**The following is a fictitious scenario that I created for one of my public health courses:
Outbreak Scenario
On October 12th, 2009 at 9:32am, a group calling themselves “The Movement” contacted members of the local media in Phoenix to tell them that a bioterrorism “bomb” had been released at the Arizona Cardinals stadium in Glendale during a football game on October 11th, which had several thousand fans in attendance. The group claimed that it had released anthrax (a category A agent) in an aerosolized manner. The group expressed that they are an anti-immigration group that is angered by Phoenix’s lax immigration standards. The media then immediately contacted the Phoenix Police Department and notified both the Maricopa County Health Department and the Arizona (state) Department of Health.
On October 12th at 10:04am, officials at the state and county health departments held a teleconference call where it was determined that the local hospitals should be contacted to notify physicians and epidemiologists to be on the look-out for cases of inhalation anthrax. Physicians were asked to confirm their diagnosis of anthrax via a blood culture test and to submit the blood culture to the state lab for confirmation. Physicians would then be notified by the state lab if there was a confirmation of the diagnosis. However, since inhalation anthrax is a fast progressing disease, physicians were instructed to begin administering antibiotics for any suspected cases of anthrax even before blood test confirmation. The public health officials also contacted the National Pharmaceutical Stockpile and asked that shipments of ciprofloxacin and Biothrax be readied in the event that there was a shortage of needed antibiotics.
The police were also contacted and notified that a HAZMAT team was assembled and was being sent to the stadium for decontamination. The HAZMAT team arrived to the stadium at 12:12pm on October 12th and decontamination procedures were initiated. The clean-up of the stadium and the surrounding area took approximately 10 hours, and some residents surrounding the stadium were evacuated during the decontamination process to protect them from possible exposure. The Arizona Cardinals stadium is a dome, but has an open roof, so it was not initially clear if the aerosolized spores of anthrax were contained within the stadium or had traveled to the surrounding areas outside of the stadium.
The HAZMAT team worked in cooperation with the local police department, fire department, and the Federal Bureau of Investigation who had also been called-in due to the terrorist nature of this event.
Residents were allowed to return to their homes after the HAZMAT team determined that there were no exposure risks outside of the stadium. However, the stadium remained closed for a week to ensure that all areas of the very large stadium had been thoroughly decontaminated and to allow the local police department and the FBI to conduct investigations.
At 12:30pm on October 12th the county health department received a call from Dr. Marquez at Phoenix Baptist Hospital indicating that a patient had reported to their ER room with symptoms that are suspicious for inhalation anthrax and the patient notified hospital staff that he had been at the game on the 11th. Dr. Marquez ordered a blood test and confirmation was confirmed on October 14th at the state lab. This patient was the first index case.
Shortly thereafter, at 12:44pm on October 12th, the county health department received another call, this time from Dr. Wongduan at St. Joseph’s Medical Center indicating that he had heard about the news report regarding the possible bioterrorist attack yesterday at the Cardinals game, and he had a patient that has symptoms that are concerning for inhalation anthrax. He wanted to report the case to the health department before lab confirmation. This case was also lab confirmed via a blood culture on October 14th.
The health departments received a total of 8 calls on October 12th from hospitals and dozens of calls from concerned citizens that had attended the game. The public health officials told those concerned citizens to report to an ER room at a local hospital and await instructions from hospital staff. The hospitals were instructed to begin administering antibiotics for any patients that presented with symptoms concerning for inhalation anthrax. A total of 10 patients that presented with symptoms on October 12th were confirmed via blood test on October 14th.
After learning of the advisement from the public health officials, some hospitals recalled patients that were initially diagnosed on the evening of the 11th and early morning on the 12th that presented to the hospital with flu-like symptoms. It is felt that these patients may have been misdiagnosed and were possibly exposed to the inhalation anthrax. However, none of these patients were confirmed as having anthrax.
Since inhalation anthrax is a fast-developing disease, it was necessary to start confirmed cases of inhalation anthrax on ciprofloxacin, along with another antibiotic such as penicillin or doxycycline given intravenously. Public health officials decided to recommend to doctors not to use the Biothrax vaccine, due to its controversial nature, unless they felt it necessary in a particular case and then the physician should discuss the possible side-effects with the patient before administering it. Exposed individuals also underwent decontamination procedures at hospitals to include removing any contaminated clothing from the patient and to have the patient shower with soap and water for about 20 minutes. Bleach solution was not recommended unless the exposed individual could not be decontaminated with soap and water for some reason, and then if necessary, the diluted bleach solution to be used after the soap and water shower, and then rinsed off after a 10 to 15-minute period. Isolation or quarantine was deemed unnecessary since anthrax is non-communicable, so only standard precautions applied.
Over the course of one week, from the exposure date of October 11th, a total of 112 people were confirmed via blood culture as having inhalation anthrax. Public health authorities had feared that there might be considerably higher numbers given the aerosolized manner of the substance. It is unclear as to why more people were not infected, perhaps when the police investigation is concluded more will be understood about how the terrorists released the substance. However, police and FBI investigations revealed that all of the infected individuals were seated in one section of the stadium, so other areas of the stadium were apparently not affected. It is unclear at this time if this was intentional by the terrorists or if the aerosolized spores somehow deviated from the planned attack area.
Of the 112 laboratory confirmed cases, 10 of them reached second stage development of inhalation anthrax, which was confirmed by a chest x-ray, presumably because these individuals did not report to a hospital ER room in a timely manner. Of these 10 individuals, 9 died of inhalation anthrax. This resulted in a total mortality rate of 8%, however, of the victims that reached the second stage of symptoms for inhalation anthrax there was a 90% mortality rate. All exposed patients are currently receiving treatment and will continue to receive treatment for up to 60 days. Currently all other patients are responding well to the treatment.
Conclusion
On October 12th, 2009 a terrorist group calling themselves “The Movement” contacted local media in Phoenix, Arizona to notify them that aerosolized anthrax had been released at the Arizona Cardinals football stadium in Glendale on October 11th. The media immediately contacted public health officials and the Phoenix Police Department. Public health officials then contacted local hospitals to notify them to be on the look-out for suspected cases of inhalation anthrax and to test all suspicious patients with a blood test. Infected patients were decontaminated and started on antibiotics which included a combination of ciprofloxacin and either penicillin or doxycycline. A HAZMAT team was also sent to the Arizona Cardinals stadium to close down and decontaminate the entire area. The decontamination of the surrounding neighborhoods was completed within 10 hours and residents were allowed to return to their homes. The stadium and adjacent facilities were closed for one week to ensure a thorough decontamination of the area.
Laboratory confirmed cases of inhalation anthrax were totaled at 112. Public health officials expected this number to be much higher, but it was determined by the Phoenix Police Department along with the FBI that only one section of the stadium was exposed to the aerosolized anthrax. Of the 112 confirmed laboratory cases of inhalation anthrax, 10 of them reached “second stage” symptoms, which resulted in a total of 9 deaths from this terrorist action. There have been no further cases identified since October 18th, 7 days after the exposure date. However, public health officials will continue to provide surveillance for up to 60 days. The Phoenix Police Department’s investigation into the terrorist actions is ongoing as is that of the Federal Bureau of Investigation.
Background
Anthrax is a naturally-occurring bacterium which lives in soil and can remain alive for years as a spore, which can then be passed to humans that handle infected livestock or eat contaminated, undercooked meat (Null, 2003). Anthrax occurs in three forms: pulmonary, cutaneous, and gastrointestinal (Heymann, 2008). Cutaneous anthrax is the most common, accounting for greater than 95% of cases affecting humans (Heymann, 2008).
Symptoms of cutaneous anthrax typically begin with itching of the affected site, followed by a lesion developing into a depressed black eschar, this last phase taking approximately 2 to 6 days (Heymann, 2008). The eschar is then surrounded by moderate to severe edema, which is quite extensive; there is usually little to no pain (Heymann, 2008). However, there is often considerable swelling around the site of the sore and bouts of shivering and chills in the affected individual are common (Null, 2003).
Common sites of infection include the hands, forearms, head and neck; this is because these are exposed parts of the body and cutaneous anthrax requires a pre-existing cut or break in the skin for it to enter into the body (Heymann, 2008). If left untreated, the disease may spread to the lymph nodes and into the bloodstream, though this is fairly rare (Heymann, 2008; Null, 2003). The fatality rate for cutaneous anthrax is between 5 to 20% if untreated, however, with treatment fatality is rare (Heymann, 2008).
If anthrax were to be used as a bioweapon, it would most likely be aerosolized which would result in inhalation anthrax (Null, 2003). Early symptoms of inhalation (also known as pulmonary anthrax) are a mild cough, headache, fever, and general malaise, which makes them virtually indistinguishable from symptoms of influenza, unless a blood test is done (Null, 2003). However, within 3 to 4 days, symptoms progress to respiratory distress, enlargement of the mediastinum, immune system failure, shock, and death within 48 hours after the release of the toxin (Heymann, 2008; Moore, 2001). For untreated cases, fatality is 100% and may occur in as many as 95% of treated cases if therapy is begun more than 48 hours after the onset of symptoms (Cieslak et al., 1999).
Gastrointestinal anthrax is not common in developed countries, but is seen in poor or developing countries, usually by way of eating contaminated meat (Heymann, 2008). The consumption of tainted meat usually takes the form of gastrointestinal anthrax, though oropharyngeal may also develop (Heymann, 2008). With oropharyngeal anthrax the lesion is in the mouth cavity, on the tongue, mucosa, tonsils, or pharynx wall (Heymann, 2008). Early symptoms of oropharyngeal anthrax include sore throat and extensive edema in the throat that may lead to blockage of the trachea (Heymann, 2008). The lesion of gastrointestinal anthrax is typically found in the intestinal tract and is ulcerative and massively edematous, which leads to hemorrhaging and obstruction of the gastrointestinal tract (Heymann, 2008). The incubation period for both gastrointestinal and oropharyngeal anthrax is approximately 3 to 7 days (Heymann, 2008). It is not always fatal, but even with treatment, this form of anthrax has a high fatality rate (Heymann, 2008).
Naturally occurring cases of anthrax may come about from environmental disasters, like tsunamis or floods which can cause erosion of burial sites of infected animals, which in turn can lead to contact of the disease by humans (Null, 2003). Any contact with an infected animal, including touching the hair or skin of the animal as well as handling bones of a deceased animal that was infected can result in a human becoming infected with anthrax (Cieslak et al., 1999). Biting flies that have bitten a diseased animal and then bite a human can also infect the human, as well as touching contaminated soil (Heymann, 2008). Inhalation anthrax occurs primarily in industrial or factory settings where animal hides are processed and there is poor ventilation, which results in ingestion of the anthrax spores (Heymann, 2008).
The incubation period for anthrax is generally 1 to 7 days, though incubation periods of up to 60 days is possible (Heymann, 2008). Person to person transmission is exceptionally rare and has only been documented with cutaneous anthrax (Heymann, 2008).
Anthrax has also been both used and studied as part of some countries bioweapons programs, perhaps most notoriously by the Japanese Imperial Army during the 1930’s and 1940’s, through the infamous Unit 731; and by the Soviets during the cold war era (Miller et al., 2001). Anthrax has also been used as a bioweapon by domestic terrorists, most recently and perhaps most notably in October of 2001, which infected and killed a number of Americans (Null, 2003). According to military and counterterrorism experts anthrax is near or at the top of any list of most likely bioweapon (Cieslak et al., 1999; Moore, 2001). Given the relatively short incubation period, and rapid progression of disease, identification of the exposed population within 24 to 48 hours and employment of therapeutic and prophylactic strategies are likely to present a challenge (Cieslak et al., 1999).
There is a vaccine for anthrax, Biothrax (also known as AVA, which stands for Anthrax Vaccine Adsorbed), though it is not made available to the general public, it is recommended for lab workers and workers that handle potentially contaminated raw materials who may come into contact with anthrax through their job duties (Heymann, 2008). The vaccine was also administered to American military troops prior to their campaign in Iraq, as a precautionary measure against Saddam Hussein’s army which it was feared might use anthrax as a bioweapon against American soldiers (Null, 2003).
The vaccine is effective in preventing cutaneous and inhalation anthrax and is designed for preventing exposure to anthrax, though it can be administered as an “after-the-event” treatment in the case of a biological weapons attack, for example, and would be combined with antibiotic therapy, of which ciprofloxacin is considered the first line treatment though doxycycline or amoxicillin maybe used in some cases (Heymann, 2008). However, ciprofloxacin and doxycycline have side effects which may be more severe than other antibiotics which also may work against anthrax, like penicillin (Null, 2003).
Prevention control for naturally acquired anthrax includes vaccinating livestock, properly disposing of dead livestock by burning them, ensuring proper ventilation systems in factories and labs, and educating employees that might come into contact with anthrax about safe practices such as wearing protective masks and clothing (Heymann, 2008).
Anthrax is essentially non-contagious, so quarantine of humans is unnecessary and standard preventive measures when handling the patient such as wearing disposable gloves, changing bedding soiled with lesion fluid, disinfecting clothing, and washing hands regularly would be applicable (Heymann, 2008).
Assumptions
On October 12th, 2009 a group calling themselves “The Movement” contacted members of the local media in Phoenix to tell them that a bioterrorism “bomb” had been released at the Arizona Cardinals stadium in Glendale during a football game on October 11th, which had several thousand fans in attendance. The group claimed that it had released anthrax (a category A agent) in an aerosolized manner, though this has yet to be confirmed.
Of great concern to the county and state health departments is the high number of citizens in Phoenix that might be affected due to the amount of residents potentially exposed at the football game. Shortly after receiving the call from The Movement, physicians at hospitals in Phoenix began reporting patients that were beginning to show early symptoms of what might be inhalation anthrax. The disease progression is expected to have a normalized progression and those patients reporting to local hospitals are being tested for inhalation anthrax and will receive “after-the-event” vaccinations and antibiotic therapy as well as decontamination if the tests are positive. The local and state health departments are currently working with the media to release a message to those in attendance at the game to report immediately to an ER room at a hospital to get tested for possible inhalation anthrax exposure.
References:
Cieslak et al., T.J. & Eitzen, E.M. (1999). Clinical and Epidemiologic Principles of Anthrax. Emerging Infectious Diseases, 5(4), 552-555.
Heymann, D.L. (2008). Control of Communicable Diseases Manual (19th ed.). Baltimore: United Book Press.
Miller et al., J., Engelberg, S., and Broad, W. (2001). Germs: Biological Weapons and America’s Secret War. New York: Simon & Schuster.
Moore, P. (2001). Killer Germs: Rogue Diseases of the Twenty-First Century. London: Carlton Books.
Null, G. (2003). Germs, Biological Warfare, Vaccinations: What You Need to Know. New York: Seven Stories Press.
China and Russia put the blame on some screwed up experiments of US for the earthquake that happened in Haiti.
Chinese and Russian Military scientists, these reports say, are concurring with Canadian researcher, and former Asia-Pacific Bureau Chief of Forbes Magazine, Benjamin Fulford, who in a very disturbing video released from his Japanese offices to the American public, details how the United States attacked China by the firing of a 90 Million Volt Shockwave from the Americans High Frequency Active Auroral Research Program (HAARP) facilities in Alaska
If we can recollect a previous news when US blamed Russia for the earthquake in Georgio. What do you guys think? Is it really possible to create an earthquake by humans?
I came across this article about Haiti Earthquake in some blog it seems very interesting, but conspiracy theories have always been there.