Smallpox Fact Biosecurity - Literature review Example

Smallpox Biosecurity Smallpox is derived from the Latin word Variola vera which means “spotted,” referring to the coalescing pustules that appear on the face and body of the infected person ("Frequently Asked Questions About Smallpox", 2006). It is a disease that is unique in humans with no known animal or insect vectors and reservoirs ("Smallpox", 2005). It is extremely contagious, disfiguring and often leads to death. The World Health Organization (WHO) in 1967 suggested that an estimate of 15 million people was infected with the disease with 2 million deaths that year (Veenema, Weinstein, & Alibek, 2006). Smallpox is caused by the DNA virus Variola, which is a member of the genus orthopoxvirus. It presents in two main forms: Variola major smallpox and Variola minor smallpox. Variola major is the more common, severe and deadly with a typical mortality of 30% of those who contract it. There are four clinical types of V. major smallpox: ordinary, modified, flat and hemorrhagic (Weir, 2001). The most recurrent type accounting to 90% of all cases is ordinary. Modified smallpox is mild and occurs in persons previously vaccinated against smallpox. Flat and hemorrhagic smallpox are the very severe but rare types (Veenema, Weinstein, & Alibek, 2006). The other type, Variola minoris a much less severe form of smallpox, death rates of only 1% (SNL Biosecurity Team, 2005). The variola virus that causes smallpox can only infect humans. It is very virulent and contagious that for it to produce an infection it only needs about 5-10 virions (Veenema, Weinstein, & Alibek, 2006). Virions are the brick-like structures that are seen under the microscope, which are made up of proteins. Tegnell, Wahren & Elgh (2002) added that orthopoxviruses, to which the variola belongs are large and complex viruses (Veenema, Weinstein, & Alibek, 2006). The prodromal signs and symptoms of smallpox that present after an incubation period of 7-14 days are sudden high fever, head and body aches, general body malaise and vomiting. Some even experience abdominal pain and delirium (Tegnell, Wahren, & Elgh, 2002). After 2-4 days, a maculopapular erythematous rash presents first in the mouth, then on the face, spreading from the extremities to the rest of the body, all appearing in the same form. The rashes are concentrated more on the face and extremities than on the trunk that is centrifugal in distribution ("Smallpox", 2005). The rash changes into vesicles, later becoming pus-filled. The pustules are deeply rooted in the skin, Days after, crusts form over, scabs over and later fall off leaving a disfiguring pitted scars due to the destruction of the sebaceous glands (Tegnell, Wahren, & Elgh, 2002). In some however, secondary bacterial infections may appear in the vesicles that can progress to some organs including bones and joints (Veenema, Weinstein, & Alibek, 2006). Tegnell, Wahren & Elgh (2002) cited E. Z. Munch af Rosenschöld (1775–1840), a Swedish physician describing the diseased person with “the whole body from head to feet is covered with innumerable coalescing pustules, which burn like fire. The face is dreadfully swollen and disfigured, the eyes bereft of their light. The swollen, wheezing throat exhales a rotten stench. From the eyes tears and pus flow, from the mouth a flow of sour saliva, from the intestines rotten excrement, often mixed with pus and blood. The whole body is an abscess. One cannot any longer see the human in the diseased.” Although majority of the patients with smallpox recuperate, death in 3 out of 10 cases most likely results due to toxemia secondary to circulating immune complexes during the second week of illness (Veenema, Weinstein, & Alibek, 2006). Tegnell. Wahren & Elgh (2002) noted that if the patients survive the course of the disease, they are left with disfiguring scars and blindness in one or both eyes caused by corneal scars. The infected person is not contagious during the incubation period (Veenema, Weinstein, & Alibek, 2006). The infected person becomes most contagious from the end of the incubation period when the first rash manifests on the skin shedding virus until the last scab heals and falls off. Direct contact and prolonged face-to-face contact are the modes of transmission of the smallpox from one person to another ("Smallpox: Current, comprehensive information on pathogenesis, microbiology, epidemiology, diagnosis, treatment, and prophylaxis", 2006 ). Direct contact with infected bodily fluids and scabs and exposure with contaminated articles such as bed linens or clothing can easily transit smallpox to others (Tegnell, Wahren, & Elgh, 2002). Weir (2001) added that it is also transmitted via inhalation of the discharges respiratory droplets from the infected person’s oropharynx when talking, sneezing and coughing. Once the virus enters the host’s body, it immediately replicates in the host’s cells and quickly multiplies in the lymph nodes, spleen and bone marrow. After which it settles in the skin’s vascular system and in the mouth and nasal mucosa, releasing large amounts of the virus in the saliva ("Smallpox: Current, comprehensive information on pathogenesis, microbiology, epidemiology, diagnosis, treatment, and prophylaxis", 2006 ). Once the symptoms of smallpox start to manifest, there is no effective antiviral treatment and the only way to prevent smallpox infection is vaccination (SNL Biosecurity Team, 2005). Preexposure vaccination prevents or considerably improves the illness. It is also generally effective in improving the illness if given within the first 4 days after exposure (Weir, 2001). Veenema, Weinstein & Alibek (2006) pointed that immunity wanes variably, neutralizing antibodies usually declines substantially 10-20 years after or earlier in some people (5-10 years), suggesting uncertainty of the immune status of those vaccinated more than 25 years ago. It is assumed that those who when they were still children when they received their single-dose shot do not have lifelong immunity. In contrast, those who received vaccinations at birth and at a much later year (ages 8-18) had a steady neutralizing antibody levels during a 30-year period (Henderson, 1999). Smallpox have followed the humankind for a thousand years until 30 years ago (Tegnell, Wahren, & Elgh, 2002). In 1816, Sweden spearheaded the legislation of smallpox vaccination in all children under 2 years of age (SNL Biosecurity Team, 2005). The World Health Organization (WHO) decided in 1959 to implement the global vaccination program to eradicate smallpox. This ambitious program was only initiated in 1967. In the U.S. the last case of smallpox was in 1949 (Smallpox Vaccine, 2003) and the very last case was reported in Somalia in 1977 (Weir, 2001). After massive efforts, smallpox was declared to be wiped out globally in 1980. Because of the success of the vaccination program, the World Health Assembly (WHA) suggested to halt all vaccinations against smallpox among the general public in the same year because prevention was no longer crucial ("Frequently Asked Questions About Smallpox", 2006). According to Weir (2001), the United States was left with a limited reserve supply of the vaccine believed to provide protection to about 6 to 7 million persons. The vaccine were produced in the 1970s by Wyeth Laboratories, Lancaster, Pa. is now in custody of the Center for Disease Control and Prevention which are freeze-dried in vials stored at -20’C (Henderson, 1999). Weir (2001) added that these vaccines consist of concentrated virus-containing liquids from scarified calves skin. It is recognized that the sum of stocks of vaccines globally is inadequate. And unfortunately, smallpox vaccine manufacturing came to a close because there was no longer a commercial incentive for its production after the eradication of the smallpox in 1980 (Enserink, 2002). In addition, at present, there are no manufacturers equipped to create a hefty quantity of the vaccine (Beeching, Dance, Miller, & Spencer, 2002). These scenarios made WHO to push for most countries to find ways of augmenting their stocks (Enserink, 2002). Currently, the United States has an adequate amount of smallpox vaccine to vaccinate every person in the country in the event an outbreak comes about (Tegnell, Wahren, & Elgh, 2002). In fact, in September 2002, an instruction addressed to all health officials in every state to immunize every person in America when a need is called for was released by the Centers for Disease Control and Prevention (SNL Biosecurity Team, 2005). There is however a conservative list of persons whom the US Food and Drug Administration (FDA) has currently approved the use of the smallpox vaccine. Persons classified in special- risk categories include laboratory researchers and workers who directly handle authorized smallpox vaccine specimens and related viruses belonging to the orthopox Family (Henderson, 1999). Beginning in 2002, President George W. Bush issued an order allowing all American military personnel for a compulsory vaccination. Clinicians, public health officials and first emergency response personnel and law-enforcement personnel are under a voluntary program for smallpox vaccination (Veenema, Weinstein, & Alibek, 2006). Virology experts say that ”vaccinia vaccine causes a fatal complication in about one of every 1 million people who receive it and that means that if the entire American population were to be vaccinated, 300 people would be expected to die of complications from the vaccine. Another 3,000 or so might develop painful sores and severe scars, while 600 others would likely have residual brain damage from encephalitis — a potentially fatal brain inflammation “ (SNL Biosecurity Team, 2005). Despite the success and safe administration of the smallpox vaccine to ages from birth onwards, certain age groups were found to be at risk for vaccination complications (Henderson, 1999). Tegnell, Wahren & Elgh (2002) added that the incidence of complications increases with age but lessens with the number of doses given. Decision whether to vaccinate the general public should be given a lot of thought because the smallpox vaccine poses real potential of a severe and sometimes fatal complications. And because of the number of serious harms and complications, both the CDC and WHO urge no vaccination be administered to the general public (Sidell & Franz, 2003) In case there is a procurement of additional supply of the vaccine, a decision has to be made if whether being protected from the threat of contracting the disease far outweighs the relative grave risks posed by vaccination. But in an occurrence of an epidemic or emergency, a massive vaccination is indicated and necessary (SNL Biosecurity Team, 2005). The virus was not eradicated entirely, samples of the Variola virus still exists in laboratories. They are officially kept in two-high security laboratories for research purposes (Rotz, Khan, Lillibridge, Ostroff, & Hughes, 2002). The two approved places where the remaining virus samples remain in custody and under strict international–agreed protocols are: the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia and Russian State Research Centre of Virology and Biotechnology, in Koltsovo (Enserink, 2002). Some officials have expressed concerns that the variola viruses that are stored in the laboratories may be in the hands of terrorists (Enserink, 2002) or that rogue nations may have made the virus into a deadly weapon (DeNoon, 2006). Biological warfare agents are disease-causing organisms which are utilized to cause disease and death in man, animals and plants (DeNoon, 2006), which are either duplicating (e.g. bacteria or viruses) or non- duplicating (e.g. toxins, proteins or peptides) (Sidell & Franz, 2003). These according to Rotz, Khan, Lilibridge, Ostroff, & Hughes (2002) have lead to the fear that it will be used as a biological warfare agent for bioterrorism that threatens every leader of every country. Biological warfare has a long history. Dating back to at least 1346, attackers hurled bodies of humans and animals inflicted with plague over the city walls under siege, hoping to sicken or kill enemy combatants and civilians (Wright, 2004). War isn’t just the use of explosives and firearms, the use of biological warfare agents is now also used for waging war by several nations and terrorist groups to inflict harm on target enemies and civilians as well. Henderson (1999) noted that biological agents are in fact the most feared form of weapon of mass destruction over nuclear and chemical. Beeching, Dance, Miller & Spencer (2002) echoed that “biological agents have particular appeal for use in terrorist attacks because they are reasonably easy to acquire, are inexpensive to produce, and have the potential to affect large populations of people.” The use of biological agents would not only indisputably result to a catastrophic impact on public health (Rotz, Khan, Lillibridge, Ostroff, & Hughes, 2002) but would also cause fear, havoc, anxiety and panic among the general population (Sidell & Franz, 2003). In the aftermath of the terrorist attack on the U.S. on September 11, 2001, the looming threat of bioterrorism has called the attention of the military, as well as the medical sector. There is now a heightened concern and a widespread agreement of the possible disruptive consequence that the variola virus will be used for bioterrorism (Wright, 2004). The intentional release of smallpox to cause an outbreak is not a remote possibility. Since variola virus has been eradicated in 1980 and no incidence of naturally occurring smallpox has occurred since, a single case of smallpox at present poses a great concern (Tegnell, Wahren, & Elgh, 2002). Because routine vaccination came to an end in the United States more than 25 years ago, much of the population is susceptible of contracting the disease (Smallpox Vaccine, 2003). About 40% of Americans are unprotected against smallpox, and others were vaccinated more than 25 years ago (DeNoon, 2006). Smallpox used as a biological weapon is a very serious threat among unvaccinated individuals, killing about a third of those it infects (Enserink, 2002). The Centers for Disease Control and Prevention has set criteria on classifying agents in three priority categories (A, B, or C) for initial public health preparedness efforts (Tegnell, Wahren, & Elgh, 2002). Category A agents pose the greatest potential for harming public health because they can result to mass casualties. Category A agents also have a moderate to high probability for large-scale dissemination, resulting to mass public fear and civil disruption (Rotz, Khan, Lillibridge, Ostroff, & Hughes, 2002). Smallpox is classified under Category A agent along with the other common biological agents weaponized such as anthrax, plague, botulism toxin, tularemia, and viral hemorrhagic fevers which are all serious and sometimes fatal diseases (Veenema, Weinstein, & Alibek, 2006). Because of the ease of dissemination and spread, virulence and contagiousness, and high fatality rate, smallpox is classified as a Category A agent (Enserink, 2002) and is believed to pose the greatest threat of all the potential bioterror agents (Tegnell, Wahren, & Elgh, 2002). Orthopoxviruses, to which variola belongs, are considerably stable and easily dispersed in respirable aerosol form (particles approximately 1-10um in diameter). And this is most likely the method of a wide and rapid dissemination throughout the country (Henderson, 1999). A single case of smallpox represents an international health emergency with a possibility of a terrorist attack (Veenema, Weinstein, & Alibek, 2006). The outbreak of smallpox is frightening and because of this, precautions are being undertaken by the U.S. government in case of a bioterrorist smallpox attack. Two ways are being explored by the U.S. government are: 1) a program on a nationwide smallpox preparedness, which includes creation of a team that will respond to a smallpox attack. Members of the mentioned team, consists health care and public health personnel that might receive patients: first-response and disaster response personnel (police, firefighters, transit workers, mortuary staff) are given protection through vaccination in the event of an outbreak; and 2) enough vaccines for everyone in case of an emergency (Rotz, Khan, Lillibridge, Ostroff, & Hughes, 2002). In 1999, the U.S. Congress designated the Centers for Disease Control and Prevention as the lead agency to upgrade public health assessment, planning and response to bioterrorism. Biological terrorism preparedness and response involves planning, surveillance and epidemiological activities, quick laboratory diagnostics, improved communications and stockpiling of medicines and vaccines (Kaplan & Garrick, 1981). In the event of a smallpox outbreak after an aerosol release of smallpox, members of the team created will disseminate information on how they can protect themselves and their families through visual and print media. Instructions on where to go if they suspect they have the infection is given out too. In case of positive infection, isolation is implemented to prevent further spread of the disease to others. Isolation is done if possible in a negative pressure room (Sidell & Franz, 2003). Vaccination is also done to individuals suspected to have smallpox. The rationale behind vaccinating suspected persons is to ensure that in cases of wrong diagnoses, they are protected from acquiring smallpox. Postexposure vaccination as late as 4 days after exposure may avert or improve the illness and avoid a fatal outcome (Henderson, 1999). Smallpox vaccination is administered to all household and others in those face-to-face and close-contact with the infected person. Following vaccination, they are places under surveillance and close monitoring is done for signs of presence of the infection (Rotz, Khan, Lillibridge, Ostroff, & Hughes, 2002). Isolation for about 18 days is also done to those who come in close contact with the infected person. Vaccination may also be offered to those who were not exposed, but risks and benefits of the vaccine should be clarified (Schaub, 2002). Variola major virus is an example of an Extreme Malicious Use Risk agent (SNL Biosecurity Team, 2005)). There is much concern of this virus for several reasons: it has a high consequence potential of smallpox, high morbidity and mortality rate, high contagiousness, small percentage of the population are vaccinated and it has a history of a moderate weaponization potential as it is very stable in aerosol form ("Smallpox: Current, comprehensive information on pathogenesis, microbiology, epidemiology, diagnosis, treatment, and prophylaxis", 2006 ). The smallpox is put into spotlight again because of the possible bioweapon programs by rogue states and terrorist groups. In 1972, the Biological and Toxin Weapons Convention (BWC) had 142 nations (including Iraq and the Soviet Union) (Salerno & Koelm, 2002) signed a campaign advocating the annihilation of researches on offensive biological agents and subsequently, the destruction of the remaining stocks ("Smallpox: Current, comprehensive information on pathogenesis, microbiology, epidemiology, diagnosis, treatment, and prophylaxis", 2006 ). Despite this and the WHO recommendation (in 1980) of the destruction or shipment of all existing stocks to any of the two official facilities (in the U.S. and in the Soviet Union), there is no means of verifying the absolute compliance of all countries that will discount the possibility of the virus ending up in the hands of potential terrorists (Salerno & Koelm, 2002). To address bioterrorism, both the Risk Assessment and Operational Risk Management have been brought to play in the implementation of military and homeland security strategies utilized in the Chemical, Biological, Radiological and Nuclear (CBRN) environments (DeNoon, 2006). Central to risk analysis are: 1) risk assessment, 2) risk management and 3) risk communication (Schaub, 2002). The use of a risk assessment approach can make a valuable contribution in elucidating the important perceptions to the bioterrorism problem. And a risk assessment framework is useful in evaluating and ranking potential points of vulnerabilities and for measuring the impact of alleviating measures on the outcome risks (Haas, 2002). According to Kaplan and Garrick (1981), the bioterrorism problem can be framed using the following questions: 1) what can go wrong? 2) how likely is that event to happen? and 3) what are the consequences if it does occur? (SNL Biosecurity Team, 2005). To serve as guide in protecting and securing high-consequence pathogenic agent like smallpox, a biological laboratory and transportation security (BLTS) standards has to be adopted nationally. The leading targets that entail protection are the high-consequence pathogens because of the grave harm it inflicts on humans and its malicious and intentional release can create a national and international security threat. According to Salermo and Koelm (2002), “the six key elements of a BLTS are physical protection, personnel reliability, adequate scientific program oversight, pathogen accountability, transportation security, and information security.” Biosecurity and biosafety are two different concepts often used interchangeably. Reduction of exposure to hazardous agents of laboratory workers is the primary objective of biosafety, whereas, the objective of biosecurity is to safeguard high-consequence agents from theft and diversion from a group or individuals with a wicked intention of conducting bioterrorism (Salermo and Koelm, 2002). Besides the high-consequence pathogens, such as smallpox, information regarding technical knowledge in weaponizing an agent should also be protected. Target information could either be verbal and written instructions pertaining to use of biological agents as warfare weapons. Other concern is to identify security threats and vulnerabilities. Threats may involve individuals who have access or not to the facilities and specimens. On the other hand, vulnerabilities include factors such as kind of the facility in focus, type of research done and the local environment. The Federal Bureau of Investigation’s (FBI) Security Risk Assessment (SRA) Program as mandated by the United States Department of Justice, will conduct security risk assessment to all nationwide laboratory personnel using fingerprint analysis who will have access to regulated dangerous biological agents and toxins (Molde, 2003 ) Persons considered restricted under the Public Health Security and Bioterrorism Response Act of 2002, are denied access to facilities and dangerous agents unless approved by the Secretary of either the Department of Health and Human Services (HHS) or the US Department of Agriculture (USDA) (U.S. Department of Justice, 2005). Although the BLTS places a priority on security to combat the creation of biological weapons, there should also be a balance between restrictions to access of high-consequence pathogens with the need for a research on such agent. Biomedical researches are vital in better understanding the high-consequence agents (Salermo and Koelm, 2002). Bibiliography: Read More