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BIOTERRORISM: Are You Prepared?
By By
Gregg S. Silberg, D.O., R.Ph., F.A.C.O.I., F.A.O.C.R.Gregg S. Silberg, D.O., R.Ph., F.A.C.O.I., F.A.O.C.R.Executive DirectorExecutive Director
Wisconsin Association of Osteopathic Physicians and SurgeonsWisconsin Association of Osteopathic Physicians and Surgeons
Chair, Department of Internal MedicineChair, Department of Internal MedicineProfessor of Biosciences, Medicine and RadiologyProfessor of Biosciences, Medicine and RadiologyWilliam Carey University College of Osteopathic MedicineWilliam Carey University College of Osteopathic Medicine
Bioterrorism
The use, or threatened use, The use, or threatened use, of a micro-organism or the of a micro-organism or the product of a micro-organism product of a micro-organism in order to generate fear, in order to generate fear, morbidity or mortality in a morbidity or mortality in a population.population.
Delivery MechanismsAerosol routeAerosol route
Easiest to disperse Easiest to disperse
Highest number of people exposedHighest number of people exposed
Most infectiousMost infectious
Undetectable to humansUndetectable to humans
Food / Waterborne less likelyFood / Waterborne less likelyLarger volumes requiredLarger volumes required
More technically difficultMore technically difficult
Roles of Clinicians
General ConceptsGeneral ConceptsHigh level of suspicionHigh level of suspicion
Hoofbeats could be a zebraHoofbeats could be a zebra
Unusual epidemiologic trendsUnusual epidemiologic trendsCase clusteringCase clustering
Severe, fulminant disease in Severe, fulminant disease in otherwise healthyotherwise healthy
Unusual for the regionUnusual for the region
Similar disease in animalsSimilar disease in animals
Roles of Clinicians
For specific Bioterrorism (BT) diseasesFor specific Bioterrorism (BT) diseasesRecognize typical BT disease syndromesRecognize typical BT disease syndromes
Perform appropriate diagnostic testingPerform appropriate diagnostic testing
Initiate appropriate treatment/prophylaxisInitiate appropriate treatment/prophylaxis
Report suspected cases to proper authoritiesReport suspected cases to proper authorities
1) Local health department1) Local health department
2) Hospital epidemiologist2) Hospital epidemiologist
3) Infectious Disease consultants3) Infectious Disease consultants
Case 1 - Dyspnea, Hypotension
• 46 year old stock trader46 year old stock trader
• Fever, malaise, cough 2 days priorFever, malaise, cough 2 days prior
• Abrupt onset severe dyspneaAbrupt onset severe dyspnea
• 38.138.1oo 115 86/40 115 86/40 32 O 32 O22sat 83%sat 83%
• Diaphoretic, DisorientedDiaphoretic, Disoriented
• CXR - no infiltrate, + small pleural eff.CXR - no infiltrate, + small pleural eff.
Case 1 - Dyspnea, Hypotension
• Patient admitted to ICU:Patient admitted to ICU:
Fluids, Intubation, Ceftriaxone, Vanco., Gent.Fluids, Intubation, Ceftriaxone, Vanco., Gent.
• Later the same day a similar patient presentsLater the same day a similar patient presents- Also a stock trader in the same building- Also a stock trader in the same building
• Both patients deteriorate and die the next dayBoth patients deteriorate and die the next day
Case 2 – Vesicular Rash34 y/o woman with fever, malaise X 2 days34 y/o woman with fever, malaise X 2 days
Today rash appeared on face & armsToday rash appeared on face & arms
39.439.4o o 106/78106/78 116 116 1818
A & O X 3 A & O X 3 Lungs clear
• Scattered macules and vesicles noted
• Dx – Chicken pox
• Rx – po Acyclovir, recheck in 2 days
Case 3 - Rapid Progressive Pneumonia
10 y/o boy with fever, dry cough for 1 day10 y/o boy with fever, dry cough for 1 day8 y/o sister also ill8 y/o sister also illVSVS 38.638.6 oo 110110 96/60 96/60 91% sat 91% satScattered crackles in both lungsScattered crackles in both lungsCXR - Bilateral infiltratesCXR - Bilateral infiltrates
Later develops severe dyspnea, hemoptysis, Later develops severe dyspnea, hemoptysis, shockshock
Case 4 - Overt Attack
A terrorist group says they have released A terrorist group says they have released 10 Kg of botulinum toxin over your city10 Kg of botulinum toxin over your city
Clostridium botulinumClostridium botulinum neurotoxin neurotoxin Lethal dose 1 ng/kg Lethal dose 1 ng/kg
Case 5 - Fever• 52 y/o male c/o 3 days malaise, fever, 52 y/o male c/o 3 days malaise, fever,
vomiting, myalgiasvomiting, myalgias
• 39.139.1o o 92/5092/50 124124 2828
• WBC 18WBC 18 platelets 45platelets 45 BUN 48BUN 48
• Creatinine 2.9Creatinine 2.9
• Within hours becomes confused, vomits Within hours becomes confused, vomits bloodblood
Case 6 – Flu-like syndrome• 40 y/o with development of a painful ulcer on 40 y/o with development of a painful ulcer on
the left thumb 2 days after flu-like symptoms the left thumb 2 days after flu-like symptoms beganbegan
ObjectivesObjectivesIdentify the six major biological threat agents Identify the six major biological threat agents
classified as Category A by the Center for classified as Category A by the Center for Disease Control (CDC)Disease Control (CDC)
Describe the natural transmission of Category Describe the natural transmission of Category A biological agentsA biological agents
Know the epidemiology, microbiology clinical Know the epidemiology, microbiology clinical features of Category A biological agentsfeatures of Category A biological agents
Describe methods of diagnosis, available Describe methods of diagnosis, available treatments and prophylaxis options for treatments and prophylaxis options for Category A biological agents Category A biological agents
Overview of Bioterrorism Agents
Ideal Qualities for a Biologic Terrorist Agent Ideal Qualities for a Biologic Terrorist Agent
High rate of illness among those exposed High rate of illness among those exposed High attack rate High attack rate
High rate of death among those who get ill High rate of death among those who get ill High case fatality rateHigh case fatality rate
Short time between onset of illness and deathShort time between onset of illness and deathSmall window to start treatmentSmall window to start treatment
Low level of immunity in the populationLow level of immunity in the population
Overview of Bioterrorism Agents
Ideal Qualities for a Biologic Terrorist AgentIdeal Qualities for a Biologic Terrorist Agent (cont)(cont)
No effective or available treatmentNo effective or available treatment
Can be transmitted person to personCan be transmitted person to person
Easy to produce and disseminateEasy to produce and disseminate
Difficult to diagnosis either clinically or Difficult to diagnosis either clinically or diagnostically (i.e. laboratory identification)diagnostically (i.e. laboratory identification)
Overview of Bioterrorism Agents
Epidemiological CluesEpidemiological CluesWhat we look for…What we look for… Large outbreak with high illness and death rateLarge outbreak with high illness and death rate
Single case of uncommon disease (e.g., Smallpox)Single case of uncommon disease (e.g., Smallpox)
Unusual symptoms or severity of illnessUnusual symptoms or severity of illness
Infection is non-endemic to regionInfection is non-endemic to region
Unusual seasonal distributionUnusual seasonal distribution
Multiple simultaneous outbreaks in non-contiguous Multiple simultaneous outbreaks in non-contiguous areasareas
Sick or dying animalsSick or dying animals
Overview of Bioterrorism Agents
BioterrorismThreatsBioterrorismThreats::
Priority Biological AgentsPriority Biological Agents
BacterialBacterialAnthraxAnthraxPlaguePlagueTularemiaTularemiaBrucellosisBrucellosisQ feverQ feverOtherOther
food borne pathogensfood borne pathogenswaterborne pathogenswaterborne pathogens
ViralViralSmallpoxSmallpox
Viral Hemorrhagic Viral Hemorrhagic FeversFevers
Viral EncephalitisViral Encephalitis
ToxinsToxinsBotulismBotulism
Staph Enterotoxin BStaph Enterotoxin B
Ricin toxinRicin toxin
Tricothecene mycotoxinsTricothecene mycotoxins
Overview of Bioterrorism Agents
AnthraxAnthraxGram positive spore forming Gram positive spore forming bacterium bacterium Bacillus anthracisBacillus anthracis
Primarily disease of herbivores Primarily disease of herbivores which are infected by ingesting which are infected by ingesting spores in soilspores in soil
Natural transmission to humans by Natural transmission to humans by contact with infected animals or contact with infected animals or contaminated animal productscontaminated animal products
““Woolsorter’s disease”Woolsorter’s disease”
Three forms of diseaseThree forms of diseaseCutaneousCutaneous
Gastrointestinal (GI)Gastrointestinal (GI)
InhalationalInhalational
CDC: Gram stain of B. anthracis
Overview of Bioterrorism Agents
Infected herbivores and soil are reservoir
Direct contact Cutaneous anthrax
IngestionGastrointestinal anthrax
InhalationPulmonary/mediastinal
anthrax
Epidemiology of Transmission
Overview of Bioterrorism Agents
Day 2-4 Day 6
Day 10
Eschar formation
Anthrax: Cutaneous Accounts for 80% of
naturally occurring Anthrax cases
Enters through openings in skin from abrasions, lacerations
20% progress to systemic form if untreated
Most cases recover
Overview of Bioterrorism Agents
Anthrax: Inhalational Inhalation of spores Incubation, 2-3 days (range up to 60 days) Spores engulfed by macrophages and
transported to mediastinal and peribronchial lymph nodes
Insidious onset: malaise, low grade fever, nonproductive cough
Abrupt development of respiratory distress Hemorrhagic mediastinitis Hematogenous spread Meningitis in 50%, usually fatal
Overview of Bioterrorism Agents
Anthrax: Pulmonary/Mediastinal
Mediastinal widening from anthrax Normal chest x-ray
Overview of Bioterrorism Agents
Ciprofloxacin400 mg intravenous every 12 hours for adults
10 -15 mg/kg intravenous every 12 hours for children
Ciprofloxacin400 mg intravenous every 12 hours for adults
10 -15 mg/kg intravenous every 12 hours for children
Doxycycline100 mg intravenous every 12 hours for adults and children > 8 yr and > 45 kg
2.2mg/kg every 12 hours for children < 8 yr (up to 200 mg/day)
Doxycycline100 mg intravenous every 12 hours for adults and children > 8 yr and > 45 kg
2.2mg/kg every 12 hours for children < 8 yr (up to 200 mg/day)
PLUS One or two additional anti-microbial agents effective against anthrax (e.g. imipenem,
clindamycin, rifampin, macrolides) Additional issues Penicillin should never be used as a monotherapy If meningitis is suspected, an antibiotic with good CSF penetration should also be
administered (e.g. rifampin or chloramphenicol) Supportive therapy for shock, fluid volume deficit and airway management may be
needed. Drainage of pleural effusions may improve clinical outcome
AND/OR
Anthrax Immune Globulin (AIG) can be used to neutralize anthrax toxin.
Patient Care Inhalational Anthrax
Overview of Bioterrorism Agents
Anthrax: Post-Exposure Prophylaxis Anthrax: Post-Exposure Prophylaxis Start 60 days of oral antibiotics ASAP after Start 60 days of oral antibiotics ASAP after
exposureexposureCiprofloxacin or Levofloxacin Ciprofloxacin or Levofloxacin
OROR
DoxycyclineDoxycyclineOROR
Amoxicillin or Penicillin (if known PCN sensitive)Amoxicillin or Penicillin (if known PCN sensitive)
VaccineVaccine
Can be given post-exposure in conjunction with Can be given post-exposure in conjunction with
antibioticsantibiotics
Overview of Bioterrorism Agents
SmallpoxSmallpoxVariola Variola virus, two forms of the disease: minor and virus, two forms of the disease: minor and
majormajorSpread via respiratory droplets or aerosols expelled Spread via respiratory droplets or aerosols expelled
from the oropharynxfrom the oropharynxMay also spread via direct contactMay also spread via direct contactPatients are most contagious during the time at which Patients are most contagious during the time at which
the skin rash is presentthe skin rash is presentApprox. 30% of patients exposed go on to develop the Approx. 30% of patients exposed go on to develop the
diseasediseaseApprox. 30% mortality with ordinary smallpoxApprox. 30% mortality with ordinary smallpox
Overview of Bioterrorism Agents
Overview of Bioterrorism Agents
Smallpox CharacteristicsSmallpox CharacteristicsFebrile SyndromeFebrile Syndrome – occurring 1-4 days prior to rash. – occurring 1-4 days prior to rash.
Classic Smallpox lesionClassic Smallpox lesion – deep-seated, firm/hard, round, well- – deep-seated, firm/hard, round, well-circumscribed; lesion may become umbilicated or confluent. circumscribed; lesion may become umbilicated or confluent.
Overview of Bioterrorism Agents
Smallpox CharacteristicsSmallpox CharacteristicsFebrile SyndromeFebrile Syndrome – occurring 1-4 days prior to rash. – occurring 1-4 days prior to rash.
Classic Smallpox lesionClassic Smallpox lesion – deep-seated, firm/hard, round, well- – deep-seated, firm/hard, round, well-circumscribed; lesion may become umbilicated or confluent. circumscribed; lesion may become umbilicated or confluent.
Lesion in Same Stage of Development Lesion in Same Stage of Development – Evolve from macules – Evolve from macules → → papules → pustules at the same time.papules → pustules at the same time.
Centrifugal distribution Centrifugal distribution – First lesion on oral mucosa, face, or – First lesion on oral mucosa, face, or forearms. forearms.
Overview of Bioterrorism Agents
Smallpox CharacteristicsSmallpox CharacteristicsFebrile SyndromeFebrile Syndrome – occurring 1-4 days prior to rash. – occurring 1-4 days prior to rash.
Classic Smallpox lesionClassic Smallpox lesion – deep-seated, firm/hard, round, well- – deep-seated, firm/hard, round, well-circumscribed; lesion may become umbilicated or confluent. circumscribed; lesion may become umbilicated or confluent.
Lesion in Same Stage of Development Lesion in Same Stage of Development – Evolve from macules – Evolve from macules → → papules → pustules at the same time.papules → pustules at the same time.
Centrifugal distribution Centrifugal distribution – First lesion on oral mucosa, face, or – First lesion on oral mucosa, face, or forearms. forearms.
Lesion on palms and solesLesion on palms and soles
Prodrome phase (2 - 4 days) Abrupt onset of fever
>38.3°C Malaise/myalgia Headache Nausea/vomiting Backache
Usually NOT Infectious
Incubation period 12 days
(range 7-19 days)NOT
Infectious
Incubation period 12 days
(range 7-19 days)NOT
Infectious
Rash Phase(21 days)
1) macules2) papules3) vesicles4) pustules5) scabsInfectious until all scabs
fall off
Early Rash Phase Mucous membrane lesions Small red spots on the tongue
and throat Lesions enlarge, ulcerate, then
shed virusInfectious 24 hours before visible skin rash
ExposureExposure
Clinical Timeline for SmallpoxOverview of Bioterrorism Agents
Smallpox Progression
Day 4
Day 6
Day 8
Day 13
Overview of Bioterrorism Agents
Papules
Vesicles
Pustules“pocks”
Scabs
Smallpox: Medical ManagementSmallpox: Medical ManagementStrict respiratory/contact isolation of patientStrict respiratory/contact isolation of patient
Patient infectious until all scabs have Patient infectious until all scabs have separatedseparated
Treatment is supportive care onlyTreatment is supportive care onlyAntivirals are under evaluationAntivirals are under evaluation
CidofovirCidofovirST246ST246
Overview Bioterrorism Agents
Smallpox: Prevention and ControlSmallpox: Prevention and ControlImmediate vaccination of Immediate vaccination of ALLALL
close contacts (close contacts (< < 6 ft) and 6 ft) and ALL ALL contacts of patients contacts contacts of patients contacts (Ring vaccination)(Ring vaccination)
Vaccination within 4 days of Vaccination within 4 days of exposure exposure maymay prevent or lessen prevent or lessen disease disease
Mass vaccination may be Mass vaccination may be necessary and/or everyone may necessary and/or everyone may want to be vaccinatedwant to be vaccinated
Case(s)
Contacts of Case(s)
Contacts of Contacts
Overview of Bioterrorism Agents
Smallpox: Current VaccineSmallpox: Current VaccineLive Live vacciniavaccinia virus virusBecause it is a live virus, Because it is a live virus, there can be adverse events there can be adverse events from vaccinationfrom vaccination
Occurs mostly in Occurs mostly in immunologically suppressed immunologically suppressed personspersons
Immunity is Immunity is notnot life-long, but life-long, but having been vaccinated in the having been vaccinated in the past may reduce morbidity past may reduce morbidity and mortalityand mortality
WHO
Overview of Bioterrorism Agents
PlaguePlague is a severe bacterial disease of humans and animals produced by the gram negative nonsporulating bacillus Yersinia pestis
•Bite of a rodent flea that is carrying the plague bacterium, or by handling an infected animal•Hundreds of millions of people died
when human dwellings were inhabited
by flea-infested rats•Modern antibiotics are effective, but without prompt treatment the disease can likely cause illness or death
Overview of Bioterrorism Agents
Types of PlagueTypes of PlagueThree types:Three types:
BubonicBubonic
SepticemicSepticemic
PneumonicPneumonic
Overview of Bioterrorism Agents
Secondary plague cases
Primary pneumonic plague
AA Flea vector such as
Xenopsylla cheopis
Animal Reservoirs
Primary bubonic plague
Primary septicemic plague
AA
BB
BB
CCCC
DDDD
Routes of Plague TransmissionA= Bite of Flea
B = Contact with animal or carcass
C = Inhalation of respiratory droplets
D = Contact with sputum or fluid
Plague: Epidemiology of Natural Transmission
Overview of Bioterrorism Agents
Early Presentation Abrupt onset of fever, malaise, headache, myalgia Chest pain and dyspnea Tachypnea (particularly in young children) Productive cough (sputum may be purulent or watery, frothy, blood-tinged) Hemoptysis
IncubationPeriod
1-6 days
IncubationPeriod
1-6 days
Late Presentation Rapid progression to pulmonary disease/ARDS Pulmonary edema, dyspnea, cyanosis Meningitis may be a complication Hypotension, DIC, septicemia, and death Lab findings -- bacterial infection and sepsis Organism usually seen on sputum gram stain Mortality approaches 100% if untreated in 24 hours
Antibiotictherapy in the first 24
hours can prevent septicemia, cardio-respiratory failure, shock, and death!
ExposureExposure
Clinical Presentation of Pneumonic Plague
Overview of Bioterrorism Agents
Plague: Patient Care
Early antibiotic treatment* is paramount to patient survival
Adults: Streptomycin 1 gm IM b.i.d. for 10 days;
Chloramphenicol 25 mg/kg IM or IV 4 times daily for 10 days Gentamicin 5 mg/kg IM or IV once daily for 10 days;
Doxycycline 100 mg IV b.i.d. or 200 mg IV once daily for 10 days; Ciprofloxacin 400 mg IV b.i.d. for 10 days;
Children: Streptomycin 15 mg/kg IM twice daily for 10 days (max 2 gm/day); Chloramphenicol 25 mg/kg IV 4 times daily for 10 days (max 4 gm/day) Gentamicin 2.5 mg/kg IM or IV 3 times daily for 10 days; Doxycycline 2.2 mg/kg IV twice daily for 10 days (max dose 200mg/day); Ciprofloxacin 15 mg/kg IV twice daily for 10 days (max 1 gm/day)
*CDC recommends initiating treatment with two drugs believed effective against Y. pestis until antimicrobial susceptibility data is available on isolates.
Overview of Bioterrorism Agents
Plague: ProphylaxisPlague: Prophylaxis
Pneumonic plague contacts (transmitted Pneumonic plague contacts (transmitted
via droplets)via droplets)Oral Doxycycline or Ciprofloxacin Oral Doxycycline or Ciprofloxacin
For 7 days after last exposureFor 7 days after last exposure
Vaccine no longer manufacturedVaccine no longer manufactured
Overview of Bioterrorism Agents
Botulism Botulism
Caused by toxin from Caused by toxin from Clostridium Clostridium botulinumbotulinum
Colorless, odorless and tastelessColorless, odorless and tasteless
Lethal dose for 70kg human is 1ng/kgLethal dose for 70kg human is 1ng/kgBotulinum toxin is the most lethal neurotoxin known to manBotulinum toxin is the most lethal neurotoxin known to man
Dispersal of aerosolized toxin, 1 gm of aerosolized toxin Dispersal of aerosolized toxin, 1 gm of aerosolized toxin could kill up to 1.5 million peoplecould kill up to 1.5 million people
Seven toxin typesSeven toxin typesHuman disease: A, B, E, and FHuman disease: A, B, E, and F
Animal disease: C, D, and GAnimal disease: C, D, and G
Overview of Bioterrorism Agents
Toxin production in foods prepared or stored at ambient temperature
Intestinal colonization and toxin production in susceptible
infants and adults
Colonization and toxin production in an open
wound
C. botulinum in the soil,
flora and fauna
Botulism:Acute, symmetric, descending flaccid
paralysis with bulbar palsies
Botulism: Epidemiology of Natural Transmission
Overview of Bioterrorism Agents
DescendingFlaccid Paralysis
Symmetric ParalysisVoluntary Muscles
1. Neck2. Shoulders3. Upper extremities4. Lower extremities
BP often normal; Mental status normal
Cranial Nerve Palsies
Cranial Nerves III, IV, VI, VII, IX
Blurry vision Diplopia Ptosis Expressionless Facies Regurgitation Dysarthria/Dysphagia
IncubationPeriod
Inhalational 24-72 hours
Foodborne 18-36 hours
(range 2 hours to 8 days) Dependent on toxin dose
IncubationPeriod
Inhalational 24-72 hours
Foodborne 18-36 hours
(range 2 hours to 8 days) Dependent on toxin dose
ExposureExposureClinical Presentation of Botulism
Overview of Bioterrorism Agents
Botulism: Medical Botulism: Medical ManagementManagement
Early administration of Early administration of antitoxinantitoxin
Supportive careSupportive careMonitoring respiratory functionMonitoring respiratory function
Providing mechanical ventilationProviding mechanical ventilationMay be needed for weeks or monthsMay be needed for weeks or months
Overview of Bioterrorism Agents
Botulism: AntitoxinBotulism: AntitoxinPreferably within 24 hours of Preferably within 24 hours of
symptom onsetsymptom onset
Type of antitoxin based on type of botulismType of antitoxin based on type of botulismBivalent antitoxin specific to serotype A and B,Bivalent antitoxin specific to serotype A and B,
Monovalent antitoxin specific to serotype E, and Monovalent antitoxin specific to serotype E, and
Heptavalent antitoxin specific against serotypes A, Heptavalent antitoxin specific against serotypes A, B, C, D, E, F, and GB, C, D, E, F, and G
1 vial per person1 vial per person
Acts by binding free systemic toxinActs by binding free systemic toxinDoes Does notnot reverse paralysis already present reverse paralysis already present
Overview of Bioterrorism Agents
Viral Hemorrhagic Fevers (VHF)Viral Hemorrhagic Fevers (VHF)Hemorrhagic fever viruses (RNA) belong to Hemorrhagic fever viruses (RNA) belong to
four taxonomic families: four taxonomic families: Filoviridae (Ebola/Marburg)Filoviridae (Ebola/Marburg)Arenaviridae (Bolivian HF))Arenaviridae (Bolivian HF))Bunyaviridae (Congo-Crimean HF)Bunyaviridae (Congo-Crimean HF)Flaviviridae (Dengue)Flaviviridae (Dengue)
Natural vectors – virus dependentNatural vectors – virus dependentRodents, mosquitoes, ticksRodents, mosquitoes, ticks
Natural occurrences have been seen in TexasNatural occurrences have been seen in Texas
Overview of Terrorism Agents
VHF as a Biological Weapon These viruses are considered
suitable weapons because:
— they have a low infectious dose
— they cause high morbidity and mortality
— they cause fear and panic in the general public
—effective vaccines are either not available, or supplies are limited
Overview of Bioterrorism Agents
Later Manifestations
External /Internal Hemorrhage• Ecchymosis• Petechiae• Bleeding from puncture site• Bleeding from nose and gums• Hemorrhagic conjunctivitis• Gastrointestinal bleeding• Severe vaginal bleeding• Pleural effusion• Renal Failure• Shock Laboratory Findings• Leukopenia or leukocytosis • Thrombocytopenia• Elevated Liver Function Tests• Anemia or Hemoconcentration• Prolonged PT, PTT
Early Manifestations
In general:• High fever• Headache• Myalgia• Arthralgia• Anorexia• Varying degrees of nausea, vomiting and diarrhea
IncubationPeriod
2-21 days (depending on
the virus)
IncubationPeriod
2-21 days (depending on
the virus)
ExposureExposure
Overview of Bioterrorism Agents
Clinical Timeline for VHF
Petechiae
Clinical Presentation of VHF
Overview of Bioterrorism Agents
Ecchymosis
Melena
Aggressive supportive care with Aggressive supportive care with intravenous fluids, colloids, blood intravenous fluids, colloids, blood products as neededproducts as needed
Specific therapy (ribavirin) may be Specific therapy (ribavirin) may be helpful in bunyaviruses and helpful in bunyaviruses and arenaviruses arenaviruses
Avoid IM injections or invasive Avoid IM injections or invasive procedures (due to bleeding)procedures (due to bleeding)
Strict aerosol precautions (i.e. Strict aerosol precautions (i.e. respiratory isolation)respiratory isolation)
VHF Clinical Management
Overview of Bioterrorism Agents
Tularemia
• Francisella tularensisFrancisella tularensis - Intracellular gram - Intracellular gram neg. coccobacillusneg. coccobacillus
• Zoonotic - usually ulceroglandular disease Zoonotic - usually ulceroglandular disease but also can be pneumonic diseasebut also can be pneumonic disease
• Presentation: Incubation 2-10 dPresentation: Incubation 2-10 d
• Mortality 35% untreated; < 10% treatedMortality 35% untreated; < 10% treated
Tularemia• Diagnosis: Culture/Gram’s stain blood, sputum, Diagnosis: Culture/Gram’s stain blood, sputum,
nodenode
• Isolation: Standard – No human-human Isolation: Standard – No human-human transmissiontransmission
• Treatment: Treatment:
StreptomycinStreptomycin Gentamicin Gentamicin Tetracycline Tetracycline
• If exposed: watch for 7 days, treat if fever developsIf exposed: watch for 7 days, treat if fever develops
Sources of InformationSources of InformationCenters for Disease Control Centers for Disease Control
(CDC)(CDC)www.cdc.govwww.cdc.gov
CDC Emergency Preparedness CDC Emergency Preparedness www.emergency.cdc.govwww.emergency.cdc.gov
CDC Quarantine and IsolationCDC Quarantine and Isolationwww.cdc.gov/ncldod/dp/index.htmwww.cdc.gov/ncldod/dp/index.htm
Overview of Bioterrorism Agents
Definition
Second highest priority agents including those thatSecond highest priority agents including those that
are moderately easy to disseminateare moderately easy to disseminate
result in moderate morbidity rates and low mortality result in moderate morbidity rates and low mortality ratesrates
and require specific enhancements of the CDC’s and require specific enhancements of the CDC’s diagnostic capacity and enhanced disease diagnostic capacity and enhanced disease surveillance surveillance
Q FeverCoxiella burnetiiCoxiella burnetii
Presentation: Incubation 10-40 dPresentation: Incubation 10-40 d
• Sx variable - Fever, HA, myalgia, malaiseSx variable - Fever, HA, myalgia, malaise
• Occ. cough, rales, CXR infiltrateOcc. cough, rales, CXR infiltrate
• WBC usually normal, but WBC usually normal, but LFTs commonLFTs common
Low mortality, but malaise may last monthsLow mortality, but malaise may last months
Q FeverDiagnosis: Serology, Antibody or ELISADiagnosis: Serology, Antibody or ELISA
Isolation: StandardIsolation: Standard
Treatment: Antibiotics will shorten courseTreatment: Antibiotics will shorten course
TetracyclinesTetracyclines
Erythromycin, Azithromycin, Erythromycin, Azithromycin,
Quinolones, chloramphenicol, TMP/SMXQuinolones, chloramphenicol, TMP/SMX
Brucellosis
• Zoonotic, slow-growing gram neg. rodZoonotic, slow-growing gram neg. rod
• Presentation: Incubation 5-60 d or longerPresentation: Incubation 5-60 d or longer
• May last weeks or months, but rarely fatalMay last weeks or months, but rarely fatal
BrucellosisDiagnosis: Serology; Culture of blood, marrowDiagnosis: Serology; Culture of blood, marrow
• Isolation: Standard. Contact if open lesionsIsolation: Standard. Contact if open lesions
• Treatment: Combination antibioticsTreatment: Combination antibiotics
Most recover even without Most recover even without antibioticsantibiotics
Case 7 – Headache, Vomiting
• 39 y o woman presents with 2 d worsening 39 y o woman presents with 2 d worsening HA, nausea, vomiting, fever, malaiseHA, nausea, vomiting, fever, malaise
• Better after fluids, acetaminophen -Released Better after fluids, acetaminophen -Released
• Returns following day with confusion, Returns following day with confusion, seizureseizure
Viral Encephalitis• Venezuelan, Eastern, Western Equine Venezuelan, Eastern, Western Equine
Encephalitis Encephalitis
• Presentation: Incubation 2-14 dPresentation: Incubation 2-14 d
• Fever, HA, myalgia, photophobia, vomitingFever, HA, myalgia, photophobia, vomiting
• Small % of VEE progress to neurologic sxSmall % of VEE progress to neurologic sx
• Delirium, coma, seizuresDelirium, coma, seizures
Viral Encephalitis• Diagnosis: Viral isolation or serologyDiagnosis: Viral isolation or serology
PCR for somePCR for some
• Isolation: StandardIsolation: Standard
• Treatment: SupportiveTreatment: SupportiveAnalgesics, AnticonvulsantsAnalgesics, Anticonvulsants
• Vaccines available, but poorly immunogenicVaccines available, but poorly immunogenic
Cases 8 – Vomiting, Diarrhea
• Multiple patients present to ER with Multiple patients present to ER with vomiting, diarrhea, headache, myalgias, vomiting, diarrhea, headache, myalgias, malaise, fever, chills, coughmalaise, fever, chills, cough
• All had been at a large outdoor festivalAll had been at a large outdoor festival
Staphylococcal Enterotoxin B
• Presentation: Incubation 1-6 hrsPresentation: Incubation 1-6 hrs
• Diagnosis: Clinical and epidemiological. Diagnosis: Clinical and epidemiological.
• Isolation: StandardIsolation: Standard
• Treatment: SupportiveTreatment: Supportive
Other Category B Agents• Epsilon toxin of Clostridium perfringensEpsilon toxin of Clostridium perfringens• Food safety threats (e.g., Salmonella species, Escherichia coli Food safety threats (e.g., Salmonella species, Escherichia coli
O157:H7, Shigella)O157:H7, Shigella)• Glanders (Burkholderia mallei)Glanders (Burkholderia mallei)• Melioidosis (Burkholderia pseudomallei)Melioidosis (Burkholderia pseudomallei)• Psittacosis (Chlamydia psittaci) Psittacosis (Chlamydia psittaci) • Q fever (Coxiella burnetii) Q fever (Coxiella burnetii) • Ricin toxin from Ricinus communis (castor beans)Ricin toxin from Ricinus communis (castor beans)• Typhus fever (Rickettsia prowazekii)Typhus fever (Rickettsia prowazekii)• Water safety threats (e.g., Vibrio cholerae, Cryptosporidium Water safety threats (e.g., Vibrio cholerae, Cryptosporidium
parvum)parvum)
Definition
Third highest priority agents include emerging Third highest priority agents include emerging pathogens that could be engineered for mass pathogens that could be engineered for mass dissemination in the future because ofdissemination in the future because of
availabilityavailability
ease of production and disseminationease of production and dissemination
and potential for high morbidity and mortality and potential for high morbidity and mortality rates and major health impact rates and major health impact
Agents
• Emerging infectious diseases such as Emerging infectious diseases such as Nipah virus and hantavirusNipah virus and hantavirus