 Good afternoon. Let me welcome you to this broadcast. This is a joint collaboration between the United States Army Medical Research and Material Command and the Centers for Disease Control and Prevention at the U.S. Department of Health and Human Services. This is a well-timed look at the military and public health response to the deliberate use of biological agents. It's another example of our departments working together on emerging infectious diseases. There's no room for doubt. We must join forces to combat the threat of biological warfare and terrorism. The military has invested time and resources in this area for many years. At the same time, public health agencies at all levels have built a cadre of trained professionals to detect and respond to infectious disease outbreaks regardless of their cause. Today, you will hear how many potential terrorists have turned their attention to the possible use of biological agents. We're all aware of the threats to do just that. Make no mistake, these threats could become a reality that could potentially overwhelm this country's public health and medical infrastructure. The President and Congress have launched efforts to upgrade our public health systems for disease detection and early warning by expanding local preparation and our response capacities. But we must do more. We know we can't win this fight acting separately. That's why it's up to all of us to forge new working partnerships among public health and military, public safety, emergency response, laboratory and the medical communities. The purpose of this broadcast is to help all of us to prepare for this challenge. Thanks so much for joining us. This program is presented by USAMRAID, the United States Army Medical Research Institute of Infectious Diseases, and the Centers for Disease Control and Prevention. Forty years ago we prepared for nuclear war. Now the Cold War has ended and we face a new threat. Unprecedented and unpredictable. It may not come with explosions. It may not come with rockets overhead. We may not see it when it happens, while it quietly infects. Whether you're a soldier or civilian on the battlefield or at home, as patients roll into your emergency rooms and clinics, your aid stations and field hospitals, will you recognize the symptoms? Will you recognize the signs? Will you know what to do? Welcome to the first day of our three-day live broadcast. For the last two years now, our satellite programs on the medical management of biological casualties have been enormous successes. And we hope to continue that tradition with the help of all of you out there in the audience. This year you are made up of civilians and military members. You are docs and nurses, firemen and policemen, epidemiologists and public health officials. You represent local, state and national institutions. You include soldiers, sailors, marines, airmen and coast guardsmen. Welcome to all of you. I'm Lieutenant Colonel Ted Cislak from the Operational Medicine Division at USAMRAID, the US Army's Medical Research Institute of Infectious Diseases. I'm going to be your host for the first two days of this course. During that time, we're going to review some of the material we discussed last year, but the majority of our program has been completely reformulated and updated. We have with us this year several world-class medical experts in the fields of biological warfare defense and biological terrorism planning. And they're going to be live in the studio with us over the next three days. We also have pre-taped interviews with a variety of experts who couldn't be here in the studio. We have several compelling video scenarios and diagnostic exercises that you can complete at your downlink sites. Now what we're going to do is today discuss the threat agents. We don't have time to discuss every potential agent, nor do we feel this is necessary. So this year we're going to focus on the major representative agents from the various classes of pathogens, namely the bacteria, the viruses, and then finally the toxins. Tomorrow on day two, we're going to use a military bio warfare scenario to teach you the proper sequence of effectively managing a battlefield biological warfare attack. On the third day of the course, that day is going to be presented by the Centers for Disease Control and Prevention, and it will focus on the civilian public health and medical response to bioterrorism. We want you to have ample chance to ask questions during this program, so you can fax questions or comments in anytime during the broadcast, but we've also scheduled call-in segments, and we'll let you know when the lines are open for your live phone questions. You should have received your student booklets, and they should look like this, but due to last minute registrations, some of you may not have received them. Not to worry. You'll have to share with someone for the time being, but you should get yours eventually. The student packet consists mostly of reference materials, but it does include the site activity, the evaluation, and the final exam that you're going to need to complete in order to get credit for this course. Now, you can download each portion of the student materials from our website, and our website address is www.biomedtraining.org. You can also complete the final exam and evaluation in one of two ways, either with the original scan forms received from your site facilitator, or directly through our internet website. We strongly encourage you to use this website for both registration and for completing your test and evaluation. In that way, you'll be able to receive continuing education credit immediately upon finishing the exam. Now, to start us off, I think it's useful to start talking about the threat, and I find it convenient to consider the threat on at least three levels. So today I want you to consider the strategic threat, the tactical threat, and the terrorist threat. Now, in the military, we are very accustomed to dealing with the first two of those. Military planners for centuries have dealt with the strategic and the tactical threat. But I think all of you in the military also realize that as we reap the peace dividend, as the Cold War is now over, as we become involved more and more in humanitarian missions, peacekeeping missions, and missions other than war, we in the military are being called on to deal with the terrorist threat as well. Furthermore, if you're a civilian public health official out there, or a first responder, and God forbid you ever have to deal with biological agents, then it almost certainly will come in the form of a terrorist attack. So what I want to do is talk briefly about each of these three levels of warfare or bioterrorism. So what do I mean by the strategic threat? Well, here I mean, what would the Albanian four-star general think makes a good weapon? His goal is to win the war, to alter the course of global politics. What would help him do that? Well, if you look at it from that perspective, the news for us as public health officials and medical countermeasure planners is actually quite good, because very, very few biological agents have the necessary properties that downwind drift the stability in the atmosphere, for example, to make them viable large-scale strategic threats. That list might include anthrax, it might include smallpox, and it might include plague, but it probably includes very little else. So I think it's entirely conceivable that with a little bit of effort, we might come up with effective medical countermeasures for everything on that very short list. Now let's switch gears for a moment and talk about the tactical threat. What do I mean here? Here I mean, what would the Albanian Lieutenant Colonel think makes a good weapon? His job is to take that hill. What would help him take that hill? Well, if you look at it from that perspective, the list of possible agents gets a little bit longer, and now some of the toxins, like botulinum toxin, staph enterotoxin B, which would not have had the stability to make large-scale strategic weapons, might at least make viable tactical weapons. But still that list is only seven or eight agents long, and still it's entirely conceivable that we might develop countermeasures for everything on that list. Now just as an aside, many military planners would argue that biological weapons never make good tactical weapons, and that's because biological weapons have one very important characteristic that chemical, conventional, and nuclear weapons don't have, and that's an incubation period. There's a delay between the time I release my weapon and the time I see its effect, and that delay may vary from a few hours in the case of a heavy SEB attack to several weeks in the case of brucellosis, but in general, for most of the agents we're going to discuss during this program, it's on the order of several days. So if I'm told to take that hill, I probably don't want to throw my weapons at that hill and sit around and twiddle my thumbs for several days, waiting for them to have their effect. So in that sense, again, many military planners would argue that biological agents never make good tactical weapons, but even if you could envision a tactical use for them, again, that list is probably only seven or eight agents long. Now, when we switch gears and talk about the terrorist threat, I'm here to tell you that our task as public health officials becomes immense, because I think you have to ask yourself, what is the average terrorist seeking? Well, often the answer to that question is simply publicity. And if that's all I'm after, then I'm here to tell you almost anything makes a good weapon. And I think we're going to hear some great examples of that problem from some of our guests later on in today's broadcast. Okay, now we know how busy all of you are out there. Therefore, we're offering you the option of viewing only one, two, or all three days of today's program, or of this year's program. If your time is limited and if you are in the military, you may want to focus on days one and two. If you are not in the military, days one and three perhaps will interest you the most. However, I think most of you realize that there are tremendous similarities in how both our civilian and military systems would function in the case of a large biological pathogen release. I think all of you will gain a lot from watching the entire program, and I fully encourage all of you to do so. Now, when you complete the evaluation and exam, you will only answer questions related to the days on which you participated. For each day of the broadcast completed, physicians will receive four continuing medical education credits, nurses will receive 4.8 CNEs, and all others will receive 0.4 CEUs. And I'm going to give you more details about that at the end of each day's program. Now, don't worry too much about the exam. We want you to sit back, enjoy the course. The exam will be open book, and as long as you pay attention, I don't think anyone out there will have any difficulty with the test. If anyone at the downlink cites still needs a student packet, please ask your site facilitator to send us a fax. And our fax number is 301-619-4789. And on that fax, tell us how many packets you need, give us your address and phone number, and we will FedEx those forms to you in time for the final exam. Please, no post office box addresses. FedEx will only deliver to a street address, and they have to have a phone number. Now, you should receive those by Thursday, the last day of our broadcast, at the latest. Now, before we get started, let's go over today's course objectives. We're going to learn about several biological pathogens that both military and civilian practitioners should be familiar with. These agents will include anthrax, plague, smallpox, botulinum toxin, and ricin. And by the end of today, you'll be able to describe the epidemiology, pathogenesis, clinical features, and medical management of these various bioagents. Furthermore, you'll be able to identify the characteristics that make a biological pathogen an effective weapon useful for warfare or terrorism. Again, we can't discuss every single agent as we have tried to do in previous years. But, I think if you understand the principles of defense and of medical management, as they apply to the five agents we're going to discuss, then you can readily generalize much of that learning and apply it to other potential bioweapons. All right, let's get this show on the road now for real. I am pleased to have with me today Dr. Denise Koo, and Dr. Koo is director of the Division of Public Health Surveillance and Informatics at the Epidemiology Program Office at the Centers for Disease Control and Prevention in Atlanta, and also my commander, Colonel Jerry Parker, commander of USAMRIT at Fort Dietrich. Colonel Parker has extensive experience with medical biological defense, having served as chief of toxinology and deputy commander at USAMRIT, then as director of the research and development directorate on chemical and biological medical defense, and finally now as commander of USAMRIT. Thank you for being here, sir. Colonel Parker, since biological weapons have been around for centuries, why the recent emphasis on BW? Well, Ted, the proliferations of weapons for mass destruction to include biological weapons has become one of the greatest new threats that we face today. Many threat assessments in recent years have concluded that biological warfare and bioterrorism is highly favored as an equalizer by root countries or groups hostile to the United States. And at the same time, we have realized the extent of the biological weapons programs in the former Soviet Union and Iraq, even though they signed the Biological Weapons Convention in 1972. And to get an idea of the extent of the program in the former Soviet Union, one only need to read the recently published book, Biohazard, by Dr. Ken Alabaq. Dr. Alabaq is now a colleague of ours, but he was the deputy director of Biopreparat. Biopreparat was an organization who performed offensive BW research, R&D, for the former Soviet Union. That organization employed thousands of scientists, technicians, and engineers, and had many, many facilities in the former Soviet Union. I think Dr. Alabaq's book is a chilling description of how vast that program was and how many thousands of scientists were employed there. And again, chilling reading, and I'd highly recommend it for anyone out there. Well, yeah, that's true. And further, today we know that there are a number of countries that are trying to develop BW programs. And you just have to imagine if some of the associated pathogens or associated technologies, dissemination technologies, are just the right scientific expertise were to get into the hands of a rude country, or group that is intent on causing terror, or mass casualties, well, that result could be catastrophic. You know, there's been a tremendous amount of dissemination in the press and media lately, sir, about biological weapons. And I think most of us out there understand that using a biological weapon can really be as simple as contaminating an adversary's drinking water, perhaps by throwing an animal carcass in a well, or using human feces to contaminate that water or food. There's certainly many historical examples that we're going to discuss over the course of today's broadcasts. But Denise, let me ask you, why is our nation and the CDC and public health infrastructure in our country concerned about domestic bioterrorism? Well, actually, Ted, as you know, concern about biological terrorism is not new for us in public health. In fact, it was concern about biological warfare and bioterrorism during the Cold War that led to the establishment of the Epidemic Intelligence Services CDC in 1951. Dr. Alexander Langmuir recognized that epidemiology would be crucial to the detection, investigation, and control of a bioterrorist event. Through the EIS, he wanted to ensure that we always had a cadre of trained epidemiologists who would be available at a moment's notice to investigate potential threats to the public's health, which included bioterrorism. So really, the question is, where are we more concerned now? And it's because our nation's vulnerability to a terrorist attack has been clearly illustrated over the past few years by several events. In 1993, the bombing of the World Trade Center in New York City was intended to drop both towers to the ground with nearly 100,000 workers and visitors inside. Luckily, actual casualties were minimal. However, this incident led the nation for the first time to seriously consider the threat of foreign terrorists operating on our shores. In April 1995, the Oklahoma Federal Building Bombing enlarged our focus to include not just foreign terrorists, but also domestic terrorism and violence. In June 1995, an extremely toxic nerve agent called Sarin was intentionally released on several subway trains as they converged at the same time in downtown Tokyo. This resulted in 12 deaths and over 5,000 people seeking care at local hospitals that day. This event signified that weapons of mass destruction, in this case a chemical weapon, are now a part of the terrorist arsenal. We now know that the religious group responsible for this attack, the Aum Shinrikyo, also had attempted to develop the biological weapons and means of dissemination for anthrax and botulinum toxin, which is 100,000 times more toxic than Sarin. So now the concern is that some of these countries with bio weapons program also harbor terrorists and could pass their knowledge and technology to terrorist organizations. So far, Denise, most of our experience comes from these publicized hoaxes that I think most people in the audience are probably familiar with. And in those cases, the bad guy out there apparently does us the favor of announcing his intentions. I presume, though, that bad guys aren't always going to tell us of their plans. Exactly, Ted. That's why we in the healthcare sector and in public health have to be alert to the possibility of a biological attack. Well, you know, before we go further, we need to define what we mean when we use the term biological warfare. According to the definition that we use for biological weapons convention and in our treaty negotiations, biological warfare can be defined as the intentional use of a biological pathogen or a toxin derived from a living organism to produce death or disease in humans, animals, or plants. And this would seem pretty straightforward, kind of a no-brainer definition, if you will. But I'm here to tell you that nothing about the topic of biological warfare is straightforward. And in fact, even the very definition has been the source of great controversy over the years. The Soviet Union would accuse us of being our own worst violators of the biological weapons convention because they would say that our use of agent orange, for example, in the jungles of Southeast Asia, constituted anti-plant biological warfare. Now, we would say no, agent orange was a chemical. If anything, perhaps that was anti-plant chemical warfare, but it definitely wasn't biological warfare. On the other hand, we would accuse the Soviets of waging biological warfare in those very same jungles by employing trichothesine mycotoxins, fungal toxins, yellow rain, if you will, against the sympathizers of the U.S. government. Now, the Soviets have never admitted doing that, but what they have said in certain backdoor sessions was, well, we didn't do that, but even if we did, we don't consider that biological warfare. We consider that chemical warfare. Well, I'm not here to argue who's right or who's wrong, just again to show you that even the very definition of biological warfare has been the source of great controversy. Now, Denise, let's turn our attention to bioterrorism. Is the concern or the definition really much different in the case of bioterrorism? Not really, Ted. What we care about in public health is the deliberate or threatened use of biological agents to harm large numbers of civilians. You know, Colonel Parker, something that's always puzzled me, you Sam read studies perhaps only 15 to 20 different infectious disease agents. How do we decide which particular infectious diseases and toxins would make legitimate, viable weapons candidates? Well, Ted, you know, there are many pathogens, hundreds, perhaps thousands that could be used to intentionally cause disease. Fortunately, not all pathogens are created equal. We try to look at the list of pathogens in terms of a medical risk analysis. So physical characteristics such as infectivity or toxicity, ease of production, stability, allows us to characterize pathogens in terms of strategic, tactical, or limited threat. Fortunately, the list of pathogens thought to have strategic mass-casualty in producing capabilities is really small, as you mentioned earlier. From that, the agents that we're most concerned about are those that could be disseminated from great distance and cover a large area. The ideal biological pathogen must be stable enough to be disseminated in aerosol form. It should be capable of being produced in large quantities and effective at low doses and stable in storage and in a weaponized form. What about pathogens spread by food or water? We've talked about aerosol for a minute, but how about spreading some of these things via food or water vehicles? Well, we're not as concerned or too concerned about pathogens that could be spread through the food and water for several reasons. In the battlefield setting, we generally have good control over our food and water sources, although we need to take precautions from locally procured foods in an Oconus-deployed situation. In addition, effective contamination of large water sources is unlikely due to dilution, chlorination, and filtration. And it generally takes an enormous quantity of biological pathogen to significantly contaminate water reservoirs in the battlefield setting. You know, that's a good point you make, sir. In the military, we're definitely less concerned about cutaneous and gastrointestinal exposures than we would be with disease spread perhaps by the aerosol route. Denise, I wonder, in the domestic situation, would your concerns be a little bit different? Actually, Ted, our concerns are probably more similar than they are different. In fact, just as in the military, we're also the most concerned about aerosolized biological weapons because of the significant potential for greater mass casualties. However, our mission is to protect the health of the entire public, and there are a greater range of environmental factors that are more difficult to control, such as food and water supplies. For this reason, public health practitioners have a longer list of bioagents to be concerned about, and we'll discuss these on the last day of the show. Well, you know, I think we have to ask ourselves why would a terrorist or a belligerent or an enemy go to a biological weapon? Certainly, history is full of examples of how terrorists and how potential adversaries can achieve their aims using conventional weapons, so Oklahoma City, World Trade Center, Cobar Towers, all great examples of terrorists achieving their aims using conventional weapons. Furthermore, thanks to the gang down at the Aum Shinrikyo, we now know that terrorists can achieve their aims with chemical weapons as well. So given that conventional and chemical weapons are readily available to our adversaries, why would they reach for a biological weapon? Well, at USAMRAD, we concern ourselves with studying that threat, but we like to think that perhaps these are the ultimate terrorist weapon. And I'm going to give you ten reasons why that might be the case, although I'm sure you can think of plenty of others. First of all, these things are available in stores everywhere. Now, what do I mean by that? Well, there are many legitimate biological supply companies that exist for very legitimate peacetime purposes, and these companies sell microorganisms for scientific study, and in fact, there are 450 some of these supply companies in existence in 67 countries around the globe. Interestingly, 54 of those ship and supply the anthrax bacteria. And you can get these agents from many of these supply houses without a great deal of difficulty, and it's interesting to note that the Iraqis, when they went to obtain the seed stocks to start their biological weapons program, obtained those stocks from a legitimate medical supply company in the United States. So again, they're available in stores everywhere. Second reason why a bad guy might reach for a biological agent as opposed to other forms of terrorist devices is they're available for an everyday low discount price. In 1969, the United Nations commissioned a study and they looked at what it would cost a terrorist to produce mass casualties over one square kilometer area. And they defined mass casualties as 50% casualties. And again, these are 1969 figures, so you can triple them to put them into 1999 dollars, but I think the ratios are instructive nonetheless. If I were a bad guy and I wanted to produce mass casualties in 1969 with a conventional weapon, it would have cost me $2,000. If I wanted to do that with a nuclear weapon, it would have cost me $800. Now I realize it costs more than $800 to build a nuke, but you also get more than one square kilometer worth of bang for your buck. If I wanted to do it like the Tokyo Subway Gang or the Baron, it would have cost me about $600. And if I wanted to do it with anthrax, it would have cost me about a buck. So I don't think it's too difficult to see why a poorly funded terrorist might look attractively at the biological option. Okay, third reason a bad guy might reach for a biological weapon, no roaming charges. What do I mean here? Well, basically the seed stocks necessary to produce biological programs and biological weapons are very, very tiny indeed with one little vial of anthrax spores, for example. I can start an entire biological weapons program and I can spirit that anthrax vial around the world in my coat pocket. I can move through radar detectors at airports, for example, without anyone detecting that I'm carrying the seeds that could destroy a large chunk of humanity with me. So again, no roaming charges. Fourth reason a bad guy might reach for a biological weapon, they taste great and they're less filling. And with me in the audience today, Colonel James Madsen, those of you who saw last year's chemical show may recognize Colonel Madsen as the star of that show. And last year, last April rather during the chemical broadcast, Colonel Madsen probably told you that if you're bopping along the battlefield out there and you see this green hazy cloud float by and it smells like geraniums or horseradish or whatever Colonel Madsen thinks it's supposed to smell like, that you ought to duck or get out of the way or put your mask on and I fully recommend you do that. But unfortunately in the case of biological weapons that's not going to happen. The clouds that are generated by the release of some of these biological agents are likely to be odorless, colorless and tasteless. You're not going to see them out there on the battlefield or in America's cities should a terrorist release them. Fifth reason a bad guy might choose a biological weapon, they won't harm your carpets. And by this I mean that you can use these weapons to destroy people without destroying infrastructure. So if I'm an enemy and I want to take out an American city but I want to leave the buildings intact and I want to leave the bridges and the highways intact then biological weapons is a good way to do that. Obviously nuclear and conventional weapons come up a little bit short in that regard. Six threes in a biological agent might look attractive to an adversary. They work while you sleep. Remember we mentioned earlier in the show that biological agents have one very important characteristic that chemical, conventional and nuclear weapons don't have. That's an incubation period. In general that incubation period is at least 24 hours in length. In this day of jet travel I can be anywhere in 24 hours. So I can release my weapon and I can be soaking up the sun on the Riviera before anyone knows what hit them. Seventh these agents have been tested and found effective by leading government institutions. We had an offensive biological warfare program in the United States between 1943 and 1969. And we got rid of that program in 1969. The Soviet Union had an extensive program during their heyday as well. So there are many scientists out there. There are many publications out there. There is much information on how to do biological warfare. So if there's anyone doubt in anyone's mind that these weapons work that question has been asked and answered. These weapons have been validated by scientists in both programs. Eighth reason a bad guy might reach for a biological agent what your Uncle Sam doesn't know will kill him. And basically by that I mean we are not yet up to standard as far as detection goes. We have some great detectors in the pipeline. We are making great strides as far as our ability to detect biological weapons goes. But we are not yet where we are in the chemical arena. So again if you saw Colonel Madsen a nifty M-8 alarm system which you can position around your battalion and then go about your business secure in the knowledge that if some nerve gas floats by you'll get an early warning of that. And that's great. And in the biological arena we are working on that and we hope to be there soon. But we are not there yet. Ninth reason that a bad guy might reach for a biological agent is 4 out of 5 doctors who do terrorism recommend bioterrorism. And if you look at the list of the most suspects out there you'll note that there is a preponderance of physicians and microbiologists serving as perpetrators out there. And my favorite personal story concerns a gentleman known as Dr. Suzuki. And this is my favorite story because Dr. Suzuki was a legitimate infectious disease physician. A man after my own heart if you will. And he was studying typhoid fever in Japan in the 1960s. He was going to write his dissertation and he wasn't accruing cases fast enough. So he decided to take matters into his own hands. He infected several of his colleagues with typhoid fever. Unfortunately four of them died. There are many other famous incidents. There was a physician in Kansas City named Debra Greene who tried to kill her husband, also a physician with ricin. There are a couple more Japanese physicians who also infected some of their colleagues with these agents. There are several microbiologists and microbiology techs that you will hear about and it's good enough for the docs out there who know what they're working with. That might mean something. Tenth reason that these agents might be the weapons of choice of terrorists out there is that you can be the envy of your friends and think about it. Some of these agents have brand name recognition and that's almost immaterial of whether they work well or not. But be the first guy on your block to have Ebola. Be the first guy on your block to have smallpox. And even if the weapons don't work on your headlines, you will be the envy of your terrorist friends. So, I want you out there in the audience to put yourselves in the role of the potential terrorist. We've told you why you might want to choose a biological agent if you were inclined to terrorism. Now, the next question is how are you going to get your hands on the agent? Well, I've already told you that these agents would be available in stores everywhere. And that's one way to get them is to buy them. But there are other ways to get them as well. For example, many of these agents are naturally found in the soil. Clostridium botulinum, the agent that produces botulinum toxin, grows in the soil in almost all parts of the world. So any of you with two semesters of microbiology training might be able to go outside your front door, dig up a scoop full of dirt, and culture yourself clostridium botulinum. So I've told you why a terrorist might choose a biological weapon. I've told you how a terrorist might get his hands on the agent. The next question is how would a terrorist disseminate this agent? For the answer to that, let's turn to Mr. Bill Patrick. And he on video is going to explain to us how a terrorist might disseminate one of these biological agents. Now, Mr. Patrick is a good friend of mine, and he was the head of product development during the old U.S. offensive warfare program before it was halted by Richard Nixon in 1969. So let's turn to Mr. Patrick. There are two major ways of distributing a BW aerosol. Each has its own unique advantages and disadvantages. The first method is referred to as line source dissemination. That is, a vehicle, a plane, a person distributes the aerosol, perpendicular to the wind, and the wind then transports the aerosol downwind. This is the most effective way of creating large target coverage because you see you're using the energy of the wind to distribute the aerosol. The problem with aerosols that are generated as line sources is that they are very, very sensitive to meteorological conditions. You must always have an inversion or a near type of inversion in order for that aerosol to go downwind. Now, inversions occur primarily early in the morning or late in the afternoon or at night, so therefore, biological warfare is a type of warfare that must be planned and advanced. The second way of distributing an aerosol of a BW agent is by point source means. That is, you release large numbers of little bomblets perhaps for about three inches in diameter and you saturate the target. The advantage to point source release is that you can overcome to some extent bad meteorological conditions or unfavorable meteorological conditions. The drawback to point source munition distribution is the fact that the bomblet never distributes all of the material from itself. You have a residue of powder or you have a residue of liquid which can then be rushed back to the laboratories state side and you initiate the identification procedures. Okay, we've told you why a terrorist might want to be a bioterrorist. We've told you how he might procure the agent. Mr. Patrick's now told you how he might choose to disseminate that agent. Next question is how can that terrorist get the most bang for his buck? Well, let's listen again as Mr. Patrick discusses some of the characteristics of biological agents that would be critical for weaponization. Liquid agents are easy to prepare but they are very difficult to disseminate in the small particle aerosol that's needed for an infection. On the other hand, dry powders are very difficult to prepare. The processes are much more complex but they can be disseminated very readily into the one to five micron particle size. I'd like to demonstrate the fact that bioterrorists can manufacture liquids very readily but in manufacturing a liquid although the process is simple it requires a great deal of energy in order to develop an aerosol composed of small particles. The easiest way of disseminating a BW agent, although it's not very effective, is the use of a single fluid nozzle illustrated as follows. You notice there's a spray that's creating an aerosol for a very short period of time but the aerosol quickly falls out of the air because of large particle size and becomes not very effective in terms of giving you an infection. Single fluid nozzle. A terrace can then evolve into what we refer to as a double fluid nozzle, a two fluid nozzle. Now this material is much smaller as you disseminate it. I hope you can see that this aerosol is remaining for a much longer period of time. But again even a two fluid nozzle with the amount of energy that I can generate by pushing this plunger is not very effective. You're probably getting only about one percent of your total number of organisms airborne in the right particle size. On the other hand terrorists, particularly state supported terrorists can use small powders, small particle powders that can be disseminated very easily as demonstrated by this simple garden sprayer for rose powder. Rose insecticides. Now, I've carried all these visual aids across many many airports and I've passed very well without ever being asked what is this material? What is this device? It illustrates one point I think very dramatically and that is our air support, air security points look for devices that go bang your knives, your pistols and what have you, but they have not been included into what constitutes a BW agent, what it looks like and how it's disseminated. Now, state supported terrorists can bring into this country through diplomatic pouch any number of bad actors like tularemia or anthrax. Today, I'm carrying about 200 grams of material that could very easily pass for tularemia, dry tularemia. This amount of material would cause 50% infections in a building as large as the World Trade Center. It can be derived from as few as 500 blood-arga plates and then dried. So you see, it does not take very much material of a BW agent to cover a very large area and infect a very large population of people. Okay, we've talked about how easy this is potentially for a terrorist to do, how allegedly any terrorist can do biological weapons in his bathtub for a buck. Dr. Karis has demonstrated for you now how simple the technology is. Well, I think the question that's probably out there in many people's minds then is, if it's so easy to do, why isn't everyone doing it? Why aren't we seeing large-scale, successful bioterrorist attacks in American cities on a weekly basis? Well, before we answer that question, I want to introduce our next guest. Our next guest is Dr. Seth Karis. Dr. Karis is a senior research professor at the Center for Counter-Proliferation Research in Washington, D.C. Dr. Karis, welcome aboard. Dr. Karis, you authored this book, a working paper entitled Bioterrorism and Biocrimes, the Illicit Use of Biological Agents in the 20th Century. We've talked now about how easy it is to disseminate these agents, and I want to ask you again, if it is so easy, why aren't they being used more often? Well, unfortunately, there's been a tremendous growth in the last decade in the number of people who've used a lot about using biological agents. As you've already mentioned, there's been a great explosion in anthrax threats just in the last year. Fortunately, the number of victims in these events has been limited because most of the events have been hoaxes, and most of them have been biological crimes, biocrimes, rather than bioterrorism events. Okay, you mentioned biocrimes. What distinguishes a bioterrorist incident from a biocrime? What a bioterrorism incident was. I like to think of a biocrime as an incident where a pathogen is used, or there's a threat of use, but there's no real ideological, religious, or political rationale for it. Biocrimes usually involve a small number of people, and they're represented in murder plots, or extortion, or revenge, and they involve not aerosols, but injections, or perhaps contamination of food and water. Well, there's an interesting case that happened a couple of years ago back in 1996 involving a laboratory technician by the name of Diane Thompson working in Texas. She contaminated pastries of some of her co-workers with a rare strain of chigella. She gave, basically she gave the pastries to her co-workers because she was upset with them. In 1998, a Texas court sentenced her to 20 years in prison for this crime. One of the mistakes she made, correct me if I'm wrong, is she actually sent out an e-mail message to her co-workers, inviting them to partake of the donuts, so... Among other mistakes, there was also a camera that was focused on the door of the room that this happened in, so they caught her off. Well, hopefully we'll be that lucky, and next time a terrorist tries this or a criminal tries this, but you make in your paper a distinction between biological terrorism and biological crimes. Have we seen any biological terrorism very rare, and they haven't been used effectively on a large scale? The one real example of a bioterrorism incident happened in the United States, and it involved a group called the Rajnishi who successfully made more than 750 people ill with a rather common pathogen by the name of Salmonella Typhimarium. This was back in 1984. Now, the Rajnishis were a cult group that established the commune in rural Oregon. They came into conflict with the local community there and devised this plot where they thought they could take over the community by making all the voters sick at an upcoming election. They decided to do a test of the concept a couple of months before the election. They contaminated, among other things, salad bars in the community, and as a result of this got a fairly large number of people sick. Well, this was a tactical victory. They did make a lot of people sick. They had a strategic failure in that they were not able to accomplish what they'd hoped to accomplish. Didn't win the election anyway. Well, it would be difficult, I guess, to affect large numbers of people in some of the ways you've described, but I think it's a real possibility nonetheless. Now, both domestically and in the military, our concern, of course, is the possibility of mass casualties, of casualties on a larger scale than you've here to for indicated. So, Colonel it's a kind of larger scale casualties. There's a lot that we can do to minimize the strategic mass casualty event. And our nation's chemical and biological defense doctrine first calls for increasing our intelligence about our adversary's capability of releasing a biological weapon. Who are they? What agents, delivery systems do they possess or have access to? Second, we must develop physical countermeasures to include environmental, improved environmental detection systems, protective clothing and safety contamination procedures. Third, we need improved medical countermeasures to include enhanced disease surveillance in public health infrastructure. Appropriate vaccines, therapeutics and diagnostics. And finally and probably most important at this stage is education and training of our medical and public health personnel. Hence, this is why we are here today to make you more aware of the threats out there without the paranoia. And finally, to raise your index of suspicion in case you are ever confronted with a biological warfare attack scenario. Why are biological weapons and the proliferation of biological weapons so difficult to control? Well, you're right, they are difficult to control but there are some non-proliferation efforts and treaties that are helping to decrease the proliferation potential. However, biological weapons treaties have proven very difficult to verify because of the simplicity and speed at which biological pathogens can be produced and the dual use nature of key equipment needed for their production. The same equipment and supplies that have legitimate research, agricultural, medical or other use can be misused for biological weapons production. The duplicity of supplies and equipment means that there is no unique signature to a biological weapons facility. The relatively simple equipment that can be used for small scale production makes it easy to hide illicit activities. Even large scale production is difficult to locate and we have to look no further than the UN inspection teams in Iraq to see an example of this. Iraq successfully deceived, denied and hid from UN inspectors information about their biological weapons program for four years after the Gulf War. It took the defection of Saddam Hussein's son-in-law in 1995 to confirm that Iraq maintained a standby biological weapons capability that went and detected despite the most intrusive inspection program ever. Well, thanks very much for enlightening us in this regard, Colonel Parker. That concludes the first part of today's discussion. I'd like to thank Colonel Parker and Dr. Karris for being here today and I now want to switch gears and begin the discussion of specific agents. The first agent we're going to talk about today is anthrax and we're going to use anthrax as our example of a spore-forming bacterial organism. Anthrax is released onto the tracks of the subway system of a large metropolitan area and dispersed by the passage of the trains through the tunnels. There is no warning of this event and no one claims credit for it. The subway system has 450 stations, approximately 6,000 cars and uses about 700 miles of track. Trains depart from stations every 2 to 5 minutes during rush hours. If not immediately treated, 500 people will die in the first 3 days. Within 5 days, more than 42,000 people will die and another 300,000 will seek medical care. Okay, to help us discuss anthrax today, we once again have with us Dr. Denise Koo and joining us for the first time is Dr. Ali Khan. Dr. Khan is deputy director for bioterrorism preparedness and response at the Centers for Disease Prevention in Atlanta and I want to thank you both for joining us here today. Before we get to the questions, let me give the audience out there a little background on anthrax. Anthrax is a disease that's caused by infection with the gram positive spore forming rod bacillus anthracis. And when we say gram positive spore forming rod, I think most of you out there know pretty much what that means, but the business end of that phrase for our purposes concerns is that most bacterial organisms don't form spores and the ones that don't form spores need the same things that you and I need in order to survive. They need food and water and love and affection and all that sort of stuff. But if I form a spore I can get by for many decades without nutrients, without food and water and anthrax is very stable in the environment in that sense. Now the word anthrax derives from the Greek root anthraxis and that means coal like looking lesions. For those of you unfamiliar with the disease anthrax, anthrax is one of the great diseases of antiquity and most biblical scholars now believe that anthrax was almost certainly responsible for the fifth plague of the book of exodus, the plague on cattle. So Denise without further ado why don't you tell us a little bit about the epidemiology of anthrax. Well as you describe anthrax has been a disease of cattle and other herbivores that have been a disease of cattle and other herbivores for centuries. During the middle ages it was called the black bane because it wiped out the cattle population as well as many people. Man is generally infected secondarily through work with animals or other animal products such as hide, hair or bones. It was during the industrial revolution that inhalational anthrax was first recognized as a new disease. The population at risk were persons who worked in the wool industry in the United States. When the wool was processed the workers were exposed to aerosolized spores of anthrax and subsequently developed disease. It was first called woolsorters or rag pickers disease and it's thought to be the first occupational respiratory illness. Well Denise in addition to this inhalational form of disease there is also a gastro intestinal and a cutaneous form of the disease that depends on the initial route of exposure. Now the most common form of the disease and this represents about 95% of all cases. This form is really fatal if it's properly treated. However without treatment there's about a 20% case fatality associated with the disease. Now the gastrointestinal form of the anthrax occurs from ingesting tainted meat of animals that have died of anthrax and this has a higher case fatality generally about 50%. And this higher case fatality is due to the fact that people usually consider that diagnosis so the disease is not recognized. The rarest form of the disease is the inhalational form of the disease and that's clearly the one that has the highest case fatality approaching up to 90% if you're not treated. If you are treated you need to be treated generally within the first 24 hours of clinical illness. However there's very limited human data on this form of the disease. As you're saying anthrax is a relatively rare disease here in the United States. At the beginning of this century before the advent of control measures such as vaccination of animals and import controls there are around 130 reported cases each year most of which were the cutaneous form but in the last 15 years there have only been 5 cases of anthrax reported in the US all of which were cutaneous. In fact there have only been 18 cases of inhalational anthrax reported in the United States in this century. The last case of anthrax reported in 1978. You know the ability to be infected by aerosol is really only one reason that anthrax makes a good biological warfare agent. Now to the audience out there I want to make it clear that there is no perfect bio weapon presumably if there was we would see a lot more people using these weapons as terrorist devices but if there's some bad news about this it's the fact that anthrax is probably the closest thing we have to the perfect weapon for many reasons. First of all it's really accessible and I told you a little while ago how most of you with a couple of semesters of microbiology training could go outside your front door dig up a scoop full of dirt and readily culture your self-clostridium botulinum. Well in some areas of the world you could do the same thing with bacillus anthracis. The spores of anthrax the spore form is incredibly hardy as we've already discussed. Moreover anthrax bacteria can be milled in a particle size of 2 to 6 microns and that's perfect for reaching the human lower respiratory tract. Particles much smaller than 2 microns are exhaled as readily as they're inhaled. Particles much bigger than 6 microns get stuck in your nasal mucus. But particles of 2 to 6 microns are perfect for reaching the lower respiratory tract and staying there and again anthrax spores can be milled in that very particle size. Now when we talk about the spore form of this organism, I think at least from a military's perspective it's useful to consider the dilemma of the ordinance officer. If I'm an ordinance officer and I am charged with maintaining a stockpile of weapons and those weapons happen to be biological, let's take a look at what I need to do. If I have a plague weapon and plague is a vegetative organism, it doesn't form a spore like anthrax. I screw the top off my warhead, I fill it up with plague, I screw the top back on, I put it in the bunker, a few days later I take it out of the bunker, there's a chance my plague cultures are all dead. But if I fill that weapon with anthrax 50 years later, take that weapon out of the bunker and it's good to go. So that makes the task of stockpiling anthrax weapons much less formidable. Now for a little bit more on the history of anthrax let's take a look at our video roll in. The idea of using disease as a weapon gained a new level of sophistication in the early 1930s as nationally funded research programs on biological warfare were developed. The Japanese had a very active offensive bio warfare research program which included a battalion known as Unit 731. In their program the Japanese conducted experiments on humans using 15 to 20 different disease causing agents with anthrax being one of their favorites. Allied prisoners of war and innocent Manchurian civilians in nearby villages provided an almost endless supply of experimental subjects. When word of Unit 731 leaked to the west, Allied forces began their own programs concerned that Japan and possibly Germany would gain a military advantage in bio warfare research. On the third day after exposure the casualties begin dead sheep can be seen further down the line. It is of course necessary to confirm that they've died of anthrax. In 1942 on Grineard Island off the coast of Scotland the British conducted their first scientifically controlled BW field trials. Scientists exploded anthrax bombs near a mobilized sheep to determine if the spores would survive an explosion and retain the ability to infect anyone nearby. Test results showed that anthrax could in fact be effectively dispersed by explosive devices and could also remain viable in the soil for decades. This brought home the realization that if an anthrax bomb were dropped on a city like London the results could have been catastrophic. Grineard Island was declared off limits until it was decontaminated in the 1980s. It's now safe for both humans and animals. Like our allies the United States responded to the perceived threats from Germany and Japan. In 1943 we began an offensive biological program with a modest research and development facility at Camp Dietrich which is now Fort Dietrich, Maryland. By the end of the program we had weaponized a total of seven incapacitating or lethal human agents including anthrax. In 1969 Richard Nixon renounced the use of biological weapons for the United States. I have decided that the United States of America will renounce the use of any form of deadly biological weapons that either kill or are incapacitated. President Nixon visited Fort Dietrich on the 25th of November 1969 I remember that date quite well because following his announcement of taking munitions and beating him to plow sheds we all lost our job and that was a very traumatic experience but following his presidential announcement on this date the entire United States offensive program on biological warfare came to a close within two years. We destroyed all of our seed stocks we destroyed all of our production material at Pine Bluff, Arkansas and we completely got out of the biological warfare business. Even at its peak the U.S. offensive program paled compared to the Soviet Union's. The Soviets had a massive extensive sophisticated top secret program which employed tens of thousands of scientists and engineers in numerous research and production facilities. The Soviets signed the Biological Warfare Convention in the 1970s and yet their program continued uninterrupted and in fact intensified. Our worst fears were confirmed in 1979 when an accidental release of anthrax occurred at a biological research facility in the town of Sferdlask. You'll hear more about this incident later in the program. Much of our most recent knowledge about their joint military and civilian program comes from a Soviet defector Dr. Ken Alebeck formerly known as Dr. Konadzin Alebekov. He was the Deputy Director of Bio Preparat a cover organization for their civilian bioweapon and production facilities. Although we had suspected for years that they had continued their offensive program some of the information he provided was a real wake-up call for the United States. Prior to the Gulf War the intelligence community suspected that the Iraqis had done research on anthrax but they didn't know how extensive their program was. So as a precautionary measure during the war about 150,000 U.S. service members were vaccinated against anthrax and more would have been immunized if the war hadn't ended so quickly. After the war the Iraqis admitted to producing and weaponizing anthrax although the weapons were never used. This past decade anthrax moved from being an agent of concern for biological warfare to the top of the threat list for terrorism. The Aum Shinrikyo cult in Japan which released the nerve agent Sarin on the Tokyo subway in 1995 allegedly made multiple unsuccessful attempts to infect people with anthrax. Since anthrax has so many properties which are ideal for a biological weapon I have no doubt that we haven't heard the last of anthrax. Well as fearsome as the anthrax bacteria is it actually lacks two qualities that would make it an even more deadly weapon. First of all compared to other biological agents anthrax actually has a fairly high infectious dose or ID 50 and that's estimated to be somewhere between 5 and 10,000 spores so you need to inhale between 5 and 10,000 spores before you have a reasonable chance of contracting anthrax. Unfortunately though in a concentrated cloud you probably could inhale that amount of breath Denise. But also second 10, inhalational anthrax is not transmissible from person to person therefore no special precautions are required to care for patients with either cutaneous or inhalational anthrax. Well that's a good point you make Denise. In fact the fact that it's not transmitted person to person actually makes anthrax a better weapon to the battlefield commander in one sense. If I'm a battlefield commander one of my main tenets is to maintain control of the battlefield. If I use plague which is contagious person to person I throw it out there on the battlefield it does its dirty work like I intended but I also now have to worry that when I subsequently want to march my troops through that area they're at risk of contracting anthrax or contracting plague rather from the enemy around them. In the case of anthrax I don't have to worry about that. The lack of secondary aerosolization of anthrax also makes it an even better weapon. What do I mean by this? Well if I throw anthrax out there it does its dirty work but there's very little chance that it will be secondarily aerosolized and the reason for that's not entirely clear but it probably has a lot to do with this 2-6 micron particle size that's required. It takes some effort to mill anthrax into that particle size when I blow it out there on the battlefield if it settles out into the dust it binds to dust particles it has a static charge on its surface binds to those dust particles it's now present in particles bigger than 6 microns in diameter and difficult to get it down into the human lung. So again it has a low secondary aerosolization potential and that again perhaps makes it a better weapon to the battlefield commander. I throw it out there it does its dirty work I roll my tanks through I kick a lot of dust without the fear that my own troops again are going to catch anthrax. Yeah but we need to keep in mind that this lack of person-to-person transmission or the lack of secondary aerosolization is really independent of the ability of the spores themselves well disseminated as a small particle aerosol. In the former Soviet Union in 1979 there was an accidental release of anthrax spores from a biological weapons facility which gave us a glimpse of the magnitude of downward spread and resulting mass casualties that could occur from an intentional dissemination of this agent. In 1980 we got reports coming through through the western press about a large outbreak of anthrax in the town of Sferdlask. Now the government initially reported that the disease was gastrointestinal anthrax caused by improperly cooked infected meat that I just talked about. Very plausible explanation. However we couldn't get permission to go in and study this outbreak. Well you know they were so bold as to actually attend an American Scientific Convention in 1988 these Soviet scientists and they presented their data at that convention. Whether the scientists presenting the data actually knew the true story is a little bit open to question the data that seemed to indicate that this was in fact a gastrointestinal outbreak. Unfortunately for the Soviets intelligence data continued to filter out, ultimately including autopsy data and this autopsy data seemed to indicate that these victims in Sferdlask were succumbing to what looked like anthrax of the chest. Not the type of anthrax one would expect to see if it were contracted by eating contaminated beef. Well after the break of the Soviet Union in 1991 Boris Yeltsin finally admitted that perhaps military developments played a role in that anthrax outbreak. And in fact he ought to know because back in 1979 when it happened Boris Yeltsin was the local Communist Party Commissar for the Sferdlask oblast. Well after this admission was made a team of American epidemiologists was allowed in to Sferdlask and they were chaired by Matt Messelsen at Harvard. They conducted a very simple, very elegant epidemiologic study. They interviewed family members as well as some of the physicians who cared for patients and they conducted some autopsies on the victims. And I think it would be interesting now to turn to Dr. Messelsen and allow him to describe the results of his study. There's an immense amount to be learned from each epidemic of this sort and one should not let such an epidemic go unstudied because for example from this we learned that although up till then it was only theoretical that it's really true that an anthrax cloud can remain infectious. 50 kilometers downwind. Before that you could have said well maybe there's something in the atmosphere that we don't know about that will kill the spores. Well it didn't happen there. There was one other remarkable thing that we learned from this and that was that amongst the 68 people who were reported to have died and we had information on the majority of them, nobody was younger than 24 years old. No infants, no babies, no children, no adolescents, no young adults. A big surprise when we looked into the old literature on inhalation anthrax of which there are a number of reports including quite a few from Russia from Tsarist and post-revolutionary times we also found that there were no young people. Now whether that really means that young people are less susceptible to inhalation anthrax and perhaps to other inhalation infections is a very important lead and we would never have asked this question if we hadn't done the epidemiology and we still don't know the answer but there's another example of how epidemiology can not only tell you what happened in a given case but can bring up new questions perhaps very important new questions for future research. I hope most of you found that interesting. I'd like to do, what I'd like to do now is move into the clinical aspects of the disease anthrax. Now I think most of you appreciate and Dr. Kahn has already taught us that anthrax spores can enter the body in one of three ways. They can theoretically I guess be inoculated through the percutaneous route. You can eat them or you can breathe them in but regardless of how you get anthrax spores into your system some of the common pathways of pathogenesis begin to converge as anthrax spores are into your system they're taken up by macrophages by white blood cells and those white blood cells do exactly what they're supposed to do in taking up the anthrax spore but anthrax has a polysaccharide capsule on the surface of its spore and that allows it to at least to a degree resist the killing effects of the macrophage so the macrophage takes it up like it's supposed to but it has a difficult time killing it and what it ends up then doing is acting as a taxi cab transporting those anthrax spores to the nearest regional lymph node and it's within the milieu of that lymph node that anthrax really thrives and it comes out of its spore form it vegetates, goes into its vegetative form starts reproducing and starts cranking out its toxins and it makes two main toxins that we know of edema toxin and lethal toxin and these cause edema and lethality. The edema causes the lymph nodes to swell they break apart and anthrax bacteria get out of those lymph nodes, get into the blood stream and circulate around to the rest of the body and if you were to draw blood on a patient with anthrax in this stage of the game you would see what we're going to show you here on the video screen the overwhelming bacteria bacteria in the blood overwhelming bacteria that one sees in a case of clinical anthrax now keep in mind that you wouldn't see this till late in the stage of the disease it's unspun peripheral blood out of the arm of a patient with anthrax I think it's not too difficult to see why patients with anthrax don't do well if you delay therapy no amount of guerrilla-cylind or sephakillimol in the world is going to fix that and if that doesn't drive the point home strongly enough let's take a look at this scanning electron micrograph and this scanning electron micrograph is of the terminal arterial in a rhesus monkey infected with anthrax and I think you can see that that terminal arterial is absolutely chock-full of living viable bacillus anthracis organisms again, not too difficult to see why anthrax patients don't do well if you delay therapy and I think not too difficult to see why the Department of Defense is so keen in stepping off on this plan to immunize the force against anthrax ahead of time well, I'll get off my soapbox now but throughout today we're going to be using a new teaching tool to help us illustrate the clinical effects of the biological agents we're going to discuss so let's try out that tool right now let's go to our virtual hospital and join a group of clinicians on rounds as they discuss what I think you'll find is a fascinating patient Hello, Sergeant McCollum the doctors are here to take a look at you Good morning, Sergeant McCollum I brought Colonel C. Slack he's one of our infectious disease docs I wanted to have him take a look at you and see what he thinks about what's going on with you and we're going to talk a little bit about you in the room here I hope that's okay with you just in a nutshell he presented yesterday with complaints of flu-like symptoms myalgia fever, temp to 102 cough non-productive cough and has tended to get worse over the course of the past 24 hours his initial signs on exam essentially normal chest exam except for the fact that he's dysmic with normal clear lung fields chest x-ray was normal on admission and he's had also sputum grahamstein done which is unremarkable as well as blood cultures and a white count on his CBC about 15,000 so anything happen overnight anything new? a couple of things not too long ago he was dropping a satin to the mid 80s we put him on 02 had trouble keeping a satin mid 90s to high 90s on four liters nasal cannula if you ask him to do anything move, take him out of high phallus position he drops his sats back down to the low 80s and has some respiratory difficulty so we've been trying not to tax him that's one of the reasons I called you because his chest x-ray has changed the initial one was normal this one has some abnormalities which I'm not used to seeing it's not a pneumonia but it's something abnormal I want to have you take a look at there's normal yesterday and today's so it has changed and in addition he's been on erythromycin and seftra action and I'm concerned that he's not improving so he has one other bit of information that's kind of interesting he serves on a UN inspection team and they were recently overseas on a mission where they were supposed to look for chemical weapons and apparently they found some fermentation technology or something like that so I had some concerns about that as well so how long we overseas Sergeant McCollum? about a week sir a week and you were working with chemical weapons? yes sir we went in looking for chemical weapons and while we were in we found some biological stuff so they pulled us out so you think you may have encountered some biologicals? yes sir do you think maybe I was exposed to something? well it's certainly something we need to check out if you don't mind let me take a listen to you if you could sit forward to quickly take a listen to your chest if you could take a deep slow breath and again well I agree with you Mark he certainly sounds clear on auscultation at least I don't hear any ralls but you said you have an x-ray? yeah let me show it to you this is what I was concerned about there oh yeah yeah I think I think you've got your diagnosis there to me that's a clear cut case of a widened mediastinum and there really isn't much that causes a widened mediastinum in the world of human medicine obviously in the military we tend to think of shrapnel wounds gunshot wounds to the chest cause some bleeding and a widened mediastinum on x-ray that clearly isn't relevant in sardine maculums case so without a history of trauma to the mediastinum one of the things I think of is an inhalational anthrax what anthrax? yeah I know that sounds alarming and of course it is the good news sardine maculums is that you saw medical treatment very early good antibiotics and hopefully things are going to turn the corner for you real soon you'll start feeling better but there really isn't much else that causes a widened mediastinum short of trauma so when I see something like that especially given this peculiar history of potentially encountering biological weapons programs I think you've got to think of inhalational anthrax now would we expect to see anything on this putum? his putum is negative in the gram stain well it's certainly worth looking at I think but I wouldn't expect to get my answer or get my confirmation by looking at the sputum again anthrax is a disease predominantly of the mediastinum you tend to see bacteria in the mediastinal tissues in the lymph nodes but not typically in the pulmonary secretion so I wouldn't expect to see it although you may want to look a better place to look though would be the blood so certainly blood cultures might be expected to give you your confirmation in this case now the problem with that though is that gram positive rods of which of course bacillus anthracis is one tend to be common blood culture contaminants and laboratories tend to discard those without working them up so you got to let your laboratory know that we suspect anthrax in this case and that way they ought to be able to fairly readily isolate the organism out of blood so for treatment are the drug season on right now subtraction of everything my son adequate you know endemic forms of anthrax or endemic strains of anthrax tend to be sensitive to virtually any antibiotic you might choose to use so in that sense maybe but on the other hand if I knew I was dealing with anthrax and pending the sensitivity data I think I would put them on something like cyprofloxacin cyprofloxacin generally recognizes the drug of choice for anthrax and I would probably give it to him intravenously and the intravenous dose would be 400 milligrams twice a day so we may get sensitivity data back in the next day or two we may be able to to change his antibiotics after that but right now I think I'd go with cyprofloxacin do we have any nursing concerns about infection control issues do we need masks or anything like that? well again the organisms not shed in the pulmonary secretions it's not coughed out it's not spread via that route so basically standard precautions ought to be adequate what about you know he was on this inspection with a number of other individuals do we have to worry about them is there anything we would do for them? well I don't think his contacts necessarily need to be treated again this isn't a contagious disease but people who were there in the area with him who were potentially exposed to the same environment probably would be a good idea to put them on prophylaxis so if they were symptomatic I would treat them the same way you're treating him but if they're asymptomatic and we're truly speaking of prophylaxis I would probably give them oral cyprofloxacin 500 milligrams twice a day well major nurses if you could get a hold of the lab let them know about it and we'll go ahead and change them over to cypro I'll notify the commander because I think this has broad implications for potential you know other people and you know international implications potentially so well I appreciate your coming by and Sergeant McCollum will it's good to meet you Sergeant McCollum hang in there I think you're going to do fine once these antibiotics really start kicking in Sergeant McCollum I'll be back in a few minutes take care of you well if you were watching closely you got a quick glimpse of what I think is a real interesting chest x-ray and I think it's worth taking another look at that x-ray so this is an x-ray that exhibits or demonstrates a widened mediastinum and I think it's important out there in the audience to remember that there really isn't a whole lot that looks like this and since I'm in the military I'll kind of use the battlefield paradigm here but if you're out on the battlefield what else looks like this well the only thing I can think of that's relevant is trauma is a bullet hole through the mediastinum so if you somehow suspect presumably by doing a chest x-ray that a given patient has a widened mediastinum and you turn that patient over and there's no bullet hole through the center of his chest then he has anthrax and that's the hallmark of clinical disease so what I want you to remember from this particular segment is widened mediastinum on the battlefield in the absence of trauma that's probably going to be inhalational anthrax now Dr. Kahn how would a case of anthrax appear earlier in the course of disease say before they had a chance to develop this chest x-ray finding what's the take-home message for the docs and nurses out there in the audience well Ted, what I think the take-home message is that following aerosol exposure within one to six days patients present what a nonspecific febrile illness would cough and malaise now note out there to the audience I didn't say flu-like illness and the reason I didn't say flu-like illness is that unlike influenza these people do not have a runny stuffy nose or cryo they do not have a sore throat they have fever and this cough and malaise now they may have a brief period of improvement but after one to two days they usually generally suddenly worsen with stridor, dyspnea, cyanosis and frank respiratory death now the differential diagnosis that the docs out there would have to think about you've already talked about in the military context in a civilian context there would be other respiratory pathogens including viral and bacterial pneumonias and then some of the other biological warfare agents which would include staphylococcus, endotoxin, betoxin, tolaremia, plague and Q fever would be the first ones that I would think about okay, well thanks Denise, maybe you could review the treatment for anthrax now well Ted because of some concern about penicillin and possibly acquired doxycycline resistance a recent consensus paper published in JAMA recommends intravenous ciprofloxacin as the initial drug of choice for treatment doxycycline is the second line antibiotic or penicillin can also be used if there's a relative contraindication to either of the first two drugs once the sensitivity of the organism is known of course treatment should be tailored to the best antibiotic okay so you've talked about treatment what about prophylaxis well for virtually all strains of anthrax an oral fluoroquinolone is our first drug of choice for post-exposure chemoprophylaxis with doxycycline is an acceptable alternative and penicillin is our third choice of antibiotic all are generally effective as chemoprophylaxis following anthrax exposure once again sensitivity testing of the organism should guide you to the best antibiotic okay well thanks Denise now Ollie I want to go back to you and I want to thank you for helping us with this discussion and say thanks one more time say goodbye for now we're going to see both Dr. Kahn and Dr. Kuh later on the broadcast we'll see them frequently on the third day of the program as well well let's go to the audience now and see if there's any questions audience members any questions out there major nurses colonel Cislak my anthrax series say I didn't have this series and I was exposed anthrax would get in the vaccination after exposure helped me out at all okay so you forgot to get your anthrax vaccines or for some reason didn't get your anthrax vaccines you're out in the battlefield you get exposed to anthrax well what I'm going to do there is if you're floridly symptomatic I'm going to hospitalize you and treat you with intravenous chemoprophylaxis and we would call that post-exposure chemoprophylaxis and I would do that presumably with oral syprophylaxis and again as Dr. Koo outlined now the question is do you need the vaccine now and the answer in general to that question at least in a military context would be yes so I would start you on antibiotics immediately assuming a war's going on maybe vaccine isn't readily procurable right up at the front lines where you are but as soon as I forget the anthrax vaccine to you I would start immunizing you and I would give you the doses along the regular schedule and based on some animal data we think that it would be safe to stop your chemoprophylaxis after your third dose of vaccine is in in other words 30 days down the road 4 weeks down the road once your third dose of vaccine is in now what if we can't get anthrax vaccine we're in the middle of World War 3 what if we're in a civilian context and we just don't have the manufacturing capability to get enough anthrax vaccine out there well then some public health officials are recommending that we give you 60 days worth of chemoprophylaxis in the absence of vaccines so in order to summarize current department of defense recommendations call for the use of anthrax vaccine for both pre-exposure as well as post-exposure immunoprophylaxis if you're going to get a blown anthrax then vaccine is not recommended not because it would necessarily cause any harm to the patient but because by that time we don't think it would have any effect on the disease if you're going to survive the natural immunity it would probably take the place of anthrax vaccine now we get a lot of questions about anthrax vaccine especially since the department of defense has launched its program in women in the army navy air force coast guard and marine corps active reserve and guard elements to help me discuss some of the questions that I think a lot of you have out there about this anthrax vaccine program we're fortunate to have with us today lieutenant colonel randy randolph and colonel randolph is director of the anthrax vaccine immunization program and it's in a response to the secretary's decision to immunize the total force both active and the reserve components against the biological warfare agent anthrax because of the threat that you've discussed because of the lethality of the disease because we have this six-dose protocol it was imperative that we use this health protection in our force now the anthrax vaccine immunization program is being executed in three phases basically predicated by the limited stockpile phase number one which we're currently in vaccinates those forces which are currently assigned or scheduled to deploy to the high-threat areas of Korea and southwest Asia phase two which we anticipate beginning sometime when we deploy early into those high-threat areas Korea and southwest Asia again and then finally phase three beginning probably in FY03 we'll begin vaccinating the rest of the total force and begin vaccinating those forces coming through our training base so where are we in the program now how many folks have been vaccinated to date with those doses everyone is somewhere in that six dosing protocol I for instance have had five doses okay now we've talked about the 2.4 million active duty reserve and guard members I assume only military are going to receive this vaccine what about their family members what about the soldier station in Korea in a country where there's no military service and DOD contractors we've immunized a number of those who are considered emergency essential in other words mission essential to our wartime effort family members are not able to get the anthrax vaccine at this time again supply 2.4 million service members it's a lot of people each of them needs several doses of vaccine is there enough vaccine for all of our military forces we began with a stockpile of about seven million doses eventually the manufacturer the sole licensed manufacturer in the United States BioPort will have the capacity to produce 4.2 to 4.5 million sales commercially I think you know as well as I do in the next war we're likely to fight alongside various allies so is there a provision to provide our allies with this anthrax vaccine well absolutely and up to this date we have provided limited amounts to countries who have requested this basically there countries who have been alongside a normal civilian and I for whatever reason I want the anthrax vaccine either I the veterinarian or I work in a textile mill or I'm just afraid of all the terrorists out there and the cultists out there and I want to be vaccinated can I get vaccine can I go to my doctor and ask him to prescribe anthrax vaccine for me a normal civilian to populations at risk such as textile workers such as veterinarians such as researchers how about in the future let's say the six-year program goes off without too many hitches the military has finally brought up to speed everyone's immunized now will there be a supply available to civilians who want it just for whatever reason we have said there will in fact as early as four point two to four point five million again twenty percent of that should be available for their commercial sales okay well one of the questions I get as a clinician and I'm sure you've had to deal with this many times is is the vaccine safe and I have my spiel that I give to patients but I wonder if you could give us the official word on that some of the official data on vaccine safety sure this is not an experimental vaccine sure of the way it's made we would expect it to be safe it is not a live vaccine it's an inactivated vaccine it's basic component is the protective antigen the protective antigen does not cause disease now and it's almost thirty years use there have been no reports of any ill effects from this vaccine in numerous studies since 1970 one notably done at the disease they followed a cohort of about fifteen hundred ninety people over the course of twenty seven years about ten thousand doses of vaccine given to this cohort when you look at the diseases and symptoms that this cohort shows compared to an unvaccinated population there's simply no difference in what's exhibited between the two I'd like to talk a little bit now and I think pediatricians internists family practitioners public health personnel out there in the audience are very familiar with the VAERS form the vaccine adverse event reporting system form and as a pediatrician over my career I many times have had to fill out or have my people fill out a VAERS form because some child had an adverse reaction to a vaccine some child developed a rash after measles vaccine or a fever I've heard that anthrax is now or anthrax vaccine reactions are now reportable using the VAERS form and I wondered if you had some data as to how many VAERS forms have been filed and what you're finding in that regard well I do and in fact over the course of the last 29 years of course you would fill out a VAERS or at least since the FDA mandated VAERS what's most notable in the military in the civilian world it is not mandatory for practitioners in the military it has always been mandatory in fact they have to fill it out if a symptom or an effect subsequent to a dose of the vaccine causes a loss of duty greater than 24 hours or hospitalization of any period of time now the FDA normally reviews these VAERS for this vaccine and all vaccines to look at trends over time to see if there's anything that this is concerned for its purity its potency sterility general safety in addition to the FDA review we asked the department of health and human services to establish a special civilian medical expert panel to review the anthrax VAERS ones that's called the adverse or the anthrax vaccine expert committee the AVEC has as of six submissions on the anthrax vaccine of that number only 17 required hospitalization and the AVEC has only been able to give attribution probably caused certainly caused by the anthrax vaccine to five all five of those were allergic inflammation reactions at the injection site more importantly since this program has been in effect there has been nothing through this review of these VAERS ones that have caused them to make any recommendation to change DOD's anthrax vaccine immunization program well thanks you know this this vaccine goes down with this ominous wording in its package insert that it's category C vaccine for pregnancy what does that mean is this safe for pregnant women all vaccines have clinical studies on adverse effects on pregnancy prior to distributing it and improving it for human use the anthrax vaccine likewise had no long-term studies all vaccines then that are category C are simply deferred during pregnancy in women okay we have soldiers occasionally ask us can this cause infertility sterility cancer do you have any data in those states has ever been shown to have an adverse impact on fertility in males or females subsequent to taking a dose of vaccine anthrax included okay I guess one of the big concerns that comes up with regards to this vaccine and one that's been brought up to me many times is some of the studies the early studies that led to its licensure seem to indicate that okay it works against cutaneous anthrax but the real question is does this vaccine protect against aerosolized anthrax this study of course is the field trial study that brought this to licensure it was a study during the 1950s in four textile mills in the northeastern united states they looked at a cohort of about 450 individuals vaccinated with the anthrax vaccine during the course of the four year study there were 26 cases of anthrax the majority of those 21 cases were cutaneous and yes protection at about the 92 and a half was afforded the other five cases of anthrax were inhalational anthrax cases all those cases were in the unvaccinated population however because of the small number of inhalational cases there could be no statistical significance given to that data now over the course of the last several years there have been numerous numerous animal studies done most importantly on human primates in every single study the results have found that when challenged with aerosolized anthrax there is protection at the 95 to 98 percentile in those non-human primates we've also done studies on the antibody response human antibody response to the anthrax vaccine again we see a good antibody response after the second dose of anthrax vaccine 91 percent of those persons who have had that second dose show an antibody response after the third dose that increases to 95 percent with every subsequent dose past that up to the sixth dose it approaches 100 percent of an antibody response in the human population and so even though we have a paucity of data of human inhalational anthrax challenges in fact it would be unethical to do any more studies animal data and the antibody response in humans provides compelling evidence that this would protect against inhalation challenges well that certainly makes me feel better certainly encouraging news it seems though that every time I turn around there's a TV program or an article discussing people who are refusing the vaccine and I wondered how much of a deal this is or how big a deal this is how many people are refusing the vaccines with the services and with their lawyers that we have about 200,000 refusals to date all those refusals by the way are being separated from the service okay and I think you know as well as I do that during our experience in Operation Desert Storm 150,000 or so soldiers received at least one dose of the anthrax vaccine now one concern that was raised by people who were receiving the vaccine at that time perhaps some of the Gulf War illnesses or the illnesses in Gulf War veterans returning from that war and I wondered if you had any data or any information in that regard Ted this has been looked at extensively by military and non-military scientific panels they all conclude that there is no evidence of any link between the anthrax vaccine used during Desert Shield Desert Storm and illnesses found among Gulf War veterans okay we hear concerns that some strains of anthrax might be resistant to the vaccine is that possible is it possible that anthrax strains be resistant to our vaccine we don't think so technologically this would be very difficult to do we don't know of any strains of anthrax that this would be resistant to by the very fact that it's made up from the protective antigen and that component is common among all naturally occurring strains we would believe against all of these okay so antibiotic resistance really doesn't have much to do with vaccine resistance and an antibiotic strain that wouldn't assume would be resistant to vaccine but what about genetically engineered products could it is it possible the Soviets could have genetically engineered an anthrax strain that is somehow resistant to our vaccine we have no evidence of that technologically it is possible however remember for the very reasons that this bacillus this organism makes it also perfect to weaponize and if you change that in any way it makes it less perfect as a disease less perfect to weaponize less stable well thanks very much Randy and I hope that calms a lot of fears out there and puts some people's minds at ease now vaccine issues are certainly the ones we get the most many many questions still lingering out there you can find the answers to many of your questions hopefully at the anthrax vaccine website and the web address for that site is www.anthrax.osd.mil now we know we've thrown a lot at you already so what we're going to do now is give you the opportunity to take a break for the next 15 minutes at the same time please remember send in your faxes to 28 361 40 11 now when we return from the break we'll move on to the second of our bacterial diseases plague so enjoy your 15 minute break and we'll see you back after then you're starting archival hey sir he's got some respiratory distress and he's starting to cough up a little bloody sputum he doesn't look good let's get a blood pressure put him on a list of his lung feels let's bag him with a hundred percent please okay got it sir listen to his lung feels got it it sounds real junky do we have any history from this guy he's my soldier sir he got it for four or five days he's been coughing up stuff I got three or four other soldiers that are really sick too they're coughing up blood the medic says he doesn't know really what it is it's a CBC okay and let's get some blood cultures too okay I'm in I got the blood alright he's starting to throw up will you get the suction please keep bagging him keep bagging him do we get the suction over here alright suction him out okay that's good that's real bloody stuff I want to send some of that for a gram stain okay a little bit better seal there sorry I should be okay doc alright I hope so well four days ago none of the alarms or anything went off so that's when everyone started to get sick alright there we go he seems to be pinking up pretty well now there we go sox is about 95 we got that second line in Fred yeah both of them are wide open okay do I have any lab results back yet oh okay oh he's got gram negative rods well welcome back everyone before we get started on our next disease I just wanted to correct something I think I may this may be my fault I have this little microphone in my ear or my director yells at me throughout the course of the day but I think during the last section with Colonel Randolph I heard him say that there were 200,000 refusals of anthrax vaccine and again if that's what I heard then I wanted to correct that there have actually been about 200 refusals and well each one of those soldier sailors or airmen who refuses certainly generates a fair amount of press coverage over a million doses of anthrax vaccine that have been given out to date and if you do a little bit of rough mathematical calculations the refusal rate amongst anthrax vaccinees or potential anthrax vaccinees is actually about 0.06 percent well let me tell you as a pediatrician I would be ecstatic if 99.94 percent of my mothers accepted my recommendation so I think our record actually isn't so bad in that regard but without further ado let's get on with today's broadcast and I want to welcome Danis well thanks Ted I must say that Roland that was the fastest grand scene in the west well you know Danis that's not very unusual for our military hospitals they all operate with a blazing speed and efficiency and in fact I have a good friend who's a recruiter and he probably could get you switched over from the public health service to the army so why don't you come join us well thanks for the offer Ted but I've got enough at the CDC to keep me busy for well over a year and I'm going to talk about the big picture of the plague conjures up images of destruction in many people's minds and plague for the studio audience out there is another of the great diseases of antiquity just like anthrax is there have been three global pandemics of plague in recorded history we right now are in the third pandemic the first of those pandemics was often referred to as the plague often of the Byzantine empire the second pandemic of plague is the one that is referred to in folklore as the black death it peaked in about the 1350s 1360s in continental Europe and killed the third of the population of Europe and then the modern pandemic the third pandemic that we're in right now began in about 1898 let's listen to a little background history on plague as well as some history on its use as a biological weapon and I think that'll give you the potential of this disease man has used organisms found in nature to kill or disable his enemies since the middle ages one of the earlier examples occurred in the 14th century when the Tatar army laid siege to Kafa a walled city along the black sea when an outbreak of bubonic plague began to ravage the Tatars they decided to catapult the plague ridden corpses into the city thereby hoping to start an outbreak within the walls shortly thereafter the Genoese defenders within the city were stricken with plague and fled to Italy they carried this infection with them to Europe beginning the outbreak of the horrible black death which decimated the European population with our current knowledge of the epidemiology of plague we know that fleas leave a body quickly after it cools therefore it's most likely that the outbreak was actually spread in Kafa by flea infested rats which were already within the city the Japanese imperial unit 731 operated in the 1930s and 40s when Japan was mobilized and ready for war General Shiro Ishii mastermind of this terrible program had a mission to turn illness into weapons of murder Ishii was particularly fascinated by plague because with plague a BW attack could present like a natural epidemic person to person spread could then produce disease out of proportion to the original amount of agent used the Japanese were unable to disseminate plague by either aerosol or in the water supply so they used nature's vector for spreading the disease the common flea ceramic bombs loaded with infected fleas were dropped over several cities in mainland China causing large outbreaks among their populations plague is attractive as a weapon because it generates fear it spreads easily and it kills very quickly the United States offensive program did some research on plague but it was never fully weaponized in this country it did not overcome the challenge of maintaining virulence when it was grown in large quantities it's just as well I guess that we didn't weaponized plague because it's a weapon that you know it's a contagious agent and we felt that in retrospect that we had enough problems controlling an aerosol under meteorological conditions that can change without having an organism that is so contagious you're not able to control where that organism might end up it might come back to bite you not only bite your forces but some of your friendly allied forces also plague was however a favorite organism in the soviet arsenal because of its communicability the soviets overcame the virulence problems experienced by the US according to interviews with a soviet defector Dr. Alibek they had 1500 metric tons of plague on hand at any given time and kept it ready for use in their intercontinental ballistic missiles due to storage problems they frequently recycled their stockpile of plague with fresh agent we're very concerned about terrorist use of plague because the agent is found not only in nature but also in numerous biological supply houses throughout the world well Denise we certainly heard some chilling guests you could say about the history of plague why don't you start us off now by talking about the microbiology of this disease plague is a disease that results from infection by the bacteria Yersinia pestis the organism is a non-modal gram-negative Rob and when stained it's easy to see the unique bipolar properties characteristic of this organism as in the picture here it's often described as looking like a safety pin Yersinia pestis from Bacillus anthracis first they are transmissible person to person and second they do not produce spores okay what does clinical plague look like there's three clinical manifestations of plague with naturally occurring plague the most common form is bubonic plague this form is characterized by development of an acute regional lymph adenopathy or swollen lymph nodes near the site of exposure we call these swollen painful lymph nodes the semic plague occurs when Yersinia pestis invades and continues to multiply in the blood stream this can occur secondarily to bubonic plague or can develop without any detectable buboes pneumonic plague is actually the least common but the most dangerous and fatal form of the disease okay let's listen now to an expert on plague Colonel Russ Byrne who's chief of bacteriology at usamered up at Fort Dietrich and he's going to describe for us some of the the pathogenesis of pneumonic plague occurs two ways the first is as a complication of bubonic plague the infection progresses untreated to invade the blood stream followed by seeding of the lungs with progressive pneumonia the other way Yersinia pestis causes pneumonic plague is when it's introduced as an aerosol as a bioagent in that setting it's it's deposited in the alveoli taken up by alveolar macrophages and then transported by lymphatics to local lymph nodes after this the change in temperature results in a transformation of the organism it starts making a lot of the F1 capsule which protects against phagocytosis in addition a lot of virulence factors are produced this accelerates the infection and is probably responsible for the rapid downhill course in untreated pneumonic plague death usually occurs within two to five days after the onset of illness if effective treatment is not initiated within 24 hours death usually results from pneumonic plague okay, Denise right now we're in the third global pandemic of plague and that would tell me that I should be seeing or I might be expected to see cases of plague why are we not seeing more human cases of plague actually plague continues to be an endemic problem in various parts of the world but we have only a handful of human cases reported each year in the United States mostly of the bubonic type you can see here on this graph the number of reported human cases in the US from 1967 to 1997 and of course the reason we still have human plague in the US is because as we heard earlier it's a zoonotic disease that's transmitted largely by the cold rodents and their fleas to other animals and people okay I think Bill Patrick explained pretty well some of the problems and challenges of weaponizing plague and why it might or might not be a weapon or a viable weapon to certain enemies out there on the battlefield again I want to remind the people out in the audience plague is transmitted from person to person and that might make it a less attractive weapon to the battlefield commander and as I told you the battlefield commanders maintain control of the battlefield plague might be a very awesome and fearsome weapon in one sense but it is contagious and furthermore there's no effective vaccine so if I use it as a weapon I subsequently march my troops through I have to worry that they're going to get plague and I really have no good way to protect them from getting plague what's more as you've already heard plague is a vector born disease it's transmitted by fleas I infect everybody around me but I infect all the fleas and rats in the area as well so I've got to worry about them also and my problems or the range of infectivity goes well beyond the initial people I intended to affect so if I'm a battlefield commander I want to maintain control of the battlefield maybe plague isn't that attractive of a weapon on the other hand if I'm a terrorist and I want to leverage my gains then maybe I'm going to have a rapid doctor's on clinical rounds in virtual hospital and I think you're going to see they probably have another fascinating patient today they're fortunate in that Dr. Tom Butler a world-renowned plague expert from the University of Texas just happened to be visiting virtual hospital when this particular patient presented to the staff Hello PSC Williams the doctors are here to see you PSC Williams I brought a couple other doctors who is one of our outside consultants here visiting he's an infectious disease physician in addition I have Lieutenant Colonel C. Sluck who's one of our infectious disease docs just want to give you a brief rundown on what's the course of illness he was on exercise in California for about a week with his unit returned yesterday about midnight last night had the cute onset of wrigers chills he's deteriorated throughout the course of the day despite treatment with rithromycin and seftriaxin and he's developed hemoptysis over the course of the day hemoptysis, huh you know that of course presents an interesting differential obviously tuberculosis can cause that Staphylococcal pneumonia comes to mind pneumococcal pneumonia of course if he was elderly or debilitated then Klebsiella really any gram negative pneumonia can do this were other members of his unit involved well he was on this exercise with members of his unit there are about four others who have presented with similar constellation of symptoms about the same time course I would like to examine him sure sure he's by far the worst of the fire Mr. Williams does it hurt you when you take a deep breath right here sharp would you breathe yes I hear rails in the chest confirming the presence of pneumonia was there a gram stain done on the sputum yes his gram stain showed multiple polys and gram negative rods in addition his cbc showed a white count about 20,000 with a left shift and we did blood cultures too which are pending with the presence of gram negative rods in the sputum and several people involved suggest an outbreak and this could be plague plague surf you're thinking it's plague well standard mandatory masks be okay we should wear masks all of us here in this room to protect ourselves against droplet spread we need HEPA filter master surgical masks will be useful the other important thing to do is get effective antibiotic to treat this possible plague infection what did you say you had him on seftrax doxycycline or chloramphenicol is there streptomycin available in the formulae not streptomycin no could we get doxycycline sure 100 milligrams intravenously as soon as possible right now can we go ahead and do that now isn't gentamycin another alternative yes gentamycin should work as well as streptomycin we should have that as well sir I'd like to show you the chest x-ray if I could suggesting plural involvement explaining his right-sided periodic chest pain which is common with plague pneumonia Dr. Butler is this a typical clinical presentation that you'd see with mnemonic plague yes when mnemonic plague is primary that is a patient inhales an aerosol in about three days after exposure patients will develop fever, chills and cough shortness of breath sometimes the symptoms are nonspecific including headache muscle aches now could this be secondary could he have bubonic plague that's generalized to the lungs or spread to the lungs yes some patients with mnemonic plague will be secondary to a bubo which is a tender enlarge lymph node did he have a bubo physical example no not not physical well then this is probably a primary inhalational plague there have been two patients in the United States well described who handled sick cats the cats had mnemonic plague and three days after the exposure they became sick and both of them died which was about three days after the onset of symptoms now we can say we're very fortunate that Mr. Williams came to us in less than 24 hours and we expect you to do well with the antibiotic treatment however if treatment is delayed beyond 24 hours most patients do not have a good outcome now what about other people in his unit who were not ill at this time of course we'll treat the others who are ill similarly as soon as possible what about the members who were there with him in California but are not ill right now they should receive prophylactic antibiotic and the choice is tetracycline or trimethyper himself and methoxazone doctor cycling work I'm sure yes now what about health care providers people who have been taking care of him they should also receive prophylaxis okay major nurses can we get a hold of his commander and try to get those unit members rounded up I'll get McCall I'll bring him into the EO you can see him there well I really appreciate both of you coming today and sharing your expertise with us P.S.C. Williams I think you're going to do okay right you've got the medicine going on P.S.C. Williams I'll be back in a few minutes to take care of you