Biological

Warfare Attack
Diagnosis and
Treatment

Dan Gervich, MD
Gregory C. Gray, MD, MPH
 “The one that scares me to death,
perhaps even more so than tactical
nuclear weapons, and the one we have
the least capability against is
biological weapons.”

General Colin Powell, 1993

NY Times 10/14/01
http://abcnews.go.com/sections/us/terrorism_groups/
 Ideal Biological Warfare Agents

• Inexpensive
• Easy to produce
• Aerosolized (1 to 10um diameter)
• Survives sunlight, drying, and heat
• Causes lethal or disabling disease
• Results in person-to-person transmission
• Has no effective therapy or prophylaxis.

Osterholm, MT. Bioterrorism: A real modern threat. In Emerging Infections 5. Scheld WM,
Craig, WA, and Hughes JM eds. ASM Press, Washington, DC. 2001. Pps 213-222
 Russian Bioweapons Program

• 25,000 and 32,000 people were employed in

a network of 20 to 30 military and civilian
laboratories and research institutions
• 40,000 metric tons of bioagents were
produced; much was weaponized
• The program was supposedly dismantled in
1992
•Preston R. Annals of Warfare New Yorker 1998 March; Alibek K Biohazard Random House, NY, NY
2000; Emerg Infect Dis 1999;5:523-27.
 Russian Bioweapons Program

• Smallpox • Typhus
• Anthrax • Melioidosis
• Plague • Foot and mouth virus
• Equine encephalitis • African swine fever
viruses virus
• Tularemia • Trichothecenes
• Marburg virus mycotoxins
• Q fever • Glanders

•Alibek K Biohazard Random House, NY, NY 2000

•Kortepeter MG, Parker GW. Potential Biological Weapon Threats Emerg Infect Dis 1999;5:523-27.
•Preston R. Annals of Warfare New Yorker 1998 March
 Destroying the Evidence
“In 1988, Soviet scientists were scrambling to destroy their secret
stockpile of anthrax, which they had manufactured in violation of the
Biological and Toxin Weapons Convention (BWC). Alarmed at the
possibility that the West was catching on and could call for inspections,
the Soviets moved quickly to cover their tracks. Scientists placed
hundreds of tons of the deadly pink powder in huge stainless steel
canisters, doused it with bleach to kill the spores, then sent the drums on
a 1,000-mile train ride to a remote island in the Aral Sea, a secret
biological weapons testing site. There soldiers dumped the sludge into
11 shallow pits, poured in more bleach, and buried the anthrax mixture
under Vozrozhdeniye Island’s sandy soil.”

Choffnes E. Germs on the Loose. Bulletin of Atomic Scientists 2001 March/April

From NASA’s Terra satellite….. Rebirth island joins the mainland
http://earthobservatory.nasa.gov
http://www.lonelyplanet.com/mapshells/central_asia/uzbekistan/uzbekistan.htm
 Iraq’s Bioweapons Program

• Anthrax • Botulism toxin

• Congo-Crimean • Clostridium
hemorrhagic fever perfringens
virus
• Aflatoxin
• Yellow fever virus
• Enterovirus 17 • Ricin
• Human rotavirus • Camelpox
• Trichothecenes • Wheat cover smut
mycotoxins
JAMA 1997;278:418-424
Epidemiologic Clues of a Biowarfare Attack
• Large epidemic with similar disease in a discrete
population
• Many cases of unexplained disease
• More severe disease than expected
• Disease unusual for the population
• Disease normally transmitted by a vector uncommon
in your area
• Uncommon disease
• Unusual strains of pathogens

From USAMRIID’s Medical Management of Biological Casualties

Handbook, 2001
 Public Health Assessment
• Many diseases caused by bioterrorism
actions will initially present with
nonspecific clinical symptoms
• Your responsibility is to be informed
regarding biowarfare threats and to
weigh this information along with clinical
and epidemiological data in assessing
your patients
• Dan Gervich begins presentation here
 Viruses Causing Encephalitis as
Biowarfare Agents

• Venezuelan equine encephalitis

• Western equine encephalitis
• Nipah viruses
• Others less likely - Eastern equine encephalitis,
Japanese encephalitis, St. Louis encephalitis, Murray
Valley encephalitis, Lacrosse encephalitis, etc.
 Venezuelan Equine
Encephalitis
• Endemic - The Americas
• 8 mosquito-born viruses cause disease in
horses, mules, donkeys, and humans
• Zoonotic reservoirs - bats, birds, rodents,
and certain tropical jungle mammals.
• Weaponized by the United States under a
program that was discontinued in 1969
• Transmission – aerosolized threat; human to
human and equine to equine risk is low
• Infective dose (aerosol) -10-100 organisms
 Venezuelan Equine Encephalitis
• Incubation – 1-5 days
• Duration of illness – days to weeks
• Lethality – Low (17,000 human cases in
Mexico 1969-71 with no deaths)
• Vaccines – Two IND human unlicensed VEE
vaccines under study; do not protect against
all serotypes
• Immunoprophylaxis – none
• Chemoprophylaxis – alpha-interferon and
interferon-inducer poly-ICLC effective in
animal models
 Venezuelan Equine Encephalitis
• Clinical presentation (similar to influenza)
– nearly 100% of infected develop symptoms
– Sudden onset general malaise, chills, spiking
fevers (380C to 40.50C), rigors, severe headache,
photophobia, leg and back myalgias, nausea,
vomiting, cough, sore throat, injected conjunctiva
– leukopenia
– <4% children & <1% adults develop encephalitis
• Diagnosis
– virus isolation (blood, CSF)
– Serologic studies include IgM ELISA indirect FA,
hemagglutination inhibition, CF, and IgG ELISA
– PCR
• Management
– Supportive, no quarantine needed
 Hemorrhagic Fever Viruses
as Biowarfare Agents
• Arenaviridae – Junin (Argentinian), Machupo
(Bolivian), Guanarito (Venezuelan), and Sabia
(Brazilian) fever, and Lassa Fever viruses
• Bunyaviridae
– Nairovirus - Congo-Crimean hemorrhagic fever virus
– Flebovirus – Rift Valley Fever virus
– Hantaviruses
• Filoviridae – Ebola, and Marburg viruses
• Flaviviridae – dengue, yellow fever, West Nile viruses
 Crimean-Congo Hemorrhagic Fever
• Endemic – Kazakhstan, Uzbekistan, Pakistan,
Afghanistan, Dubai, Iraq, South Africa, Greece,
Turkey, Albania, and India.
• Weaponized - by Russia
• Transmission – Aerosolized threat; transmission by
tick bites (genus Hyalomma), also direct or
aerosolized exposure to the blood of viremic sheep,
cattle, or humans. Nosocomial transmission is
common.
• Reservoir - include hares, hedgehogs, birds, and
large animals.
• Infective dose (aerosol) –1-10 organisms
SAMJ, Vol. 62, p576-580, October,1982
 Crimean-Congo Hemorrhagic Fever

• Incubation – 1-3 days, range 1-12 days

• Duration of illness – days to weeks
• Lethality – can be high
• Vaccines – inactivated mouse brain vaccine has
been used in Russia; no vaccine available in the
United States
• Prophylaxis – tick repellants
• Chemoprophylaxis – none
 Crimean-Congo Hemorrhagic Fever
• Clinical presentation
– abrupt high fever, myalgias, headache, abdominal pain, back pain,
diarrhea, dry cough. 75% of patients show hemorrhagic features
after 3-5 days: petechial rash often appears in the throat,
nosebleeds, hematemesis, ecchymoses. DIC may follow
symptoms as well as shock and ARDS.
• Diagnosis
– virus isolation (blood) in VERO cells
– Serologic studies include IgM ELISA
• Management
– Isolation and containment with full precautions (glove, gowns,
masks, eye protection), and extreme care in handling lab
specimens, and body fluids
– Supportive care
– There is evidence that CCHF responds to treatment with ribavirin
CCHF Virus. Ecchymoses encompassing left upper extremity one
week after onset of CCHF. (Photo courtesy of Robert
Swaneopoel, PhD, DTVM, MRCVS, National Institute of Virology,
Sandringham, South Africa.)
eMedicine Journal, October 15 2001, Volume 2, Number 10
 Cholera
• Endemic – Endemic in many parts of Africa,
India and the developing world.
Transmission – oral / fecal transmission.
Thought to be a possible bioterrorism agent
through contamination of drinking water.
• Reservoir – man; copepods and other
zooplankton in brackish waters
• Infective dose –10-500 organisms
 Cholera
• Incubation – 2-3 days, range 4 hrs – 5 days
• Duration of illness – >=week
• Lethality – low with treatment; high without treatment
• Vaccines – current killed whole cell vaccine offers
only 50% protection for 3-6 months in endemic areas
• Chemoprophylaxis – close contacts only:
tetracycline, doxycycline, erythromycin,TMP-SMX,
ciprofloxacin, etc.
 Cholera
Clinical presentation - sudden onset of profuse
painless watery stools (rice water stools), nausea,
and vomiting; if untreated rapid dehydration, acidosis,
shock, hypoglycemia in children, renal failure
Diagnosis - Bacterial isolation; toxin production should
be confirmed by the laboratory
Management - Isolation is not necessary;
hospitalization with enteric precautions; aggressive
rehydration therapy, administration of antibiotics, and
treatment of complications
 Toxins as Biowarfare Agents

• Botulinum
• Staplococcal enterotoxin B
• Trichothecene mycotoxins
• Ricin
 Comparative Lethality and Dose
for Toxins in Mouse Models

Quantity of toxin
LD50 / Molecular wt Open-air exposure to
Agent (ug/kg)/ (daltons) 100 km2
Botulinum 0.001 / 150,000 85kg

Ricin 3.0 / 64,000 400 metric tons

USAMRIID. Medical Management of Biological Casualties Handbook February

2001. http://usamriid.detrick.army.mil/
 Botulinum Toxin
• Source – One of several toxins (termed A-G) from
Clostridium bacteria; most potent neurotoxins known;
100,000 times more toxic than the nerve agent Sarin
• Iraq had 10,000 liters of botulism toxin
• Endemic – Worldwide distribution; 3 forms:
foodborne, infantile, and wound botulism
• Transmission – aerosolized or food borne threat; no
human-to-human; inhalation syndrome is similar to
food borne disease
• Infective dose –0.001 ug/kg is LD50
• Method of Action – blocks neuromuscular
transmission
 Botulinum Toxin
• Detoxified – air (12 hours); sunlight (1-3 hours)
• Incubation – symptoms after inhalation can occur in
12 to 36 hours; low dose exposure delays sxs
• Duration of illness – death can occur in 24-72 hours
• Lethality – high without respirator support
• Vaccines – pentavalent toxoid vaccine is effective in
primates and is under IND status (3 dose series with
annual booster); available only for high risk groups
• Chemoprophylaxis – none
 Botulinum Toxin
• Clinical presentation
– Dry mouth, blurred or double vision, cranial nerve palsies,
photophobia, difficulty swallowing
• Diagnosis
– Clinical - Patient is afrebrile, alert, oriented; reduced gag
reflect; pupils may be dilated or fixed; reduced deep tendon
reflexes; respiratory distress may lead to cyanosis;
progressive symmetrical descending flaccid muscle paralysis
• Management
– Supportive care; ventilatory support; antixons (CDC)
– Draw sera sample for future neutralization assay
– Aerosols from patients are not a hazard
 Staphlococcal Enterotoxin B

• Source – One of several toxins from

Staphlococcal aureus; associated with food
poisoning
• Transmission – aerosolized threat; no
human-to-human transmission
• Infective dose –30 ug/person incapacitates
 Staphlococcal Enterotoxin B

• Incubation – 3-12 hours after inhalation

• Duration of illness – hours
• Lethality – <1%
• Vaccines – vaccine under development
• Prophylaxis – use of a protective mask
• Chemoprophylaxis – none
• Mechanism of action – pyrogenic toxins produce
toxic-shock like response
 Staphlococcal Enterotoxin B
• Clinical presentation
– abrupt onset fever, chills, headache, myalgias, nonproductive
cough. In more severe cases dyspnea and retrosternal
chest pain. Nausea, vomiting and diarrhea are likely to
occur. Fever may last several days. Cough may persist for
several weeks. High doses are expected to be fatal.
• Diagnosis
– Clinical (febrile respiratory syndrome without CXR findings);
large number of patients would suggest an a large scale
attack
• Management
– Supportive care; ventilation may be necessary
– Standard precautions for healthcare workers; aerosols from
patients are not a hazard
 Trichothecene Mycotoxins

• Source – A Group of over 40 compounds produced

by the grain mold (genus Fusarium); easy to produce;
allegedly released as “yellow rain” in Laos (1975-81),
Kampuchea (1979-81), Afghanistan (1979-81), and
Sudan (1999)
• Transmission – aerosolized threat; mycotoxins can
adhere to and penetrate the skin; can be inhaled and
ingested; no human-to-human transmission but
contaminated clothing can serve as a reservoir
• Infective dose – uncertain
• Method of Action – cytotoxic; inhibits protein and
nucleic acid synthesis
 Trichothecene Mycotoxins
• Incubation – 2-4 hours
• Duration of illness – days to months
• Lethality – moderate
• Vaccines – under development
• Chemoprophylaxis – topical products under
development
 Trichothecene Mycotoxins
• Clinical presentation
• Early symptoms are rapid and include: burning
skin pain, redness, tenderness, blistering, leading
to skin necrosis and sloughing of skin.
• If inhaled respiratory symptoms include cough,
dyspnea, and wheezing.
• Gatrointestinal symptoms may include nausea,
vomiting, and diarrhea.
Vesicles and erosions on the back of hairless guinea pigs at 1 day after application of (bottom to top) 25 ng, 50 ng, 100 ng, or
200 ng of T-2 mycotoxin in 2mcL of methanol. (from Wannamacher RW Jr, Wiener SL. Trichothecene mycotoxins. In: Zajtchuk
R, Bellamy RF, eds. Medical Aspects of Chemical and Biological Warfare- Textbook of Military Medicine. Washington, DC: US
Department of the Army, Office of the Surgeon General, and Borden Institute; 1997: 666.)
 Trichothecene Mycotoxins
• Diagnosis
– Clinical (high attach rates, dead animals, and
physical evidence (yellow, red, green or other
pigmented oily liquids) febrile respiratory
syndrome without CXR findings); other than
mustard one of the few agents to affect the skin
(mustard agents have an odor and symptoms are
delayed)
• Management
– Supportive care; remove clothing; bathing; burn
care
– Collect serum and urine for future study
References
Alibek K, Haldelman S. Biohazard : The Chilling True Story of the Largest
Covert Biological Weapons Program in the World-Told from Inside by the
Man Who Ran It. Random House, Inc. New York, NY 1999.

USAMRIID. Medical Management of Biological Casualties Handbook

February 2001. http://usamriid.detrick.army.mil/

CDC - http://www.bt.cdc.gov/

American Society Microbiology - http://www.asmusa.org/pcsrc/bioprep.htm

Iowa DPH - http://www.idph.state.ia.us/Terrorism/default.htm

JHU - http://www.hopkins-biodefense.org/

California DHS - http://www.dhs.ca.gov/ps/dcdc/bt/index.htm