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Nuclear, Biological and Chemical (NBC) LISTSERV INFORMATION Dear friends, Just a couple of questions to throw out to the group: Smallpox- would it be possible that anyone attempting to use smallpox as a weapon would genetically modify it so that the vaccine currently used would be ineffective? Is there any reason to suggest that if we actually saw a case of smallpox, that antiviral agents such as acyclovir or famciclovir would have any use in treating them? Anthrax- Much has been made in the press about using Cipro (ciprofloxacin) to treat this. Again, the question I pose is whether it is possible that anyone weaponizing this bug would first make it resistant to the usual antibiotics? Once a patient has pulmonary anthrax, at what point in their disease are they contagious? For some reason, I'm thinking that they are not particularly contagious at any point. In fact, I'm thinking that in terms of EMS workers coming to the scene of an Anthrax exposure, say for example a crop duster that just went over a stadium or something, that once the "dust settles", so to speak, that the EMS workers are not particularly susceptible to the Anthrax spores because once they hit the ground, they are no longer in the appropriate particle size to cause pulmonary exposure. Would other quinolones such as Levaquin (levofloxacin) or Avelox (moxifloxacin) be expected to have as much effectiveness as Cipro in treating an acute case? Plague- I recall something about safety pin like gram negative rods on sputum gram stain, and treatment with doxycycline. Anyone have any comments about the potential for weaponizing plague? How about Tularemia? Venezuelan Equine Encephalitis- Any treatment besides supportive and vaccine? Viral Hemorrhagic Fevers- Any use to giving ribavirin or other antivirals here? Again, I'm thinking these are not respiratory transmission, so it would be mostly blood/body fluid precautions, correct? Botulism toxin- I seem to recall that this is more like a chemical agent than biologic, it is not contagious, is there an anti-toxin available here? Staph Enterotoxin B- Same comments as for bot tox. From an emergency medicine point of view, there's no question that we are on the front line here in terms of identifying an exposure. Whereas an explosion will be obvious to all, a biologic attack would probably go unnoticed until people start to present in the E.D. with suspicious symptoms. Does anyone know an appropriate phone number to call for help, perhaps a CDC hotline is available, or do you think it would be better to just call our own state's public health department, realizing that there's certainly a possibility that we might raise an alarm that turned out to be false. Dean
Dobbert, M.D. Anthrax: Rx doxycycline, cipro, or PCN IV. NOTE: antibiotic therapy must be continued until the patient is immunized with first three shots! Check the immunization schedule, then check the availability of anthrax vaccine. If this doctrine has changed will someone please let me know? Plague: If inhaled, plutonic plague will be difficult to Dx. Indirect fluorescent antibody is definitive. Gram stain can be a clue. The patient will be septic and moribund. We still see this endemic in NM. I think it would be difficult to weaponries unless in an enclosed stadium or similar environment. Smallpox: We would be the Indians, and they (terrorist) would be Sir Jeffrey Amherst. I suppose the good part is that it should be pretty recognizable, and as soon as I see a case, I'll be killing the virus from the pox in my kitchen and scarifying the people I care about with dead organisms. Botox: Multivalent antitoxin? The thought of chembio attack is absolutely overwhelming and probably imminent. Warner.Anderson@GIMC.IHS.GOV Smallpox: I believe the old USSR weaponized smallpox, the regular version. They were attempting to do all sorts of modifications to smallpox, as well as Marburg, and they even worked with Ebola . I have heard no reports that they were ever successful at creating a strain of smallpox resistant to the regular vaccine, however, the best source for all of this is Ken Alibek, and he left Russia in 1992...intelligence has been lacking since then. Also, important to remember: The USSR military had smallpox virus APART from the known last source of laboratory smallpox that the WHO was aware of in Russia. So, they had a long time to work with a wild strain. No evidence that Russia has continued to work on biological weapons, however, large supply of scientists from the former USSR with the knowledge and bills to pay....(scary) The former USSR military also tried to and reportedly were successful at inserting a gene from Ebola into smallpox...they were attempting to create a virus with the disease causing properties of Ebola (not quite as communicable) and the communicability of smallpox (not quite as deadly). Not sure if they were successful...don't know if they ever tested it...? But, nobody knows for sure if the smallpox labs operated by the military there were completely destroyed, i.e. virus cultures and all. Anthrax: the old soviet military had reportedly developed strains of anthrax resistant to all known antibiotics. Very believable. Not sure if they ever tested it. As far as a modern day "non-state sponsored" anthrax lab being able to come up with a similar strain unless it was supplied by the old soviet military: Probably much less likely. So, if attacked by, for example, a US raised and cultured anthrax...probably the Cipro would be effective, as the laboratory apparatus, in my estimation, would not be able to survive long without detection, and thus, developing such super-resistant strains are less likely...but you never know. The old Soviet military always kept a very very large supply of weaponized anthrax in storage...so there was literally tons of it produced. Did they destroy it all before an enterprising young scientist left, for say, Iraq? Not sure. Anthrax is much less likely to cause inhaled form once it has settled...but it can be stirred up. In Sverdlovsk, there were reports that several people came down with Anthrax after the cleanup effort. However, anthrax spores can lie dormant in the thoracic and mediastinal lymph nodes for up to 100 days in primates, and the same is believed to be true for humans. It was later postulated that those who became sick after cleanup were those with dormant disease. (In 1979, a biological weapons plant accidentally released about 100 grams of anthrax spores into the nighttime air of the industrial city of Sverdlovsk, killing about 70 people downwind of the plant http://www.pbs.org/wgbh/pages/frontline/shows/plague/sverdlovsk/) One scenario I played out for our firefighters and police in a tabletop scenario while in the military: What would you do if someone in one of the barracks' opened an envelope and dust fell out with a letter saying it was anthrax? Their reported measure they would take: Isolate the building and not let anyone out until decontaminated....which I think is wrong...get everybody out as soon as possible: The anthrax, if is IS anthrax, will be most deadly if inhaled. Any spores on the bodies of these individuals would not be dangerous unless aerosolized. Wipe em all down with hypochlorite if no symptoms of chemical exposure and then when everybody is out, isolate the building. Treat them all with a first dose or two of Cipro until the absence of anthrax is confirmed. (This is why I'm so concerned that other firefighters/police departments might be un-prepared to deal with these types of events...keeping people inside a building where anthrax is suspected can only increase the likelihood that some will become exposed by inhalation). As far as waiting for the "dust to settle"...not feasible, as there is no way to test for anthrax spores that are suspended in air, as far as I know...so...get the people out of the area away from the "dust"...there will be no immediate casualties to deal with unless they are coughing etc. Decontaminate them (not in a shower) and treat them with Cipro until the agent is confirmed....The real problem here: is someone going to announce an attack while it is taking place? Probably not. If they do announce it...is it really anthrax???? If you go in loaded for anthrax and it's really botulinum toxin or mycotoxin (yellow rain...which may be a clue) you may not be properly prepared...so, the scenario of going into a stadium while victims are still there after being attacked by anthrax is not a probable scenario. Also, Cipro in children??? Use it until the anthrax's susceptibility to PCN can be established...risk vs. benefit ratio is in favor of this, according to consensus based recommendations published in JAMA (May 12, 1999 vol 281, No. 18) Many from USAMRIID, CDC, and Johns Hopkins Center for Civilian Biodefense Studies folks in on this one Plague: Plague was weaponized by the US and Japan (probably amongst others). Japan actually tested it on humans, as reports go, in "unit 731". As with many biological weapons: none are all that useful as a battleground agent, one reason why the US stopped its program. Plague has been weaponized, however. Same for Tularemia. These agents are great for terrorist use, however, so don't count any of them out. VEE: as far as I know, no human studies of antivirals, alpha-interferon, or interferon inducers. VHF: Ribavirin has some efficacy if given within the first 4 days for certain types of hemorrhagic fever viruses. Poor activity against Marburg, Ebola. Marburg, Ebola, Lassa, and Congo-Crimean: There are reports of aerosolized nosocomial spread. (Medical Management of Biological Casualties Handbook, USAMRIID, 1999) Bot tox: There is a vaccine, reluctant to use, however, because it precludes the medicinal use of bot tox in anybody immunized. Not communicable, acts to kill axons, so there are similarities with nerve agents in that respect. Be more worried about food source contamination...that's still the best way to use it. SEB: No vaccine. Suspect this in febrile people with respiratory syndrome and without CXR abnormalities (Medical Management of Biological Casualties Handbook, USAMRIID, 1999). In general, we are the front lines of a biological attack, and a true intentional use of biologicals would go unnoticed unless the attackers were complete idiots (and they are...so they are likely to be noticed in some respects) Aum Shinrikyo has the most comedic collection of attempted biological attacks known to man, but they went unnoticed...so even a group like this carried out many unsuccessful but unnoticed biological attacks. The first steps as an emergency physician: suspect it and don't feel like a conspiracy freak for doing so. It's not a question of IF...but WHEN as the new saying goes. When you start seeing an influx of atypical infections, you should notify your hospital epidemiologist, local law enforcement, talk to other hospitals...they may be seeing the same thing....veterinarians are an excellent and overlooked part of the team, too...many of these agents also kill animals, and they would be the ones to notice this. This is the number I keep in my palm pilot, along with numbers for the local FBI: The CDC Emergency Response Office: (770) 488-7100 This number may be outdated...I have never tested it. But, I would call it if I were embroiled in a real or possible attack. They may be able to at least offer guidance or make other phone calls for you. This is the hard part...getting the plan down. There are many ways to attack this, as there is what I would generally refer to as a Charlie Foxtrot as far as government agencies involved with responding to these scenarios. The problem with the governments "top down" approach is that it leaves my local firefighters and paramedics "out of the loop" as far as knowledge and equipment necessary to deal with such a scenario. Sure, there are regional response teams...but how long will it take them to get to your neighborhood??? Will all your first responders be the second set of casualties??? That's the biggest problem we face, in my estimation. Also, how about your nurses in the ER and your technicians, and your ward secretary and the check-in secretary? Is your hospital security adequate to stop a mass panicked crowd from storming the doors to your hospital??? In the military hospital where I used to work, we discussed, but of course, never authorized, use of deadly force by hospital security to keep contaminated people out of the hospital....is that reasonable??? I think it may be...but of course, these are military trained security officers, and not your garden variety of security guard...but still...you see what I'm saying??? Reference: Charlie and Foxtrot...essentially, this is military jargon. when communicating letters, we use words that start with that letter, so if you can't figure out what it means, put two words together the first of which starts with C and the second that starts with F, and is generally used slang to denote disorganization and incompetence amongst a large group of people. I keep a large list of links to biological and chemical terrorism websites at erdoc.com. Also, some great books of reference. These are available online or at Amazon.com: 1. Biohazard by Ken Alibek with Stephen Handelman..Dr. Alibek was the head of the former soviet biological weapons program until he defected to the US. 2. Living Terrors, by Michael T. Osterholm and John Schwartz (Dr. Osterholm has been seen many times lately on CNN and FoxNews, and was one of the authors of the consensus statements in JAMA. 3. Medical Management of Biological Casualties, USAMRIID Available online...there's a link at erdoc.com 4. The Military Textbook of Medicine (Available online: http://www.nbc-med.org/SiteContent/HomePage/WhatsNew/MedAspects/contents.htm l) 5. Toxic Terror: Assessing Terrorist Use of Chemical and Biological Weapons by Jonathan B. Tucker, editor 6. Biological Weapons: Limiting the Threat by Joshua Lederberg, editor with a forward by former defense secretary William Cohen 7. Plague Wars: The Terrifying reality of Biological Warfare by Tom Mangold and Jeff Goldberg...and excellent book about actual use with biological and chemical weapons 8. The Biology of Doom, by Ed Regis..about the US germ warfare program 9. Anthrax: The Investigation of a Deadly Outbreak by Jean Guillemin ...about the Sverdlovsk accident, cover up, etc. 10. Factories of Death: Japanese Biological Warfare, 1932-45 and the American Cover-up by Sheldon H. Harris 11. Saddam's Bombmaker by Khidhir Hamza with Jeff Stein...Dr. Hamza was the head of the Iraq nuclear arms program until he defected to the United States...a very excellent book from another insider, not unlike Ken Alibek's book. Hope this is helpful, and sorry it is long winded...but as you can see, I've spent a great deal of time thinking about this. It was one of my main military duties to be up on this stuff, a duty I took quite seriously. William
E. Franklin, DO
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