BIOLOGICAL WARFARE
BIOLOGICAL WARFARE
AND TERRORISM
AND TERRORISM
PierrettePierrette MelinMelin
Medical microbiology, University hospital of Liege, Belgium
Medical microbiology, University hospital of Liege, Belgium
The dark side of microbiology The dark side of microbiology The dark side of microbiology The dark side of microbiology
The dark side of microbiology The dark side of microbiologyThe dark side of microbiology The dark side of microbiology
Definition
Definition
Historical perspective
Historical perspective
How real is the threat
How real is the threat
Biological agents
Biological agents
Anthrax overview
Anthrax overview
Smallpox, hemorrhagic viruses
Smallpox, hemorrhagic viruses
Clues to a potential
Clues to a potential
biocrime
biocrime
Are we prepared
Are we prepared
Bioterrorism
Bioterrorism
Intentional
Intentional
or
or
threatened
threatened
use
use
of
of
Viruses
Viruses
,
,
bacteria
bacteria
,
,
fungi
fungi
, or
, or
toxins
toxins
from living
from living
organisms
organisms
To
To
produce
produce
death
death
or
or
disease
disease
in
in
Biological
Biological
warfare
warfare
is
is
not
not
new
new
even
even
without
without
a
a
precise
precise
understanding
understanding
In
In
Greek
Greek
and
and
Roman
Roman
’
’
s
s
times
times
14th
14th
Century
Century
:
:
Plague
Plague
at
at
Kaffa
Kaffa
, Ukraine
, Ukraine
Once upon a time
Biological
Biological
warfare
warfare
is
is
not
not
new
new
Modern Biological Warfare
Modern Biological Warfare
During
During
World
World
Wars
Wars
: Use
: Use
of
of
biological
biological
weapons
weapons
WWI, WWI, GermansGermans infectedinfected French French cavalrycavalry
(
(B.malleiB.mallei, , B.anthracisB.anthracis))
WWII, WWII, JapaneseJapanese ProgramProgram overover ManchuriaManchuria
(
(B.anthracisB.anthracis,,V.choleraeV.cholerae, , ShigellaShigella, , Salmonella,
Salmonella,Y.pestisY.pestis))
After
After
WWII
WWII
US, Soviet Union US, Soviet Union andand othersothers initiatedinitiated
research
Biological Warfare Agreements
Biological Warfare Agreements
19251925 Geneva Geneva ProtocolProtocol
Use Use ofof biologicalbiological weaponsweapons prohibitedprohibited
Basic Basic researchresearch, production , production andand possession possession notnot proscribedproscribed
= = ineffectivenessineffectiveness
1972 1972 BiologicalBiological WeaponsWeapons ConventionConvention
DevelopmentDevelopment, production, , production, stockpilingstockpiling «« prohibitedprohibited »» ((QtyQty) )
Destruction Destruction ofof stocks stocks requiredrequired
19751975 Geneva Conventions Geneva Conventions RatifiedRatified
> 100 > 100 signatorysignatory nations (Iraq nations (Iraq andand Soviet Union Soviet Union includedincluded))
Bioterrorism
Bioterrorism
:
:
How
How
real
real
is
is
the
the
Treat
Treat
?
?
Hoax
Hoax
versus
versus
Actual
Actual
BT
BT
Event
Event
By the end of the
By the end of the
XX
XX
ththcentury,
century,
running to the next millennium
1984, Oregon1984, Oregon
751 cases 751 cases ofof SalmonellosisSalmonellosis
EatingEating atat saladsalad bars in 10 restaurantsbars in 10 restaurants
CriminalCriminal investigation investigation identifiedidentified perpetratorsperpetrators as as
followers
followers ofof BhagwanBhagwan ShreeShree RajneeshRajneesh
SignificantSignificant rolerole ofof
local public local public healthhealth deptdept..
earlyearly contact contact betweenbetween locallocal--statestate--national national levelslevels
Importance Importance ofof notifyingnotifying public public heathheath deptdept. . ofof anyany
suspicious
suspicious clusters clusters ofof illnessillness
A Large Community Outbreak
of Salmonellosis Caused by Intentional Contamination of Restaurant Salad Bars
12 (27%) 12 (27%) ofof 45 45 laboratorylaboratory workersworkers in a large in a large medicalmedical centercenter
had
had severesevere diarrhealdiarrheal illnessillness
8 (67%) 8 (67%) hadhad positive positive stoolstool cultures for cultures for S.dysenteriaeS.dysenteriae type 2type 2
EatingEating muffins or muffins or donutsdonuts in staff break in staff break roomroom implicatedimplicated
PFGA patterns PFGA patterns indistinguishableindistinguishable for for stoolstool, muffin, , muffin, andand
laboratory
laboratory stock stock isolatesisolates
CriminalCriminal investigation investigation identifiedidentified thethe provider provider ofof pastrypastry
coated
coated withwith ShigellaShigella to to herher coworkerscoworkers
Kolavic
Kolavic et et alal. JAMA 1997;278:396. JAMA 1997;278:396 Miller. Clin
Miller. Clin MicrobMicrob Newsletter 2001;23:179Newsletter 2001;23:179
Shigellosis caused by intentional contamination The unhappy laboratorian in Dallas (1996)
Chemical
Chemical
&
&
Biological
Biological
Terrorism
Terrorism
1991 : Minnesota, ricin 1991 : Minnesota, ricin toxintoxin ((hoaxhoax))
19941994--95 : Tokyo, Sarin 95 : Tokyo, Sarin andand biologicalbiological attacksattacks
1995 : Arkansas, Ricin 1995 : Arkansas, Ricin toxintoxin ((hoaxhoax))
1995 : Ohio, 1995 : Ohio,
Yersinia
Yersinia
pestis
pestis
(sent in mail)(sent in mail)
1997 : Washington DC, 1997 : Washington DC, «« AnthraxAnthrax »» ((hoaxhoax))
1998 : 1998 : NavadaNavada, , nonnon--lethallethal strainstrain ofof B.anthracisB.anthracis
Agent
Agent
selection
selection
considerations
considerations
«
«
Catastrophic
Catastrophic
»
»
public
public
health
health
consequences
consequences
High
High
morbidity
morbidity
and
and
mortality
mortality
Mass
Mass
casualties
casualties
which
which
overwhelm
overwhelm
medical
medical
systems
systems
«
«
Terror
Terror
»
»
perspective
perspective
Distress of population
Distress of population
Panic among those who decide
Panic among those who decide
Irrational measures
Irrational measures
Paralysis of public utilities
Paralysis of public utilities
Biological
Biological
Agents
Agents
of
of
Highest
Highest
Concern
Concern
(
(
Category
Category
A)
A)
Variola
Variola
major
major
(
(
Smallpox
Smallpox
)
)
Bacillus
Bacillus
anthracis
anthracis
(Anthrax)
(Anthrax)
Yersinia
Yersinia
pestis
pestis
(
(
Plague
Plague
)
)
Francisella
Francisella
tularensis
tularensis
(
(
Tularemia
Tularemia
)
)
Botulinum
Botulinum
toxin
toxin
(
(
Botulism
Botulism
)
)
Filo
Filo
-
-
and
and
Arenaviruses
Arenaviruses
(Viral
(Viral
hemorrhagic
hemorrhagic
fevers
fevers
)
)
-- EasilyEasily disseminateddisseminated or or transmittedtransmitted,,
-- HighHigh mortalitymortality, social disruption,, social disruption,
Biological
Biological
Agents
Agents
of
of
Highest
Highest
Concern
Concern
(
(
Category
Category
A)
A)
ALL
ALL
suspected
suspected
or
or
confirmed
confirmed
cases
cases
should
should
be
be
reported
reported
to
to
health
health
authorities
authorities
IMMEDIATELY
IMMEDIATELY
Why
Why
these
these
biologics
biologics
as
as
weapons
weapons
InfectiousInfectious via via aerosolaerosol
OrganismsOrganisms fairlyfairly stable in stable in thethe environmentenvironment
SusceptibilitySusceptibility ofof civiliancivilian unprotectedunprotected populationpopulation
DelayedDelayed onsetonset
HighHigh morbiditymorbidity andand mortalitymortality
PersonPerson--toto--personperson transmission (transmission (smallpoxsmallpox, ,
plague
plague, VHF), VHF)
DifficultDifficult to diagnose to diagnose andand / or / or treattreat
Other
Other
advantages
advantages
of
of
biologics
biologics
as
as
weapons
weapons
ItsIts easyeasy to do but hard to traceto do but hard to trace
Small Small amountsamounts -- devastatingdevastating effectseffects
EasyEasy to to obtainobtain
InexpensiveInexpensive to to produceproduce
PotentialPotential for for disseminationdissemination overover large large geographicgeographic areaarea
Invisible, Invisible, odorlessodorless, , tastelesstasteless
DifficultDifficult to to detectdetect
CreatesCreates panicpanic
Can Can overwhelmoverwhelm medicalmedical servicesservices
Overt
Overt
Attack
Attack
(
(
Anounced
Anounced
release
release
of
of
biological
biological
agent)
agent)
Problems
Problems
Verifying
Verifying
if an
if an
attack
attack
has
has
taken
taken
place
place
Influx
Influx
of
of
«
«
worried
worried
well
well
»
»
-
-
need
need
triage
triage
Need
Need
for infection control
for infection control
Covert
Covert
Attack
Attack
(
(
Biological
Biological
agent
agent
released
released
secretly
secretly
)
)
Problems
Problems
with
with
recognition :
recognition :
Symptoms
Symptoms
overlap
overlap
common
common
illnesses
illnesses
Delayed
Delayed
onset
onset
from
from
time
time
of
of
exposure
exposure
Victims
Victims
present
present
to
to
different
different
centers
centers
Likely
Likely
Scenarios
Scenarios
Aerosol
Aerosol
release
release
Major
Major
city
city
, large
, large
event
event
, or
, or
key
key
function
function
Recognition
Recognition
of
of
attack
attack
through
through
epidemiologic
epidemiologic
patterns or
patterns or
lab
lab
specimen
specimen
From
From
catastrophic
catastrophic
terrorism
terrorism
with
with
mass
mass
casualties
casualties
To
To
microevents
microevents
producing
producing
civil
civil
unrest
unrest
,
,
disruption,
From an ancient disease
From an ancient disease
to bioterrorism
to bioterrorism
From an endemic disease in
From an endemic disease in
poor countries to terror in
poor countries to terror in
2001
Anthrax :
Anthrax :
overview
overview
Naturally
Naturally
occuring
occuring
anthrax
anthrax
BacillusBacillus anthracisanthracis
A zoonoseA zoonose
Man, Man, accidentalaccidental victimvictim
Anthrax as a
Anthrax as a
bio
bio
-
-
weapon
weapon
WhyWhy HowHow FactsFacts
The
The
anthrax
anthrax
bacteria
bacteria
:
:
Bacillus
Bacillus
anthracis
anthracis
-- IllustriousIllustrious bacteriumbacterium :: Koch, 1877 Koch, 1877 Pasteur, 1881 Pasteur, 1881 -- SurvivalSurvival : : Spores Spores -- WeaponsWeapons :: Caspule
On sheep
On sheep
’
’
s
s
blood
blood
agar
agar
NonNon--hemolytichemolytic
Large coloniesLarge colonies
FirmlyFirmly adherentadherent
NonNon--motilemotile
Non Non encapsulatedencapsulated
Gram+ spore Gram+ spore formingforming rodsrods
On
On
nutrient
nutrient
agar/CO
agar/CO
22
EncapsulatedEncapsulated bacillibacilli
Pathogenesis,
Pathogenesis,
Major factors of virulence
Major factors of virulence
The capsuleThe capsule
3 genes 3 genes capcapAA, , capcapBB and and capcapCC, carried on a plasmid, carried on a plasmid
Edema and lethal toxinsEdema and lethal toxins
Both must be present for disease to occurBoth must be present for disease to occur
Encoded on another plasmidEncoded on another plasmid
Edema factor + protective antigen Edema factor + protective antigen edema toxinedema toxin
AdenylateAdenylate cyclasecyclase activity activity fluid accumulationfluid accumulation
Lethal factor + protective antigen Lethal factor + protective antigen lethal toxinlethal toxin
Zinc Zinc metalloproteasemetalloprotease activity activity stimulates stimulates
macrophages to release
macrophages to release TNFTNFαααααααα and interleukinand interleukin--11ββββββββ + + proinflammatory
Anthrax : a zoonose
Anthrax : a zoonose
Worldwide
Worldwide
ParticularlyParticularly in in poorpoor countriescountries
Primarly
Primarly
disease
disease
of
of
herbivores
herbivores
Systemic
Systemic
infection
infection
Contamination :
Contamination :
WhileWhile grazinggrazing on on contaminatedcontaminated land (spores)land (spores)
EatingEating contaminatedcontaminated feedfeed or or drinkingdrinking from from
contaminated
contaminated waterwater holesholes
Soil
Soil
reservoir
reservoir
Man :
Man :
accidental
accidental
victim
victim
of
of
anthrax
anthrax
20,000 20,000 -- 100,000 cases/100,000 cases/yearyear
USA :<1 case/USA :<1 case/yearyear for for thethe pastpast 20 20 yearsyears
By By handlinghandling productsproducts or or consumingconsuming undercookedundercooked
meat
meat from from infectedinfected animalsanimals
FromFrom inhalation inhalation ofof sporesspores
FromFrom contaminatedcontaminated productsproducts : : suchsuch as as woolwool
Man :
Man :
accidental
accidental
victim
victim
of
of
anthrax
anthrax
3
3
Forms
Forms
occur
occur
in
in
humans
humans
Cutaneous
Cutaneous
:
:
the
the
most
most
common
common
form
form
occuring
occuring
naturally
naturally
(95 %)
(95 %)
Gastrointestinal
Gastrointestinal
(1%)
(1%)
Anthrax
Anthrax
in Europe
Man,
Man,
accidental
accidental
victim
victim
:
:
cutaneous
cutaneous
anthrax
anthrax
In an
In an aerosolaerosol bioterroristbioterrorist attack
attack, , fewfew casescases wouldwould probably
•
• Incubation : Incubation : hourshours to 7 to 7 daysdays •
• Small papule Small papule --> > ulcerulcer surroundedsurrounded by by vesiculesvesicules (24(24--48h)48h) •
• PainlessPainless eschareschar withwith edemaedema •
Gastrointestinal
Gastrointestinal
anthrax
anthrax
Ingestion
Ingestion
of
of
contaminated
contaminated
meat
meat
Incubation :
Incubation :
hours
hours
or
or
up
up
to 7
to 7
days
days
Fever
Fever
, acute
, acute
gastroenteritis
gastroenteritis
,
,
vomiting
vomiting
,
,
bloody
bloody
diarrhea
diarrhea
Intestinal
Intestinal
eschar
eschar
similar
similar
to anthrax
to anthrax
lesion
lesion
(
(hemorrhagichemorrhagic))
Progression to
Progression to
generalized
generalized
toxemia
toxemia
Mortality
Mortality
rate 50
rate 50
-
-
100%
100%
despite
despite
treatment
Man,
Man,
accidental
accidental
victim
victim
:
:
inhalational
Inhalation Inhalation ofof sporesspores
Incubation: 1 to 43 Incubation: 1 to 43 daysdays
Initial Initial symptomssymptoms (2(2--5 d)5 d)
FeverFever, , coughcough, , myalgiamyalgia, malaise, malaise
Terminal Terminal symptomssymptoms (1(1--2d)2d)
HighHigh feverfever, , severesevere respiratoryrespiratory
distress
distress, , septicseptic shockshock
HemorrhagicHemorrhagic mediastinitismediastinitis Mortality
Mortality ~ 100% ~ 100% in 24
in 24--36 36 hourshours despite
despite aggressiveaggressive treatment
Anthrax
Anthrax
Diagnosis
Diagnosis
, Culture :
, Culture :
blood
blood
or
or
sputum
sputum
Gram + spore Gram + spore formingforming rodrod
Gram Gram stainstain direct direct smearsmear
ELISA to ELISA to detectdetect antigenantigen in in bloodblood
PCR for virulence PCR for virulence genesgenes ((underunder investigation)investigation)
Isolation : standard
Isolation : standard
precautions
precautions
,
,
no
no
quarantine
quarantine
needed
needed
Presumptive Identification of
Presumptive Identification of
Bacillus
Bacillus
anthracis
anthracis
Type of Sample
Type of Sample Presumptive IdPresumptive Id Characteristic
Characteristic MethodMethod
Clinical sample
Clinical sample 1) G+ rods 1) G+ rods Gram stainGram stain AND
AND
2) Capsule
2) Capsule India ink stainIndia ink stain
Isolate
Isolate 1) Spore1) Spore--formerformer Gram stainGram stain AND
AND
2) Colony morphology
2) Colony morphology Observation on SBAObservation on SBA AND
AND
3) Non
3) Non--hemolytichemolytic Observation on SBAObservation on SBA AND
AND
4) non
Anthrax :
Anthrax :
Treatment
Treatment
Unlikely
Unlikely
to
to
be
be
effective
effective
after
after
symptoms
symptoms
AntibioticsAntibiotics
PenicillinPenicillin or or doxycyclinedoxycycline
CiprofloxacinCiprofloxacin or or otherother quinolonesquinolones
SupportiveSupportive carecare
PostPost--exposureexposure
Vaccine x3 Vaccine x3 (0,2,4 (0,2,4 wkswks)) + Cipro or + Cipro or DoxyDoxy x30 dx30 d
OR OR antibioticsantibiotics alonealone x60 dx60 d
Long
Anthrax, a
Anthrax, a
bio
bio
-
-
weapon
weapon
-
-
Facts
Facts
1979, Sverdlovsk (URSS):
1979, Sverdlovsk (URSS):
«
«
accidental
accidental
»
»
release
release
of
of
spores from a
spores from a
military
military
laboratory
laboratory
OverOver 4 km 4 km aroundaround, , atat leastleast 77 cases 77 cases withwith 66 66
deaths
deaths
OverOver 50 km, 50 km, attackattack on on livestocklivestock ((cattlecattle, ,
sheep
sheep,,……))
1995, Tokyo :
1995, Tokyo :
Aun
Aun
Shinrikyo
Shinrikyo
’
’
s
s
sect
sect
8 8 failuredfailured attemptsattempts ofof attackattack withwith anthrax anthrax andand
botulism
botulism toxintoxin
«
«
Postal
Postal
»
»
Anthrax, USA
Anthrax, USA
(CDC,
(CDC,
November
November
2001)
2001)
CasesCases Florida Florida NY NY citycity New Jersey New Jersey Washington Washington TOTALTOTAL
Confirmed Confirmed 1717 Cutaneous Cutaneous 00 44 33 00 Inhalational Inhalational 22 11 22 55 Suspected Suspected 55 Cutaneous Cutaneous 00 33 22 00 Inhalational Inhalational 00 00 00 00 TOTAL TOTAL 22 88 77 55 2222 5
Anthrax, a
Anthrax, a
bio
bio
-
-
weapon
weapon
,
,
how
how
?
?
Infection via
Infection via
aerosol
aerosol
Duration
Duration
of
of
aerosol
aerosol
:
:
few
few
hours
hours
Low
Low
risk
risk
of
of
secondary
secondary
aerosol
aerosol
Could
Could
be
be
improved
improved
as
as
bio
bio
-
-
weapon
weapon
:
:
Multi
Multi
-
-
Resistant
Resistant
strains
strains
Quiz for a champion:
Quiz for a champion:
What
What
do ?
do ?
50 kg
50 kg
of
of
Anthrax spores,
Anthrax spores,
released
released
under
under
the
the
wind
wind
, by a plane
, by a plane
over
over
a
a
urban
urban
population
population
of
of
5,000,000 ?
5,000,000 ?
Sicken
Sicken
>
>
250,000
250,000
people
people
Smallpox
Smallpox
,
,
a
a
weapon
weapon
of
of
horror
horror
1980 1980 -- Global eradicationGlobal eradication
Humans were only known Humans were only known
reservoir
reservoir
PersonPerson--toto--person person
transmission
transmission
(aerosol/contact)
(aerosol/contact)
Most contagious before Most contagious before
onset of rash onset of rash Up to 30% mortality in Up to 30% mortality in unvaccinated unvaccinated
Hemorrhagic
Hemorrhagic
Fever
Fever
Viruses
Viruses
:
:
Apocalyptic
Apocalyptic
Agents ?
Agents ?
Filo
Filo-- (Ebola, Marburg), Arena(Ebola, Marburg), Arena--, Bunya, Bunya-- and and FlavivirusesFlaviviruses
Spectacular in presentation, mysterious, exotic,frighteningSpectacular in presentation, mysterious, exotic,frightening
High fatality ratio: virus dependant (10High fatality ratio: virus dependant (10--90%)90%)
EBOLA virus EBOLA
Bioterrorism
Bioterrorism
,
,
how
how
serious
serious
is
is
the
the
threat
threat
?
?
> 11
> 11
September
September
2001, USA
2001, USA
Bioterrorism
Bioterrorism
:
:
A
A
remote
remote
risk
risk
became
became
a
a
real
real
possibility
possibility
Letters
Letters
with
with
spores
spores
of
of
B.anthracis
B.anthracis
Few
Few
cases, 5
cases, 5
deaths
deaths
Rather
Rather
biocrime
biocrime
than
than
bioterrorism
bioterrorism
Lessons
Lessons
learned
learned
RelativelyRelatively easyeasy to to produceproduce contagiouscontagious materialmaterial, ,
But, But, notnot easyeasy to manufacture to manufacture thethe adequateadequate «« sporesspores »»
SomeSome organismsorganisms ((B.anthracisB.anthracis) ) easyeasy to to findfind worldwideworldwide
EffectEffect ofof a a limitedlimited attackattack
CopycatCopycat phenomenonphenomenon in in otherother countries (countries (lettersletters
claiming
claiming to to containcontain contagiouscontagious materialmaterial))
LabsLabs hadhad to face to face unknownunknown problemsproblems
HowHow to use to use prophylacticprophylactic antibioticsantibiotics
No country No country waswas reallyreally preparedprepared
Our eyes
Are we prepared ?
Are we prepared ?
Where do we go from here ?
Where do we go from here ?
Planning
Planning
-
-
Coordination
Coordination
-
-
Preparedness
Preparedness
Medical response
Medical response
Priorities for Public Health infrastructure
Priorities for Public Health infrastructure
Are we prepared ?
Are we prepared ?
Emergency preparedness and responseEmergency preparedness and response
Enhance surveillance and epidemiologic capacityEnhance surveillance and epidemiologic capacity
Enhance laboratory capacity, network for BTEnhance laboratory capacity, network for BT
Consensus protocols, updateConsensus protocols, update
Education, training, informationEducation, training, information
Link between partnersLink between partners
Communication is vitalCommunication is vital
Create a national stockpileCreate a national stockpile
Laboratory Response Network
Laboratory Response Network
for Bioterrorism
for Bioterrorism
BSL
BSL--22 Clinical
Clinical labslabs
BSL BSL--33 BSL BSL--33 BSL BSL--44 Levels Levels:: D D C C B B A A To
To provideprovide an an organizedorganized response
response systemsystem
(
For First Responders
For First Responders
The challenge =
The challenge =
To recognize the disease !
To recognize the disease !
Why ?
Why ?
Timely initiation of appropriate and
Timely initiation of appropriate and
measured response is critical
Clues to a potential
Clues to a potential
biocrime
biocrime
Epidemiologic clues + characteristic syndromes
Epidemiologic clues + characteristic syndromes
Natural or nefarious outbreak ?Natural or nefarious outbreak ?
Geographical patternGeographical pattern
Outbreak of rare or novel diseaseOutbreak of rare or novel disease
Outbreak outside an endemic areaOutbreak outside an endemic area
Seasonal disease during an offSeasonal disease during an off--season timeseason time
Unusual resistance profileUnusual resistance profile
