EMBRACE: Setting the scene

This story starts with a group of people exposed to a biotoxin. While biotoxins are potent poisons they act relatively slowly and this, as we will see, creates significant difficulties for the emergency and security services. 

In our story our casualties are staying at a city centre hotel in Athens, and after they finish their meeting they will go home, and their homes are all over Europe. Patient zero will be found the next day collapsed in a busy street in the middle of a London festival. Unfortunately, she is by herself, separated from her belongings, with no identification on her. Police and paramedics come to help her and are confronted with a seriously ill person, unable to answer their questions. 

Thirty minutes after patient zero staggered to the ground, our paramedics are asking “what is wrong with her?” Technically we might describe their thinking as dynamic differential diagnosis. Think about all the possibilities they, and very soon the clinical team, will need to consider: is she drunk, is this an overdose, has she been assaulted, is this a suicide attempt, is this a crime, perhaps she has an undisclosed clinical condition or is this an infectious disease, or maybe she's poisoned. Life is messy, and our clinical experts may be misled by context as much as helped by it. It will be some time before a biotoxin poisoning is identified.

Our patient is taken to hospital and triaged and because she is so unwell is given supplemental oxygen and monitored closely. Blood and urine samples are taken for initial screening. Meanwhile, she deteriorates, enters respiratory failure and life-saving interventions are made. She is transferred to an intensive care unit. The police are now looking for next of kin, and the hospital is taking precautions by isolating her and implementing barrier nursing. A little while later [3 hours] toxicity is indicated from the tests, and further tests are underway; these are difficult, specialised and take time, indeed it will be 3 days before the results are available. Supplementary samples are taken from her ear-canals, finger-beds and clothing. Contact tracing of potentially exposed medical staff and patients is started. Counterterrorism escalation protocols are started

For her the plan is simple. Keep her alive, identify the poison, possible administer an antidote (if one exists), find out who she is and where she has been? 

At last! The laboratory test- data are in and a low exposure of inhaled ricin is indicated. More positive developments may be reported for missing persons have found out who she is. A national effort is under way to find the source of the ricin, and biological agent countermeasures are being spun up. 

For the last day social media and news channels are reporting a suspected bioterrorism incident in Athens. Cleaning, catering and portering staff from a hotel are in hospital with ricin poisoning. Connections are made, embassy staff make inquiries, and the link is established. 

In London specialist teams visit the patient’s workplace and home and survey for possible ricin contamination; fortunately, no ricin is detected. Further surveys are made of an aircraft, again with no ricin detected. Significant assets, large numbers of experts, and specialist resource have been used to establish that this is a contained and isolated incident.

However, in Athens the situation could not be more different. 

A busy city centre hotel is heavily contaminated with ricin that was sprayed as an aerosol into the air circulation system. Many staff have symptoms, and a major critical incident has been declared. The Greek authorities must now identify, secure, and then decontaminate a large and complicated area at the heart of their capital city. They need to monitor carefully, individuals who have been, may have been, and think they have been, exposed to ricin. There are thousands of people asking for support. Homes, shops, offices, restaurants, vehicles, and transport systems are all under consideration. It is perhaps impossible to overstate the difficulty of mounting timely, accurate and effective risk communication. The short-term disruption to everyday life in a busy densely developed world city is significant. Long-term monitoring and support programmes will be needed, and in all of this the underlying need to collect and preserve evidence to bring those responsible to justice is of paramount importance.

Lessons learned from the 2006 Polonium-210 attack in London, and the 2018 nerve agent attack on the city of Salisbury indicate that the ongoing response will take months to years to complete. Hundreds of people will be affected, many livelihoods harmed and most importantly, lives will be lost or changed forever.

Detecting, identifying and monitoring a biotoxin incident is challenging because the onset of symptoms from biotoxin poisoning takes many hours. Certainly, long enough for the casualty to have left the scene, potentially contaminated other areas, and travel a long way. Established concepts of operation for chemical poisoning do not appear to translate gracefully into such a scenario, and this is why the EMBRACE project is relevant and timely.