Recognition, Management and
Surveillance of Ricin- Associated Illness
Webcast
Script
December
30, 2003
SCHIER:
"Thank you for
joining us in this CDC clinical education Web cast. On October 15, 2003, an envelope with a
threatening note and a sealed container holding ricin toxin was found at a mail
processing and distribution facility in Greenville, South Carolina. The note threatened to poison water supplies
if demands were not met. As of this
broadcast, the individual who mailed this envelope has not been apprehended.
"Ricin has long been
considered a possible weapon of biological warfare or biological
terrorism. In addition, rare incidents
of accidental ricin poisoning have been reported. Because most physicians are not familiar with
the presentation or treatment of ricin intoxication, CDC presents this
educational Webcast. Interested
clinicians also can read the article 'Investigation of a Ricin-Containing
Envelope at a Postal Facility --- South Carolina, 2003,' published in the
November 21, 2003, issue of Morbidity and Mortality Weekly Report."
(PAUSE)
DANIELS:
Hello, I'm Kysa
Daniels. Welcome to today's program,
"Recognition, Management and Surveillance of Ricin-Associated
Illness," coming to you from the Centers for Disease Control and Prevention
in Atlanta, Georgia.
The goals for our program
are:
To provide clinicians and
public health officials with the following information related to ricin: Background, Clinical Presentation,
Recognition and Diagnosis, Personal Protective Equipment/Decontamination,
Management, and Reporting.
To provide clinicians and
public health officials with information on epidemiological clues that may
suggest illness associated with ricin or another chemical or biological toxin
in the correct clinical context.
Upon successful completion
of the program, participants should be able to:
·
Describe the
epidemiology of nonterrorism-associated ricin poisoning.
·
Describe the
epidemiology of terrorism-associated ricin poisoning.
·
Describe the
clinical manifestations of oral, inhalational, and parenteral ricin poisoning.
·
Describe the
differential diagnosis for ricin poisoning.
·
Explain the
diagnosis of ricin poisoning.
·
Identify
epidemiological clues suggestive of a possible covert ricin (or other chemical/biological toxin) release.
·
Describe the
clinical management of ricin poisoning.
·
Describe the
disposition of patients with ricin-associated illness.
·
And identify the
proper authorities for reporting of suspected or known ricin-associated
illness.
Continuing education
credit will be offered for a variety of professions, based on 1 hour of
instruction. A certificate of credit or
a certificate of attendance will be awarded to participants who complete the
evaluation.
The date of this original
webcast is December 30, 2003. The expiration
date for the Enduring Materials will be December 30, 2006.
For the purposes of disclosure, CDC, our planners, speaker and
subject matter expert wish to disclose they have no financial interests or
other relationships with the manufacture of commercial products, providers of
commercial services, or commercial supporters.
Today's presentation will
not include any discussion of the unlabeled use of commercial products or
products for investigational use.
I will give you more
registration information later in the webcast.
Our speaker today is Dr.
Joshua Schier. Dr. Schier is a medical
toxicologist at the Health Studies Branch of the National Center for
Environmental Health. Dr. Schier will be
discussing the following topics:
·
The mechanism of
action and toxicity of ricin
·
The epidemiology
of nonterrorism-associated and terrorism-associated ricin poisoning
·
Types of
exposure to ricin poisoning
·
And
·
The recognition,
management and surveillance of ricin-associated illness
Dr. Schier's first topic
will cover background information about ricin.
Welcome, Dr. Schier.
SCHIER:
Thank you, Kysa. Hello, I’m going to begin today's
presentation with a general overview of ricin and then move on to discuss the
epidemiology of ricin poisoning.
Ricin is a potent
toxalbumin present throughout the castor bean plant (Ricinus communis), but
it's primarily concentrated within the castor bean.
Castor bean plants are
common outdoor plants that are often used as an ornamental garden plant. They are large shrubs that can grow as high
as 12 feet, and have large, deep-green palmate leaves. These plants are native to Africa and common
in warm climates worldwide.
Castor beans are light
brown and have a mottled appearance. The
beans are one-half to 2 cm long and are contained in soft spined, grayish-brown
capsules.
More than 1 million tons
of castor beans are processed every year worldwide. Castor beans are a commercial source of
castor oil, which is extracted from the castor bean and used as an industrial
lubricant, as a medical purgative, and as a laxative. Castor oil is also used in pharmaceutical
preparations and as an emollient in folk remedies. Castor oil itself contains no ricin. During the preparation of castor oil, the
ricin-containing resin portion of the plant is separated from the
non-ricin-containing oil portion. The
resin is then further treated with heat to inactivate any remaining ricin. Castor bean cakes, the material remaining
after oil is removed, are fed to animals as a protein source. Again, remaining ricin is heat inactivated
before feeding.
Ricin can be prepared in
three different forms: liquid, crystalline, or dry powder. Ricin is water soluble, odorless, tasteless,
and stable under ambient conditions.
Let's examine the
mechanism of action and toxicity of ricin.
Ricin is one of several
types of toxalbumins that exert their toxicity by inhibiting protein synthesis
in eukaryotic cells, which may ultimately lead to cell death.
Ricin is one of the most
toxic biological agents known -- a Category B bioterrorism agent and a Schedule
1 chemical warfare agent. This second
highest priority biological agent category includes agents that:
·
are moderately
easy to disseminate;
·
result in
moderate morbidity rates and low mortality rates; and
·
require specific enhancements of CDC's diagnostic capacity
and enhanced disease surveillance.
Here are some examples of
other category B Bioterrorism Agents.
·
Brucellosis
·
Glanders
·
Q Fever
·
Typhus Fever
·
Psittacosis
·
Staphylococcal
Enterotoxin B
SCHIER:
Ricin toxicity and
lethality can vary by dose and route of exposure. In animal studies, inhalation and intravenous
injection are the most lethal routes.
Lethal dose for humans, by inhalation or injection, is estimated to be 5
- 10 mg/kg. Because the ricin protein is large, it is
probably not well absorbed orally or through the skin.
In animal studies, most
orally administered ricin is not well absorbed, and it may remain in the large
intestine even 24 hours after exposure until it is finally eliminated from the
gut. Although ricin is less toxic by the
oral route compared with inhalation and injection, there are hundreds of
reported cases of toxicity, and several fatalities, from castor bean
mastication and ingestion. If enough ricin
is ingested, the potential for significant morbidity and mortality exists.
Ricin is not likely to be
absorbed through unabraded skin; however, there are no reported studies on the
dermal toxicity of ricin. The effect of
adding a carrier solvent to ricin to increase dermal absorption is unknown.
In addition to the
existence of ricin within the castor bean, a potentially toxic alkaloid,
ricinine, is also present; however, we won't be discussing ricinine during this
presentation.
DANIELS:
Dr.
Schier, you've covered the mechanisms of ricin and given us the background on
its toxicity. Let's move to your next topics, which include
the epidemiology of nonterrorism- and
terrorism-associated ricin poisoning.
SCHIER:
Thank you, Kysa. I’m going to begin with a discussion of
nonterrorism-related ricin poisoning. At
this time there is very limited knowledge about the human effects of ricin
poisoning. Currently our knowledge is
derived in part from one homicide, three suicides, many cases of macerated
castor bean ingestion, and occupational exposure to castor bean pulp, dust, and
oil. Most cases of non-terrorism ricin poisoning involve mastication and
ingestion of castor beans.
Since 1900, there have
been over 400 reported cases of castor bean poisoning by ingestion, resulting
in 14 deaths (12 of these occurring prior to 1930). Occasionally, workers in or around castor oil
processing plants experience respiratory or dermal symptoms from exposure to
castor bean dust, presumably related to an allergic syndrome.
In the 1940s, accidental
aerosol exposures to ricin occurred in humans.
These exposures were sublethal, and symptoms resolved
spontaneously. The specifics of these
reports will be discussed shortly in the Clinical Presentation section.
There have been very few
documented cases of parenteral ricin exposures in humans with high or toxic
doses.
Because ricin has been
shown to inhibit tumor growth, clinical trials investigating intravenous
low-dose ricin as a potential chemotherapeutic agent have been performed.
The chemical and physical
properties of ricin make it a potential agent for use as a terrorist
weapon. Ricin would need to be dispersed
in particles smaller than 5 microns to be used as an effective terrorist or
military weapon by the inhalational route.
It is very difficult to prepare particles of this size. Ricin could also be also be used as a
terrorist weapon through the contamination of food, beverages, or potentially
some consumer products.
Although there have never
been any mass casualty reports from ricin, there have been several instances of
ricin procurement for use as a terrorist or criminal weapon. For example, Georgi Markov, a prominent
Bulgarian dissident and radio personality, was assassinated in London on
September 10, 1978, allegedly from a ricin injection in the thigh. An estimated 500 micrograms of ricin was
injected subcutaneously in a platinum pellet fired from an umbrella gun. Death followed 72 hours later.
In April 1991, 4 members
of the Minnesota Patriots' Council, an anti-tax, right wing militia, acquired enough
ricin to kill 100 people. They planned
to assassinate a Deputy U.S. Marshal and a local sheriff by dissolving the
ricin in a carrier solvent to enhance dermal absorption. Another instance happened in 1995, when an
extremist was arrested at the Canadian border with a large cache of weapons and
130 grams of ricin -- enough to kill 10,000 people. At his home in Arkansas, federal agents found
castor plants, beans, and recipes for large- scale production of ricin.
In 1995, a Kansas City
oncologist attempted to murder her husband by contaminating his food with ricin
- this story was depicted in the book Bitter Harvest.
In December 2002, six
terrorist suspects were arrested in Manchester, England, in their apartment
that was serving as a "ricin laboratory." Among them was a 27-year-old chemist who was
producing the toxin. Later, in January
2003, sub-toxic quantities of ricin were found in the Paris Metro, which led to
an investigation of a possible Chechen separatist plan to attack the Russian
embassy with the toxin.
Finally, literature and
equipment for ricin production was found in Osama bin Laden's deserted home in
a former al-Qa'eda base in Afghanistan.
DANIELS:
Dr. Schier,
thanks for that insight into nonterrorism- and terrorism- associated poisoning. Our next topic concerns the clinical
manifestations of ricin exposure.
Clinical Manifestation
SCHIER:
I’m going to cover several
different types of exposure:
·
Inhalation,
·
Ingestion, and
·
Parenteral
Exposure to ricin may
occur through:
·
Inhalation,
dermal, or ocular contact: as an aerosol, powder, or dust
·
Ingestion:
through contamination of food, water, or consumer products
·
Parenteral:
directly injected into a target
Particles
smaller than 5 microns have been used for aerosol dispersion in animal studies. Ricin is not
considered persistent in the environment, but particles of this small size may
stay suspended in undisturbed air for many hours and resuspension of settled
ricin from disturbed surfaces may occur.
Potency varies with the particle size, even in the 1-10 micron
range. Generally, it is very
technologically difficult to produce ricin particles of this size and purity.
Severe systemic toxicity
has been described in humans only following ingestion or injection of ricin
into the body. Based on limited animal
studies, ricin is expected to be a much more potent toxin when inhaled or
injected, compared with the other routes of exposure.
Ricin release from castor
beans ingestion requires mastication, and the degree of mastication is likely
to be important in determining the extent of poisoning. Swallowing of whole beans is not likely to
result in poisoning. Castor beans are
reported to have a bitter taste during mastication. Toxicity by the oral route in people is
limited to what is known from patients who have masticated and ingested castor
beans. There are no reports of people
who have ingested purified ricin toxin.
It is unclear what effect this would have on toxicity, though it is
logical to reason that the same dose-dependent risk of illness exists. Signs and symptoms -- from oral exposure to
purified ricin -- are presumed to be similar to reports of illness after castor
bean mastication and ingestion.
Ingestion and mastication
of 3 - 6 beans is the estimated fatal dose in adults. The fatal dose in children is not known but
is most likely even less. Toxicity can
range from mild to severe, and may progress to death.
Symptoms of mild toxicity
including nausea, vomiting, diarrhea, and/or abdominal cramping are invariably
present in people who chew and ingest a significant amount of castor
beans. Oropharyngeal irritation may
occur following ingestion as well.
Bloody diarrhea and systemic signs such as hypotension, hemolysis, and
renal failure are not present, and symptoms typically resolve within 24 hours.
Onset of gastrointestinal
symptoms typically occurs in less than 10 hours. Delayed presentation of gastrointestinal
symptoms, beyond 10 hours of ingestion, is unlikely to occur.
Moderate to severe
toxicity may include: gastrointestinal symptoms - that is, persistent vomiting
and voluminous bloody or nonbloody diarrhea, which typically leads to
significant fluid losses. This may
result in dehydration and hypovolemic shock, which would manifest as
tachycardia, hypotension, decreased urine output, and possibly altered mental
status (e.g., confusion, disorientation).
In severe poisoning,
hepatic and renal failure and death are possible within 36 - 72 hours of
exposure. The most common findings on
animal autopsy are multifocal ulcerations and hemorrhages of gastric and small
intestine mucosa, necrosis of mesenteric lymph nodes, hepatic necrosis,
splenitis and nephritis.
Animal studies suggest
that inhalation is one of the most lethal forms of ricin poisoning. Data on inhalational exposure to ricin in
humans is extremely limited. Severe
systemic toxicity as a result of ricin inhalation has not been described in
humans.
An allergic syndrome has
been reported in workers exposed to castor bean dust in or around castor oil
processing plants. It is characterized
by nasal and throat congestion, eye irritation, hives and skin irritation,
chest tightness, and in severe cases, wheezing.
Unintentional sublethal
aerosol exposures to ricin which occurred in humans in the 1940s were
characterized by onset of the following symptoms within 4 - 8 hours: fever, chest tightness, cough, dyspnea,
nausea, and arthralgias followed by diaphoresis. However, there was no reported progression of
illness in these cases.
In a nonhuman primate
study, inhalational toxicity was manifested by a dose-dependent preclinical
period of 8 - 24 hours, followed by anorexia and decreased activity. On autopsy, the lungs were edematous, with
accompanying necrosis and hemorrhage.
Inhalational exposure to
ricin in animals may include the development of pulmonary edema and hemorrhage,
hypotension, respiratory failure, and death within 36 - 72 hours.
Humans can probably be
expected to follow a similarly rapid course of illness progression although
dose, size of the ricin particle and duration of exposure will affect degree of
poisoning.
Now let's look at
parenteral exposure.
Intravenous ricin was
administered to cancer patients in very low doses in one large clinical
trial. Flu-like symptoms with fatigue
and myalgias were common reported side effects and lasted 1-2 days.
In the case of the
Bulgarian dissident, Georgi Markov, signs and symptoms included immediate pain
at the injection site, weakness within 5 hours and fever and vomiting within 24
hours. His clinical course worsened to
include shock, multi-organ failure and death over the next 3 days.
A 20-year-old man was
admitted to the hospital 36 hours after injecting castor bean extract
subcutaneously. He complained of nausea,
weakness, dizziness, and myalgias. He
developed anuria and hypotension followed by hepatorenal and cardiorespiratory
failure and died 18 hours following admission.
I have one more example of
Parenteral Exposure for us to consider.
A 36-year-old chemist
extracted ricin from a castor bean and self-administered intramuscular
injections for the purpose of "scientific curiosity." He developed fever, nausea, anorexia, mild
elevation of liver function tests, and tissue damage at the site of injection. Symptoms persisted for 8-10 days and then
improved, at which point he was discharged from the hospital.
I am now going to talk
about the clinical course of ricin.
There is also very limited data on this topic.
The current body of
knowledge, based on limited human and animal data, suggests that significant
poisoning through inhalation, ingestion and parenteral exposure would consist
of a relatively rapid progressive worsening of symptoms over approximately 4 to
36 hours from exposure.
Early ricin poisoning
through ingestion may resemble a typical gastroenteritis-type or a respiratory
illness through inhalation.
At first it may be
difficult to discern early poisoning from other common and less virulent
illnesses such as an upper respiratory infection or gastroenteritis.
Thus, suspicion of cases
should occur in conjunction with
·
A highly
suspected or known exposure
·
A credible
threat
·
An epidemiologic
clue suggestive of a chemical release.
These clues will be
discussed in detail shortly.
Differential Diagnosis
DANIELS:
We're now going to move
into our next topic, differential diagnosis.
SCHIER:
The differential diagnosis
of ricin poisoning is very complex and may include numerous medical conditions
as well as many different chemical AND biological agents.
Also, the route of
exposure will affect the differential, since early inhalational poisoning by
ricin will have respiratory signs and symptoms where as ingested ricin will
probably present with gastrointestinal symptoms first.
Examples of agents to be
considered in the differential diagnosis of Inhalational ricin poisoning
include:
·
Staphylococcal
enterotoxin B
·
Exposure to
by-products of organofluorines-pyrolysis (Teflon, Kevlar)
·
Nitrogen oxides
·
Phosgene
·
Influenza
·
Anthrax
·
Q-fever
·
Pneumonic plague
Some examples of diseases
which may be considered in the differential diagnosis of ricin poisoning by
ingestion includes:
Ingestion:
·
Enteric
pathogens (e.g., salmonella, shigella)
·
Mushrooms
·
Caustics
·
Iron
·
Arsenic
·
Colchicine
It is important to
remember that these are just SOME examples of other diagnoses to consider and
not an all-inclusive list.
Clinical Diagnosis
SCHIER:
An event resulting in
ricin poisoning may be obvious or overt, such as a package with a letter
identifying the agent, but the event may also be covert. An example of a covert event would be the
intentional contamination of food in a restaurant with a harmful agent,
unbeknownst to the restaurant patrons.
If illness occurs in conjunction with a highly suspected or known
exposure or if there is a concurrent credible threat then a clinical diagnosis
can be much more easily made. However,
if illness is occurring as a result of a covert event, clinical diagnosis will
be much more difficult for several reasons.
These include:
Symptoms of exposure to
some chemical or biological agents may be similar to common diseases such as
the flu or gastroenteritis.
Early symptoms of certain
chemical exposures might be nonexistent or mild despite the risk for long-term
problems.
Exposure to contaminated
food, water or consumer products might result in reports of illness to
health-care providers over a long period and in various locations.
People exposed to two or
more chemicals or biological agents might have symptoms not suggestive of a
single agent. Healthcare providers might
be less familiar with clinical presentations of chemical or biological-induced
poisonings than those illnesses with which they are more familiar.
There are certain
epidemiologic clues that may suggest the covert release of a chemical agent or
biological toxin such as ricin that the clinician must be aware of:
An unusual increase in the
number of patients seeking care for potential- chemical or biological toxin
related illness.
·
Unexplained
deaths among otherwise healthy or young people.
·
Detection of
unexplained odors on presenting patients.
·
Clusters of
illness in people who have common characteristics, such as drinking water from
the same source.
·
Rapid onset of
symptoms after an exposure to a potentially contaminated source.
·
Unexplained
death of plants, fish, or animals.
·
Presence of a particular
syndrome known to be associated with a chemical agent or biological toxin.
Again, these are general
epidemiological clues to a potential covert release of any chemical or
biological toxin.
Clinical diagnosis will
also largely depend on the route of exposure.
Again, many of the
clinical findings associated with early ricin poisoning may be nonspecific and
may mimic signs and symptoms of less virulent diseases such as the flu or
gastroenteritis.
Confirmation of ricin
poisoning requires clinical manifestations of illness with laboratory detection
of ricin in either biological fluids or environmental samples from the area
where the patient was exposed.
There are currently no
clinically validated assays for detection of ricin in biological fluids readily
available. Future clinical tests for
ricinine, an alkaloidal component of the castor bean plant, are being
developed, but also have not been tested for clinical use. The potential uses of these tests for either
ricin or ricinine in human samples would primarily be for purpose of confirming
exposure or assessing the prevalence of exposure, rather than diagnostic use.
The Centers for Disease
Control and Prevention and member public health laboratories in the Laboratory
Response Network are able to detect ricin in environmental samples, however,
testing will most likely not be immediately available to assist in clinical
decision making. Environmental testing
may document the potential for exposure or affirm the exposure
circumstance. There are no additional
laboratory tests readily available to the physician such as a cell blood count,
serum electrolyte panel or radiograph that are pathnogmonic for ricin
poisoning. The presence of a
leukocytosis and/or abnormal liver and renal function tests may suggest
ricin-associated illness in the correct clinical context but are not very
specific.
Therefore, suspicion and
clinical diagnosis of ricin poisoning should occur when clinically compatible
illness is present in conjunction with: a highly suspected or known exposure, a
credible threat or an applicable epidemiologic clue.
Decontamination and Personal Protective Equipment
DANIELS:
Now that we've discussed
how to diagnose ricin poisoning, our next topic covers decontamination and
personal protective equipment.
SCHIER:
There are only limited
data or experience regarding approaches to decontamination of victims following
a ricin release; therefore, what follows is based largely on inference from
available information and our best judgment using a prudent public health
approach.
In the event of a
recognized release or exposure, patients suspected to be contaminated with
ricin should receive gross decontamination to the extent possible prior to
arrival in the Emergency Department.
Decontamination at the scene of the release is generally preferable
unless the medical condition of a victim dictates immediate transport to the
hospital.
Gross decontamination
consists of cutting away or otherwise removing all suspected contaminated
clothing, including jewelry and watches, and washing off any obvious
contamination with soap and copious amounts of water. Showering with liquid soap and warm water is
widely considered the most effective and preferred method for removing
remaining hazardous substances from a victim's skin. The primary goal is to make the victim
"as clean as possible", after life-threatening issues have been
addressed.
There is no need to
perform skin decontamination for patients exposed to ricin through ingestion
only.
For the comfort of the
victims and to improve cooperation, the water should be at a comfortable
temperature if at all possible, and attention should be given to privacy
considerations and to security of personal belongings. The procedure should be explained to the
victim so he/she can understand what is occurring.
Environmental surfaces or
equipment, such as in the ambulance, can be cleaned with soap and water or a
0.1 percent sodium hypochlorite solution.
Used clothing removed from the victim should be double bagged and labeled
as contaminated and secured in a safe location until it can be safely disposed
of.
If not disposable,
personal protective equipment such as gloves, faceshields, and goggles should
be decontaminated by thoroughly rinsing with soap and water, soaking in a 0.1
percent sodium hypochlorite solution for 15 minutes and then rinsing with water
and allowing to air dry.
PPE for first responders,
including those who are decontaminating victims at the scene, is generally
determined by the Incident Commander based on a hazard assessment and site
conditions including the mechanism of dispersal and whether dispersal is
continuing. Preventing droplets from
contacting broken skin or mucosal membranes for example, the mouth or eyes, is
important when decontaminating someone or cleaning up body fluids that may
contain toxin, but airborne dispersal of ricin during decontamination is an
unlikely hazard.
Therefore, for those who
are decontaminating victims who arrive at the hospital without having been
adequately decontaminated on-scene, PPE can consist of a full
chemical-resistant suit with gloves, surgical mask, and eye/face protection
such as faceshield and goggles. After
completing decontamination tasks, personnel should carefully remove all PPE and
shower.
As previously discussed,
victims should have received gross decontamination prior to arriving at the
hospital or at the hospital but prior to entering the emergency
department. Once this has been
accomplished, the quantity of contaminant that health care workers treating these
patients may encounter is expected to be dramatically less than what originally
may have been deposited on them. Simply
removing contaminated clothing can reduce the contaminant associated with the
victim by 75 to 90 percent.
Although the risk for exposure
to staff in this setting is likely to be very low, it is still prudent to
follow Standard Precautions to protect yourself and other health care workers
who may be coming into contact with the patient or his/her personal effects. Health care workers should follow standard precautions, wear scrubs or, preferably, a disposable gown,
and a lab coat, disposable nitrile gloves, a surgical mask and safety glasses,
goggles or faceshield. The surgical mask
and safety glasses are suggested to prevent health care workers from
inadvertently contaminating their mucous membranes. Health care workers should follow good hand
hygiene practices after caring for patients.
Clinical Management
DANIELS:
Our next topic discusses
clinical management of patients with ricin poisoning.
SCHIER:
There is extremely limited
information on the treatment of patients with ricin poisoning because there are
very few reported cases.
Treatment of ricin
poisoning is supportive and there is no known antidote. Ricin is not dialyzable.
Healthcare providers
should continue to use standard precautions when caring for patients with
suspected or known ricin-associated illness.
This includes care given after skin decontamination and when dealing
with patient belongings and secretions.
In cases of ricin
ingestion, gastrointestinal decontamination should be performed. Gastric lavage may be considered if
presentation is early, generally <1 hour after exposure, the patient is not
vomiting and no general contraindications are present. If ingested ricin was in the form of a
powder, liquid or similar substance, gastric lavage with a nasogastric tube,
not a Ewald tube, may be considered.
A single dose of activated
charcoal should be given if the patient is not already vomiting and the airway
is secure.
The current medical
literature suggests that poisoning by the oral route significantly contributes
to gastrointestinal losses of fluid and hypotension. Hypotension will interrupt normal perfusion
of tissues and cause further organ dysfunction.
Therefore intravenous fluid administration and blood pressure support
through the use of intravenous vasopressors should be used if needed.
Inhalational and
parenteral poisoning are of much greater severity than
oral poisoning based mostly on animal data. Inhalational poisoning should be treated
similarly, but will most likely require greater and earlier respiratory
support. This includes supplemental
oxygen, pulmonary toilet and mechanical ventilation with positive end
expiratory pressure to maintain oxygenation if needed. Parenteral poisoning should be treated in a
similar fashion. Further care should
also be supportive in nature and may consist of procedures such as hemodialysis
for renal failure.
Individualized management
guidelines should always be obtained by calling your regional poison control
center at 1- 800-222-1222 or consulting your local medical toxicologist.
The disposition of
patients with symptoms that are consistent with ricin poisoning will depend
primarily on the presence of certain conditions mentioned previously:
·
Is there a
highly suspected or known exposure?
·
Is there a
credible threat?
·
Is there an
applicable epidemiologic clue to suggest a potential chemical or biological
toxin related illness?
Patients who have clinical
findings consistent with ricin-associated poisoning AND have a highly suspected
or known exposure to ricin or who present in the context of a credible threat
should be treated appropriately and admitted to a hospital for observation of
illness progression.
Although most available
evidence suggests a relatively rapid progression of symptoms in significant
toxicity, approximately 4 to 36 hours following exposure, experience with ricin
poisoning is very limited. Subsequently
the period of observation cannot be definitively specified.
Patients who have had an
exposure to a highly suspected or known ricin-containing compound and who are
asymptomatic should also be observed for development of ricin-associated
illness. It is important to note that exposures
in asymptomatic patients may vary considerably and the specific situation of
each patient will help determine ultimate disposition. For instance, a patient who was on the
opposite side of the room when a sealed container of ricin was discovered may
not reflect a true exposure. Regardless,
any patient that is sent home after a complete evaluation should be instructed
to return to the hospital immediately for development of any signs or symptoms
consistent with ricin-associated illness.
Some patients may have
clinical findings consistent with early ricin poisoning, such as
gastrointestinal symptoms for ingestion, but also consistent with a common
gastroenteritis. If they present in the
context of an epidemiologic clue suggestive of a possible chemical or
biological toxin associated illness but with no suspected or known ricin
exposure nor in conjunction with a credible threat, disposition should be
determined after the proper public health authorities have been notified. This includes the regional poison control
center and local and/or state health departments. If there is no highly
suspected or known exposure, no credible threat, and no applicable
epidemiologic clue, then disposition is left to the clinician's judgment.
The regional poison
control center and the local and/or state public health agency should be
contacted in all cases of illness consistent with ricin poisoning in the
presence of:
·
A suspected or
known exposure
·
A credible
threat OR
·
An applicable
epidemiologic clue.
The regional poison
control center can be contacted by dialing the national toll-free hotline,
1-800-222-1222 which will connect the caller automatically to the closest
poison center in the United States.
Public Health Surveillance and Reporting
DANIELS:
Our final topic covers
public health surveillance and reporting.
Dr. Schier. . . .
SCHIER:
The following cases should
be reported to local and state health agencies as well as the regional poison
control center.
·
Suspected or
known cases of ricin exposure.
·
Any cases of
ricin-associated illness.
·
Clinical illness
consistent with ricin poisoning in conjunction with a credible threat.
·
Clinical illness
consistent with ricin poisoning in conjunction with an applicable epidemiologic
clue.
DANIELS:
Thank you for this
informative and educational program, Dr. Schier.
To interact with the
faculty, if you have questions concerning the subject matter discussed during
this program, you may e-mail them to this address: ricinquestions at C-D-C dot GOV.
Questions and answers will
be posted on the course overview site shortly after the webcast at
www.phppo.cdc.gov/ phtn/ricin.
Supplementary information
and fact sheets on ricin are available on this CDC website W-W-W dot
B-T dot CDC dot GOV
slash AGENT slash RICIN.
DANIELS:
This program will remain
available as an archived webcast and will also be available on CD-Rom from the
Public Health Foundation.
You may order a CD-Rom by
phone, fax or online as follows:
Toll-free number - 1-
877-252-1200
Fax - 301-843-0159
On-line bookstore - bookstore.phf.org
Participants are
encouraged but not required to register and evaluate the program on the CDC
Training and Continuing Education Online System.
That address is W- W-W dot P - H -
P - P -O dot CDC
dot GOV slash P - H - T - N ON-LINE.
The registration and
evaluation forms will be active on the online system until January 30, 2004,
for this webcast and for up to three years for the archived webcast and CD-Rom.
Here are the course
numbers you will need.
The number for this
webcast is WC 0-0-4-8.
The archived webcast
number is WD 0-0-3-5.
And the number for the
CD-Rom is CB 3-0-9-3.
Questions about
registration should be directed to 800-41-TRAIN, 404- 639-1292, or email ce@cdc.gov.
When emailing a request, please indicate Ricin in the subject line.
DANIELS:
It has been my pleasure
being your moderator for this webcast.
Thank you, Dr. Schier, for sharing your expertise on this important
topic.
Thank you too for
participating in this program. On behalf
of everyone at CDC and the Public Health Training Network, I'm Kysa Daniels
wishing you a good day from Atlanta.