EMERGENCY RESPONSE TO CHEMICAL AND BIOLOGICAL AGENTS - CHAPTER 3 doc

Currently, there is little or no field detection equipment for biological agents available to local first responders or local hazardous materials teams.. One of the central problems in t

3 Biological Agents and

Toxins

“Ring around the rosie,

a pocket full of posies, ashes, ashes,

we all fall down!”

INTRODUCTION

The above nursery rhyme goes back to the fourteenth century when the Black Death (bubonic plague) killed over 25,000,000 people in Europe Bubonic plague symp-toms included painful, swollen lymph nodes, called buboes, in the armpit, groin, or neck, fever as high as 106°F, low blood pressure, exhaustion, confusion, and bleeding into the skin from surface blood vessels which produced a rose-colored ring Chapter 3 deals with biological agents that could be used by terrorists or others

as weapons of mass destruction (WMD) There are all kinds of bacteria, viruses, rickettsiae, chlamydia, fungi, and toxins available in the world, but only a limited number may be used as weapons Some bacteria are round (cocci), rod-shaped (bacilli), spiral (spirochetes), or comma-shaped (vibrios), and are capable of repro-ducing outside living cells Some examples include anthrax, brucellosis, cholera, plague (pneumonic), shigella, tularemia, and typhoid The nature, severity, and outcome of any infection caused by bacteria depend on the particular species, but diseases caused by bacteria often respond positively to the use of antibiotics Viruses are tiny organisms that can only grow in the cells of another animal More than 200 viruses are known to cause disease in humans Antibiotics are not much of a help for virus-produced diseases, although viruses may be at least partially responsive

to a few antiviral compounds that are available Examples would include Crimean-Congo hemorrhagic fever, dengue fever, Ebola fever, eastern equine encephalitis, influenza, HIV (human immunodeficiency virus), and Rift Valley fever Rickettsiae are small, round, or rod-shaped special bacteria that live inside the cells of fleas, ticks, lice, and mites and are transmitted to humans through bites from such pests They are similar in one respect to viruses in that they grow only within living cells, but dissimilar in that treatment of disease caused by rickettsiae often includes the use of broad-spectrum antibiotics Some of the world’s worst epidemics such as scrub typhus, Q fever, and Rocky Mountain spotted fever have been rickettsial in nature Chlamydia are microorganisms that live as parasites within living cells Two species cause disease in humans: Chlamydia trachomatis, and Chlamydia psittaci

(also known as parrot fever) Fungi are simple parasitic plants that lack chlorophyll and reproduce by making spores Of the 100,000 known species of fungi, approx-imately ten cause disease in humans Fungal infections tend to be mild but difficult

to cure Toxins are non-living poisons that come from living animals, plants, or microorganisms although some toxins can be produced or altered by chemical means Examples include botulinum toxins, mycotoxins (e.g., trichothecene), ricin, and staphylococcal enterotoxins

If you are a first responder, or hazardous materials response team (HMRT) firefighter, police officer, or emergency medical service person called to an incident, remember the following information about biological incidents: Except in unusual circumstances, you can’t see biological agents; they are odorless, colorless, and tasteless There is a delay in incubation; even the much feared Ebola fever, which has a moderate transmissibility from person to person, takes 7 to 9 days from exposure to the time when symptoms actually appear How many persons could you expose during those 7 to 9 days? And how cheaply? No other weapon, including chemical agents, nuclear warfare, military ordnance, or bows and arrows can com-pare to the sticker price of biological agents: anthrax could cost you slightly under one U.S dollar per casualty Such weapons are easy to prepare In some cases, you could even grow or produce your own if you have enough expertise to make home brew Since many biological agents will be disseminated as aerosol, the enemy can

be long gone before any reaction occurs They can be almost untraceable

A biological incident is very difficult to defend against because of ease of concealment, anonymity of the enemy, high lethal potency, ready accessibility, and relatively simple means of dissemination A small quantity can do you in; a lethal aerosol anthrax dose could be as little as a millionth of a gram As of today, bio response is beyond the capability of local government unless they have a fully trained and equipped Level A hazardous materials response team, and possibly beyond the ability of state government unless it has a top notch medical services program A mass casualty biological incident may be even beyond the experience, training, and equipment levels of the national government We won’t know until we have one Currently, there is little or no field detection equipment for biological agents available to local first responders or local hazardous materials teams Defense consultants are studying the possibilities, but delivery may take a long time There

is a very apparent lack of vaccines, antibiotics, assisted ventilation devices, experi-enced and trained medical personnel, detectors or meters for identification of bio-logical agents, and funding for vastly important local programs Federal programs will “assist” in biological response while local programs will be called upon to do the actual work of clearing, evacuation, control, triage, medical care, and urban search and rescue

One of the central problems in the copycat anthrax threats, other than the very high cost involved in responding to such hoaxes, is that biological detection in the field is just not available to many local response personnel The military may or may not have a couple of vehicle-mounted biodetectors that may or may not be currently reliable and past the developmental stage “Human beings are a sensitive, and in some cases the only, biodetector,” reports the Department of the Army Field Manual FM 89 (NATO Handbook on the Medical Aspects of NBC Defensive Operations, AMedP-6(B), Part II - Biological) Little or no field detection equipment exists for biological agents at the present time The military does have BIDS (Bio-logical Integrated Detection System), a vehicle-mounted system that can identify a

limited number of biological agents through antibody-antigen combinations by exposing samples of air to antibodies The process takes about 30 minutes and can currently detect the presence of botulism, anthrax, bubonic plague, and staphylo-coccus enterotoxin B

Biological and chemical agent detection systems for field use are a key factor

in the country’s domestic preparedness programs for terrorist attacks, which may use WMD in light of the approximately 110 anthrax hoaxes that have occurred in the United States during the past six months If local response forces do not have reliable field detection equipment, they could be forced to use unnecessary mitigation techniques ranging from decontamination to therapeutic drugs to vaccines One of the problems with so-called field detectors for biological agents is a possible false positive reading on present detection equipment

In at least one anthrax hoax, an incident that took place on February 18, 1999

at the Summit Women’s Health Organization, 530 North Water Street, in downtown Milwaukee, WI, an abortion clinic received a letter stating the envelope contained anthrax Fire department responders on-scene used a SMART® ticket detection system which reportedly indicated that anthrax may have actually been present Therefore, responders on-scene went ahead with decontamination, hospital treat-ment, and provision of antibiotic medicine Fire and medical officials said they would have taken such precautions even if the field test had actually been negative

It is not clear if the result was a false positive or an indication of the need for more adequate training in use of the SMART ticket system According to the media, fire officials at the scene reportedly said the test was “negative.” On March 1, 1999, local authorities confirmed that they did not know for certain until 12 hours later when they got results back from a laboratory in Maryland that anthrax was not present

The situation was complicated by the quality of the instructional materials The SMART ticket is supposed to turn red if anthrax is present The color chart that firefighters had was reportedly in black-and-white, and there were words to represent various colors The manufacturer faxed a real color chart A second test, using a control solution, turned the ticket pink

Environmental Technology Group, Inc (ETG) located in Baltimore, MD dis-tributes and markets SMART tickets as well as other domestic preparedness prod-ucts ETG is a prime Department of Defense contractor and an international supplier

of military products They deal in chemical and biological detection systems, as well as other products The SMART biological warfare agent detection ticket employs patented immuno-chemistry tests for specific biological agents (including anthrax, plague, ricin, botulinum toxins, brucella and several others ) They utilize antibody/antigen reactions A reaction vial contains colloidal gold particles If an agent is present in a sample, a complex forms between gold labeled antibodies and the agent A dacron swab transfers this complex to a ticket where the complex is filtered and concentrated onto a membrane and becomes visible as a red spot If an agent is not present in the sample, a complex does not form, gold particles diffuse through the membrane and are not visually detectable To operate the system, wipe the suspected area with a swab, place six drops of buffer solution into the vial, tap the tube with your finger to mix pellet, place the swab into the vial, squeeze the

swab against the vial wall to mix, and place the swab into the upper portion of the ticket and wait 5 to 15 minutes For test results, observe the test spot; if any distinct red color appears which may be in the shape of a dot or crescent and is a stronger color than that in the negative control spot, the test is positive The control spot must be free of any color other than a very faint pink If a reaction occurs in the negative control spot, or the detection spot is difficult to read, place one drop of buffer on a clean swab and wipe the reaction area Positive result will not wash away ETG also distributes the APD 2000 (advanced portable detector) which can simultaneously detect nerve and blister chemical agents, identify agents, recognize pepper spray and mace, and identify hazardous compounds Sensitivity for V agents

is four parts-per-billion (ppb) with a response time of 30 seconds Sensitivity for G agents is 15 ppb/30 seconds, for H agents is 300 ppb/15 seconds, and for lewisite

is 200 ppb/15 seconds For high concentrations of these agents, detection time is

10 seconds Selectable settings allow the APD 2000 to be used as a detector that automatically clears following an alarm or as a continuously-sampling monitor A fixed site remote detector featuring the APD 2000 system can also be supplied for force protection, fixed installation monitoring, building installation monitoring, perimeter security, remote detector networks, or decon hot/warm zone monitoring Another detection instrument, the miniature chemical agent detector (Mini-CAM), can simultaneously detect nerve, blister, blood, and choking agents and warn responders or military troops through both audible and visible alarms This detector

is currently in use by U.S and NATO forces It weighs only eight ounces, and incorporates a replaceable sensor module which allows it to operate continuously for up to four months

Biological agents may be alive; they can spread through infection; they may be able to duplicate themselves; some may be persistent, others may be transmissible from person to person The United States closed down its offensive biological weapons program in 1969 There has since been a loss of knowledge, experience, and data on new developments in offensive biological weapons as knowledgeable persons sought other employment, retired, or died over the last 30 years

Unlike chemical attacks which produce immediate casualties, biological attacks have delayed casualties, often delaying the realization that an attack has occurred

at all In a biological attack there is a delay due to the incubation period required

by biological agents, occuring hours or days after the attack later when people arrive

at hospitals with flu-like symptoms We do not presently have the reliable disease surveillance programs necessary to identify the biological agent(s) and provide the correct treatment Doctors, nurses, hospital personnel, and public health care workers would be the first line of defense against biological warfare Many such people work for private firms rather than government agencies Is the civilian medical community

in all areas of the nation really ready to deal with a biological mass casualty incident?

It will be the civilian health care system, plus local firefighters, police officers, and

Contact: Environmental Technology Group, Inc., 1400 Taylor Avenue, P.O Box 9840, Baltimore,

MD 21284-9840; 419-321-5370; 410-321-5255 (Fax).

emergency medical technicians and paramedics that will manage and do the work required by a biological attack in the United States — at least in the first 24 hours when most of the life and death decisions will be made

Biological weapons are old in the world but new in the United States We have had many bombings and some chemical agent releases, but only a very few biological agent releases There have been hoaxes and some actual attempts to use biological weapons here, but disregarding industrial incidents and releases of nuclear energy, only two incidents come readily to mind At a Dallas, TX hospital in the fall of

1996, laboratory staff were sent e-mail messages inviting them to a free breakfast

A dozen of the 45 laboratory staff fell ill with severe intestinal symptoms Inspection determined that muffins and doughnuts were treated with shigella which causes dysentery In Oregon in 1984, two members of cult leader Rajneesh Bagwhan’s religious group sprinkled salad bars in local restaurants with salmonella in an attempt

to decide a local election Over 700 persons were sickened, but there were no deaths The world has changed, and we are changing as well The Army has begun training civilian responders in 120 U.S metropolitan areas in chemical and biological agent response The National Guard is funded to form “RAID” teams around the United States The Marine Corps has a 400-person Chemical Biological Incident Response Force based in North Carolina for both domestic and foreign duty as necessary The U.S Army is forming a Chemical Biological Rapid Response Team (C/B-RRT) The F.B.I has a hazardous materials response unit The Federal Emergency Man-agement Agency can supply USAR (Urban Search and Rescue) teams from 25 local fire departments in 18 states, and the U.S Public Health Service is now developing Metropolitan Medical Strike Teams (MMST) Many other teams, such as the Army’s Technical Escort Unit as well as Explosive Ordnance Teams have been around for years and are highly trained What will these teams and local first responders find

as threats facing them in biological attacks?

Biological agents are most likely to be disseminated by aerosol, (i.e., a fine aerial suspension of liquid; fog or mist) or by solid (i.e., dust, fume, or smoke with particles small enough in size to be stable) The perfect size for human exposure is between 0.5 to 5 microns (or micrometers) which are a unit of length equal to one millionth of a meter Larger particles might be naturally filtered out by the inhalation process, while smaller sizes might be inhaled but not retained in an efficient manner Aerosol exposure can also contaminate food, water, and skin Although healthy, intact skin can resist the entry of many but not all biological agents, skin with wounds, cuts, or abrasions provides an opening for infection Sometimes the threat

is unknown and may be a single biological agent, a chemical agent with a biological agent (decon for the first before you decon for the second), or two biological agents with different incubation times When the threat is unknown, protective clothing must be worn along with respiratory tract protection such as a mask with biological filters, or a self-contained breathing apparatus (SCBA) with positive pressure The best time for spraying aerosol is late at night or just before the first rays of dawn The attackers want both security and a chance to get away with a dastardly deed; but they also need weather and atmospheric conditions as their unpaid assis-tants They need a time when conditions offer minimum interference from ultra-violet radiation, and maximum assistance from atmospheric inversion which can

assist a cloud to move along the surface of the land As an example, the early morning hours tend to be a time of slowest wind speeds The slower the wind speed, the higher the dosage, the smaller the area of coverage, and the higher the toxic effects Dosage is a very important factor in relation to biological agents Chemical agents have an “effective dose,” the amount of a substance that may be expected to have a specific effect Biological agents have a comparable term, “infective dose,” which refers to the number of microorganisms or spores necessary to cause an infection (Spores are a form taken by some bacteria making them resistant to heat, drying, and chemicals In some circumstances, the spore may change back into the active form of the bacterium Anthrax and botulism present examples of diseases caused by spore-forming bacteria.) For means of comparison, the average lethal chemical agents in storage today are thousands of times less lethal, by weight, than equivalent amounts of biological warfare agents Because of very high toxicity, the lethal biological agent dose can be far smaller than that required from chemical agents

Additionally, biological agents can be used against plants, animals, or materials rather than just against humans Local responders will probably have no early warning of a biological attack, having fewer detection devices for biological agents than for chemical agents It is entirely possible that local first responders (firefighters, police officers, and emergency medical personnel) will not even be called to the scene Sooner or later, due to the incubation time delay, everyone will be “coming down with the flu.” Always use the highest level of personal protective equipment available to protect the respiratory tract by using a full-face mask with biological filters or SCBA with positive pressure, at least until you know the specific threats

POTENTIAL BIOLOGICAL WARFARE AGENTS

Anthrax

Planned release of anthrax would probably be done by aerosol since the spore form

of the bacillus is quite stable Anthrax is viewed as the single greatest threat for use

in biological warfare; it is quite contagious with a high mortality rate (but is not contagious from person-to-person) Anthrax can easily be produced in large quan-tities, is relatively easy to weaponize, can readily be spread over a wide area, may

be stored safely, and remains lethal for a long period of time About 95% of natural anthrax infections are cutaneous; that is, they affect the skin Additional routes of entry may be by inhalation or ingestion It can also occur naturally; zebras are very much affected by anthrax Anthrax spores can settle in the soil Some herbivores may become infected in this manner, but humans are unlikely to be affected Bleach will kill anthrax spores When a terrorist or warlike act uses aerosol dissemination, inhalation-type anthrax will be the result — a much more dangerous disease than the natural form It must be treated with high dose antibiotic treatment before symptoms appear With anthrax, treatment must come quickly, within 24-hours, or most victims will die Untreated, the mortality rate of inhalation and intestinal cases

is about 95%, while untreated cutaneous (skin) anthrax can be up to 25% A unique

feature of anthrax is a treatment “eclipse” when patients start feeling better just before they die At the present time, 2 million military personnel in the United States have been or are being vaccinated

Medical classification: Bacterial Probable form of dissemination: Spores in aerosol Detection in the field: None

Infective dose (aerosol): 8000 to 50,0000 spores Incubation time: 1 to 6 days (in this case, the incubation time between exposure and onset of symptoms is 1 to 6 days for anthrax which is not transmissible from person to person Compare this incubation time with that of the virus, smallpox, which is 10 to 17 days Smallpox is highly transmissible from person to person After exposure to smallpox, a person could travel by air around the world a number of times and contaminate many people before developing any symptoms However, naturally occurring smallpox has been eradicated world-wide since 1977.)

Persistence: Spores are highly stable Personal protection: Protective clothing must be used as well as protection for the respiratory tract Use a mask with biological filters or SCBA with positive pressure, at least until you know the specific threat(s) Also, time/distance/shielding

Routes of entry to the body: Inhalation, skin, and mouth Person-to-person transmissible: No

Duration of illness: 3 to 5 days (often proves fatal) Potential ability to kill: High

Defensive measures: Immunization, good personal hygiene, physical condi-tioning, use of arthropod repellents, wearing protective mask, and practic-ing good sanitation

Vaccines: Yes Michigan Department of Public Health vaccine Drugs available: Yes Ciprofloxacin, doxycycline, and penicillin Decontamination: Soap and water, or diluted sodium hypochlorite solution (0.5%) Drainage and secretion precautions are necessary After invasive procedures or autopsy, decontaminate instruments and surfaces with 0.5% sodium hypochlorite

Botulism

A group of seven related neurotoxins (types A–G), botulinum toxins are typically found in canned foods Such toxins block acetylcholine release in a similar manner

to chemical nerve agents Botulism can cause paralysis which can lead to respiratory failure requiring assisted ventilation until the paralysis passes This toxin is not volatile and not dermally active Botulism appears to be the most dangerous toxin available, but many botulinum toxins would not work on a battlefield However, they can be effective assassination or terrorist weapons in closed areas such as subways or meeting rooms

Medical classification: Toxin Probable form of dissemination: Sabotage of food/water supply, or aerosol Detection in the field: None

Infective dose (aerosol): 0.001 mg/kg Incubation time: Variable (hours to days) Persistence: Stable

Personal protection: Protective clothing must be used as well as protection for the respiratory tract Use a mask with biological filters or SCBA with positive pressure, at least until you the know the specific threat(s)

Routes of entry to the body: Inhalation, mouth, wound Person-to-person transmissible: No

Duration of illness: 24 to 72 hours (months if lethal) Therapy consists mainly

of supportive care, such as intubation and assisted ventilation for respiratory failure

Potential ability to kill: High Defensive measures: Immunization, good personal hygiene, physical condi-tioning, use of arthropod repellents, wearing protective mask, and practic-ing good sanitation Spores can be killed by pressure-cookpractic-ing food to be canned

Vaccines: Yes IND (investigational new drug) Pentavalent Toxoid A-E Drugs available: Yes IND Heptavalent Anti-toxin A-F (equine despeciated); also, Trivalent Equine anti-toxin A, B, and E

Decontamination: Soap and water, or diluted sodium hypochlorite solution (0.5%) If contamination of foodstuffs is suspected, boil for ten minutes to kill toxin Botulism is not dermally active and secondary aerosols do not endanger medical personnel

Brucellosis

Natural infection of humans occurs through ingestion of unpasteurized milk or cheese, through aerosol present in farms and slaughterhouses, or by inoculation of skin lesions in people in close contact with animals Intentional exposure would be likely by aerosol, or possibly by contamination of food

Medical classification: Bacterial Probable form of dissemination: Aerosol; sabotage of the food supply Bru-cellosis is a “hindrance” bacteria; symptoms can take months to appear, and deaths are few and far between, even without medical care

Detection in the field: None Infective dose (aerosol): 10 to 100 organisms Incubation Time: 1 to 4 weeks

Persistence: Long persistence in wet soil and food Personal protection: Protective clothing must be used as well as protection for the respiratory tract Use a mask with biological filters or SCBA with positive pressure, at least until you know the specific threat(s)

Routes of entry to the body: Inhalation, mouth, skin, and eyes Person-to-person transmissible: No (except where open skin lesions are evi-dent)

Duration of illness: Varies greatly Potential ability to kill: Very low Defensive measures: Immunization, good personal hygiene, physical condi-tioning, use of arthropod repellents, wearing protective mask, and practic-ing good sanitation Avoid unpasturized milk products

Vaccines: Yes Drugs available: Doxycycline and rifampin Decontamination: Soap and water, or diluted sodium hypochlorite solution (0.5%) Drainage and secretion procedures are necessary

Cholera

Cholera is normally caused by ingestion of food or water contaminated with feces

or vomitus of infected persons or with feces of carriers A terrorist act would likely

be the result of an intentional contamination of water or food

Medical classification: Bacterial Probable form of dissemination: Sabotage in food and water; aerosol Detection in the field: None

Infective dose (aerosol): Has low infectivity to humans Incubation time: Hours to 5 days

Persistence: Unstable in aerosols and fresh water; stable in salt water Personal protection: Protective clothing must be used as well as protection for the respiratory tract Use a mask with biological filters or SCBA with positive pressure, at least until you know the specific threat(s)

Routes of entry to the body: Inhalation, mouth Person-to-person transmissible: Infrequent Duration of illness: Equal to, or greater than, 1 week Because of a common symptom of watery diarrhea, i.v fluid supplies can be insufficient (fluid loss for one patient can exceed 10 liters/day) Therapy consists mainly of fluid and electrolyte replacement

Potential ability to kill: Low with treatment, high without treatment Defensive measures: Immunization, good personal hygiene, physical condi-tioning, use of arthropod repellents, wearing protective mask, and practic-ing good sanitation

Vaccines: Yes Wyeth-Ayerst vaccine available in United States but provides about 50% protection lasting no more than six months Also, Swedish SBL oral vaccine effective, but not available in United States

Drugs available: Oral rehydration therapy Tetyracycline, doxycycline, cipro-floxacin, and norfloxacin

Decontamination: Diluted sodium hypochlorite solution (0.5%) Personal contact rarely causes infection Avoid vomit and feces, and wash hands thoroughly

Crimean-Congo Hemorrhagic Fever

Medical classification: Virus

Probable form of dissemination: Aerosol

Detection in the field: None

Infective dose (aerosol): High

Incubation time: 3 to 12 days

Persistence: Relatively stable

Personal protection: Protective clothing must be used as well as protection for the respiratory tract Use a mask with biological filters or SCBA with positive pressure, at least until you know the specific threat(s)

Routes of entry to the body: Inhalation of aerosol, tick bites, crushing an infected tick, or at the slaughter of viremic livestock

Person-to-person transmissible: Moderate

Duration of illness: Days to weeks

Potential ability to kill: High

Defensive measures: Immunization, good personal hygiene, physical condi-tioning, use of arthropod repellents, wearing protective mask, and practic-ing good sanitation

Vaccines: The only licensed vaccine is yellow fever vaccine

Drugs available: Prophylactic ribavirin may be effective for Crimean-Congo hemorrhagic fever

Decontamination: Diluted sodium hypochlorite solution (0.5%) Isolation measures and barrier nursing procedures are necessary

Plague

There are two variations of plague, pneumonic plague and bubonic plague Bubonic plague is the most common form, and has a secondary formation of large regional lymph nodes called buboes Blood may clot in the vessels, and may show up in blackened fingers and toes “Natural” plague most often is caused by the bite of a flea that had dined on infected rodents; a secondary source would be by sputum droplets inhaled from coughing victims There is a limited incidence of plague in the southwestern desert of the United States Usually, rodents there die of plague, fleas feed on the rodents’ bodies, plague multiplies in the flea, flea becomes unable

to bite normally, flea gets apprehensive and bites everything, and everything the flea bites gets infected with plague Some plague victims in the United States have been infected by household cats “Un-natural” plague, the result of terrorist or enemy action, could possibly be an aerosol, or less likely, a release of plague-carrying fleas

— forms of dissemination that may develop into pneumonic plague leading to quick death Pneumonic plague is an extremely virulent form, can be transferred from person to person, and seems unaffected by vaccine During World War II, the Japanese established Unit 731 in Mukden, Manchuria and carried out experiments

in biological warfare on prisoners of war from the United States, Britain, Australia, and New Zealand They tried aerosolizing plague but were unsuccessful