
backache & edema (neck area, axilla & non pitting)
Respiratory : cough, chest pain, sore throat, dyspnea,
orthopnea & presence of sputum/nasal discharge
X-ray: mediastinal widening
Neurological : agitation, confusion, delirium, neck rigidity,
Kernigs sign, Brudzinskis sign, seizures, syncope, coma
Cardiovascular: abN BP, pulse rate & cyanosis
GIT: abdominal pain, nausea, vomiting
Anthrax infection is not contagious; no human-to-human
Cadaver should not be opened within 30 min bacteria
sporulate on contact with air

Plague
Documented plague pandemic 2 millenia 200 million

Justinian pandemic: Northern Africa (mid 6 th century),

spread throughout Mediterranean impacting Roman &
Byzantine empires
Black Death: Central Asia Sicily, 1374 (ships from
Crimea) medieval Europe, including the Great Plague
of London 1655
Mid 19th, south-western China Hong Kong (1894)
port cities on all inhabited continents (rat-infested
steamship) > 26 mil case; 12 mil (1930)
Agent Y. pestis-infected rats & fleas
Highly infective, easily grown in large quantities, stored,
easily dispersed (resistant to adverse environmental
conditions

Plague
50 kg of aerosolised Y.pestis over a city of 5 million
150,000 cases of pneumonic plague & 36,000 deaths.
Forms: Bubonic, Septicemic, Pneumonic
Bubonic: sudden onset of chills, high fever, headache,
myalgia, athralgia, lethargy.
Within few hours swelling, tenderness & pain in 1/>
regional lymph nodes proximal to the portal of entry.
Mostly femoral & inguinal; axillary & cervical less
frequently. 90% cases occur at single site.
Systemic: without bubonic; coagulation of blood within
vessels, escape of blood from vessels into surrounding
tissues, haemorrhage, and blood clotting may cause a
dark, reddish-black discolouration of tissues visible
under the skin
Black Death

Plague
Pneumonic: Inhalation of aerosolised droplet
containing bacteria.
Symptoms: fever, cough, shortness of breath,
hemoptysis, chest pain, rapidly developing
toxemia, fulminant death

Chest signs in primary plague pneumonia may indicate localized

pulmonary involvement in the early stage; a rapidly developing segmental
consolidation may be seen before bronchopneumonia occurs in other
segments and lobes of the same and opposite lung

Plague

Small Pox

Variola major (orthopox)

Can be grown in large amounts
Used in destroying Native American population in 1763
Infection spreads via respiratory route 30% mortality rate
Clinical illness & fatality rate parallel with the density of skin
lesions. Lesions sparse unlikely to die & not efficient
transmitters
12-14 days after infection 2-5 day period of high fever,
malaise, headache, backache & maculopapular rash over face
extremities
7th day: rash raised bumps filled with thick opaque fluid (8th
day)
8th/9th: scabs formed pitted scars
On occasion, severe & fatal haemorrhagic form occurs
Haemorrhagic smallpox has nearly 100% fatality rate & patients
are highly infectious

Typical semiconfluent smallpox on the seventh or eighth

day. CDC

Small Pox
Initial cases after a covert bioterrorist attack probably
missed 4th-5th day of rash
Variola virus spreads most readily in dry & cool winter months
In aerosol form, virus can survive for 24 hours/more, highly
infectious at low doses
Terrorist might spray virus in an airport bus outside the target
nation, and infect passengers bound for widespread
destinations within that nation. It can also be sprayed directly
into the faces of person, under the guise of marketing parfume
Terrorist could put a solution of smallpox virus into hand-held
atomizers, and station volunteers outside places of
entertainment theme parks, military installations & critical
industries.
Smallpox virus exists legally in CDC, Atlanta & Novosibirsk
region of Russia

Tularemia

Francisella tularensis
The Japanese began germ warfare research using F. tularensis as
early as 1932 and conducted biological warfare research with it
on prisoners of war
In 1997, the CDC estimated that exposing 100,000 persons to an
aerosol of F. tularensis would result in 82,500 cases of tularemia
(82.5% attack rate) and 6,188 deaths (6.2% death rate), and cost
between $456 million and $561.8 million
Animal host: Rabbit, hare, flies, ticks, mosquitoes, tree squirrel,
opossum, coyote, bull snake, deer, red fox and sage hen.
Infections through insect bite, unapparent micro skin abrasion or
intact mucous membrane
Incubation period 2-5 days small red papules appear papule
enlarges & ulcerates; Mostly on upper extremities, face & eye.
It invades lymphatic vessels and may cause a regional
lymphadenitis and possible bubo formation.

Tularemia
A transient initial bacteremia seeds the reticuloendothelial system
and other organs, the formation of scattered foci of necrosis in the
liver, spleen, lungs, and distant lymph nodes.
Cutaneous exposure an ulcerative lesion with regional
lymphadenopathy, ulceroglandular tularemia.
Glandular tularemia: no visible primary lesion, but it resembles the
ulceroglandular form in all other respects.
Oropharyngeal tularemia follows ingestion of contaminated food or
water pharyngeal ulceration and gastrointestinal symptoms.
Inoculation of the eye conjunctivitis with local lymphadenopathy,
the oculoglandular form.
Pneumonic tularemia inhalation of the bacteria or from
hematogenous seeding of the lung.
Typhoidal tularemia is the most difficult to diagnose and refers to
systemic tularemia without an obvious external lesion or regional
lymph node swelling.
A bioterrorist release of F. tularensis may result in any of the forms of
tularemia, although inhalational tularemia is expected to predominate

Glanders/Melioidosis
Burkholderia (Bacillus) mallei & pseudomallei
Melioidosis:
Incidence in South-east Asian countries, firstly recognised in
Rangoon (1911)
Transmission through contaminated potable water supplies &
insect bites
Septicemia melioidosis characteristic features of sepsis
syndrome undergo rapid clinical deterioration death
within 48 hrs of hospital admission if septic shock present
Localised melioidosis: acute pneumonia, but mostly as a
subacute cavitating pneumonia accompanied by profound
weight loss (confused with TB/lung abscess)
Other localised: skin & soft-tissue abscess, lymphadenitis,
bone & joint infections, liver and/or splenic abscesses,
cystitis, pyelonephritis,, prostatic abscesses,
epidydymoorchitis, keratitis, mycotic aneurysms,
nasopharyngeal infections, & CNS abscesses.

Glanders/Melioidosis

Glanders:
Primarily horse disease and occasionally transmitted to
man
Initial symptoms are nonspecific; cutaneous &
subcutaneous nodules & pustules
WW I, German agents sabotage directed toward animals
shipped to the Allies from neutral countries. Both glanders
& anthrax used
Glanders was also used to infect human victims by Japans
notorious Unit 731 in Manchuria under the direction of Ishii
Shiro.
It is claimed that Glanders was weaponised & manipulated
to enhance its antibiotic resistance & was used by the
Russians to attack the mujaheddin in Afghanistan in 1980s.
Americans regarded melioidosis as a terrifyingly effective
disease for poisoning a water supply system.

Emerging Threats & Potential

Agents of Bioterrorism
> 75% emerging infectious agents are from zoonotic source
Avian influenza
There is no natural/vaccine induced immunity
Its transfer to human beings with virulence & remarkably high
(72%) mortality
SARS
Highly contagious & lethal
Difficult to differentiate clinically from other respiratory infections
No rapid diagnostic test, treatment & vaccine available
Access to the virus is not heavily restricted as for smallpox
West Nile virus
Monkey pox
Marburg & Ebola (Filoviridae), Congo-Crimean & Rift Valley Fever
(Bunyaviridae), & Lassa (Arenaviridae)

Possible Treatment

Anthrax
Inhalational anthrax: combination of ciprofloxacin, rifampicin plus therapeutic
thoracentesis
Cutaneous anthrax: penicillin could still be used
Postexposure prophylaxis: Ciprofloxacin or doxycycline
Plague
Pneumonic plague patients should be isolated
Streptomycin has long been used as drug of choice, but it is no longer
available in US Gentamicin
Postexposure prophylaxis: Tetracycline, Doxycycline, Sulfonamide &
Chloramphenicol
Tularemia
Streptomycin i.m. is drug of choice, except meningitis (combined w/
chloramphenicol)
Smallpox
Isolated under full contact & airborne precautions
Remove mirrors from patients room
Glanders/Melioidosis
Management of metabolic disturbance, abscess drainage
Ceftazidime, Cotrimoxazole or Co-amoxiclav

Image
Small Pox

Plague

Ebola/Filovirus

Yersinia Pestis

Tularemia (Rabbit Fever)

Ricin

Botulinum Toxin

Arenavirus

Ideal Bioterrorism Agent

Ready to be developed & produced in large
quantities
Efficiently dispersible
Highly infectious and effective
Resistant to medication
Stable in storage
Resistant to adverse environmental condition

Bioterrorism vs Natural
Disease caused by an uncommon agent (ex, smallpox)
High morbidity or mortality associated with a common disease
or syndrome
Increase in normal incidence
Discovery of an appropriate delivery system
Unusual disease, ex: anthrax through inhalation (cutaneous
anthrax is more common)
Illness unusual for a population/age group (chicken pox in
middle-aged adult)
Morbidity happen only in certain/limited area
Disease with unusual seasonal or geographical distribution
Large number of unexplained diseases or deaths
Unusual death or pattern of illness in animals preceding or
accompanies death or illness in humans or vice versa
Illness in people who are exposed to same ventilation system
Unusual antibiotic resistance pattern

Reference

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Final Word
Hans Zinser:
A bacteriologist & historian during the Great Depression in the
US

Infectious disease is one of the great

tragedies of living thingsthe struggle for
existence between different form of life ...
Incessantly the pitiless war goes on,
without quarter or armisticea
nationalism of species against species

THANK YOU