Bioterrorism Preparedness and the Elderly VTC
In collaboration with the Arkansas Bioterrorism Continuing Education Partnership, the Arkansas Geriatric Education Center (AGEC), the GRECC at CAVHS and the DWR Institute on Aging at UAMS hosted a video teleconference (VTC) on April 13, 2005 in EDII-B107 at UAMS. Twenty four sites throughout the State and VA facilities in Alexandria, LA; Jackson, MS and New Orleans, LA received the VTC.
Aubrey J. Hough, Jr., MD, Distinguished Professor and Associate Dean for Translational Research and Special Projects at the UAMS College of Medicine traced the historical roots of bioterrorism and inferred from them a prognosis for the future. The earliest recorded use of a bioweapon dates from c. 1000 BC when the Assyrians poisoned enemy wells with rye ergot - a fungal toxin. In the antiquity, the use of poison arrows is often mentioned. Records from China reveal the existence of formulae to produce poisonous smoke to use against enemies. Rustic, but effective bioweapons, are the contamination of enemy water supplies with diarrhea causing agents and with decomposing bodies of animals. Hurling objects such as clay pots with serpents, scorpion loaded bombs or human bodies infected with plague were all used as weapons. During a peace conference in 1763, the Delaware Indians received as gifts blankets with smallpox. Such blankets caused the decimation of Missouri River tribes. WW I brought the widespread use of mustard gas and WW II horrific experiments on humans with such agents as typhoid, dysentery and anthrax. Post WW II, all major powers developed lethal and incapacitating biological agents and biotoxins. For terrorists, biological weapons are weapons of choice because they are easy to obtain, produce and delivery and they can be disseminated in a stealth fashion over a large area. The list of scenarios where biological weapons might be used is a work in progress since terrorists create new ones as their need arises. Quoting from Faulkner, Dr. Hough concluded that looking at bioterrorism "only reveals to man his own folly and despair; and victory is an illusion of philosophers and fools.”
Preparedeness is the key to efficient response in a bioterrorist attack.
Dr. Jeanne Y. Wei, Professor and Executive Chair of the DW Reynolds Department of Geriatrics at the UAMS College of Medicine and GRECC Staff Physician at Central Arkansas Veterans Healthcare System (CAVHS) focused on the impact of bioterrorism in the elderly. As a group older adults tend to have comorbidities that increase their vulnerability to infectious and toxic agents and delay in treatment is more costly. They also react differently to these agents than younger adults, for they may have no fever or specific symptoms and this makes the proper diagnosis more difficult. The stress associated with bioterrorism threats or attacks may cause delirium and impair cognitive function in the elderly. Infections and toxins may lead to serious cardiovascular complications such as hypoxemia, arrythmias, cardiomyopathy, acute coronary syndrome, septic shock, disseminated intravascular coagulopathy and endocarditis. The elderly should prepare for a bioterrorist event by having readily available 3 gals. of water per person, non-perishable food, can and bottle openers, 2 flashlights and a battery operated radio or television as well as replacement batteries. In addition, they should have comfortable protective layers of clothing, a cell phone and cash. Medical supplies needed are a first aid kit, lists of medicines, dosages and schedules included, and allergies; medical devices and batteries for them; physician and relative's phone numbers; information sources; Medicare cards; health items used daily, such as an oxygen tank. By helping healthcare providers to recognize public healthcare emergencies and establishing a methodology to meet the acute care needs of the elderly, especially the cognitively impaired, the risk of bioterrorism in the elderly should decrease.
"Chemical Terrorism Awareness” was the topic of Dr. Margie A. Scott"s presentation. The Professor and Vice-Chair in the Department of Pathology at the UAMS College of Medicine, Chief of the Pathology and Laboratory Service and Coordinator of Bioterrorism Preparedness at CAVHS discussed three types of chemical warfare agents - nerve, vesicants and riot control agents. Nerve agents (Tabun, Sarin, Soman and VX) penetrate skin, eyes and lungs; produce loss of consciousness, seizures, apnea and even death depending on the amount; and are the most toxic of the chemical agents. Nerve agents act by attacking muscarinic receptor sites (glands and smooth muscles) and/or nicotinic receptor sites (skeletal muscle secretions). The sign and symptoms of exposure to nerve agents vary depending on whether the exposure was in the form of vapor or liquid while the intensity of the symptoms depends on the concentration of the agent and length of exposure. Antidotes used to treat exposure are atropine, 2-PAMCI and diazepam. Half-dose antidote autoinjectors for geriatric and pediatric use have been available since February 2004. Vesicant (Blister) agents damage the eyes, skin, respiratory system and cause other systemic effects. The best initial treatment is decontamination. One of them, sulfur mustard, better known as “mustard” is a systemically toxic, fast acting agent with a latent period between exposure and effect. No specific antidote exists. Lewisite, another blister agent, is fast acting but the symptoms are immediate and BAL antidote is available. Dr. Scott noted that the need for standardization of procedural protocols and communication between responsible agencies as well as in depth training of first responders and healthcare personnel is imperative to be able to respond in the event of a biochemical accident or terrorist attack.
Rebecca E. Martin, MD, Associate Professor of Medicine, Division of Infectious Diseases at the UAMS College of Medicine and Medical Director of the Ebert Diagnostic Unit at CAVHS addressed the possible use of infectious diseases as agents of bioterrorism. Infectious diseases such as smallpox and bubonic fever are old potential agents of bioterrorism, but there is a host of emerging diseases for which little or nothing can be done. Dr. Martin focused on 1) SARS, 2) avian flu, 3) viral hemorrhagic fevers and 4) variant Creutzfeld-Jakob disease (vCJD), but warned others will continue to surface. 1) SARS, a new coronavirus, emerged in China in early 2003 and by July had spread to 31 countries on 5 continents, had infected 8098 persons and had close to 10% mortality. Coronaviruses infect humans and animals and present with common cold symptoms and mild GI illness. SARS was probably transmitted by exotic animals handled by restaurant workers while preparing food. Once the virus passed to humans (zoonosis) it was spread by air, droplets or in direct contact from person to person. No effective treatment or vaccine is available. Strict contact, plus eye protection, and airborne isolation are required. 2) Avian influenza (H5N1) or “bird flu” is a greater public threat than SARS. In 2003, it had an outbreak in Asia and more than100 million birds were destroyed. Although only 43 cases were reported in Thailand and Vietnam, as of March 2005, the mortality rate was a frightening 72%. Bird flu does not spread efficiently between humans, but if the virus gains such ability, a pandemic – much like the “Spanish flu” pandemic, which caused 50 million deaths with 50% of those among young adults – could be in store. 3) Viral hemorrhagic fevers (VHF) spread by coming into contact with an infected host or by insect bites. Considered “Category A Bioterrorism Agents” are filoviruses (i.e. Ebola, Marburg) and arenaviruses (i.e. Lassa, Machupo). Other VHFs are bunyviruses (i.e. Hantavirus) and flaviviruses (i.e. Yellow fever, Dengue). Treatment for these is mainly supportive. Strict body fluids contact isolation and airborne isolation are required. Autopsies are not recommended, embalming should be avoided and cremation or immediate burial in airtight bag is prescribed. 4) vCJD or “human mad cow disease” is a degenerative fatal brain disorder transmitted through consumption of contaminated cow products or blood transfusions. No treatment exists and the outcome is death. Since the four infectious diseases discussed can cause illness with high morbidity or mortality, large-scale public health preparedness needs to be underway.