The concept of disease, controlled by the International Health Regulations Smallpox Plague Disease,...

The concept of disease, The concept of disease, controlled by the controlled by the

International Health International Health RegulationsRegulations

Smallpox Smallpox PlaguePlague

Disease, Prevention, and Disease, Prevention, and InterventionIntervention

Progression of SmallpoxProgression of Smallpox

Incubation PeriodIncubation PeriodProdrome StageProdrome StageMaculesMaculesPapulesPapulesVesiclesVesiclesPustulesPustulesScabsScabsScarsScars

Smallpox ProdromeSmallpox Prodrome

Incubation period 12 days (range 7-17 d)Incubation period 12 days (range 7-17 d)

ProdromeProdrome– abrupt onset of fever abrupt onset of fever >>101101ooFF– malaise, headache, muscle pain, nausea, malaise, headache, muscle pain, nausea,

vomiting, backachevomiting, backache– lasts 1- 4 dayslasts 1- 4 days

Smallpox RashSmallpox RashEnanthem (mucous membrane lesions) Enanthem (mucous membrane lesions) appears ~ 24 hours before skin rashappears ~ 24 hours before skin rash

– Minute red spots on the tongue and Minute red spots on the tongue and oral/pharyngeal mucosaoral/pharyngeal mucosa

– Lesions enlarge and ulcerate quicklyLesions enlarge and ulcerate quickly

– Become infectious from lesions in mouthBecome infectious from lesions in mouth– Virus titers in saliva highest and most Virus titers in saliva highest and most

infectious during first week of infectious during first week of exanthem exanthem (skin rash)(skin rash)

• ExanthamExantham (skin rash) – (21 days) (skin rash) – (21 days)- Stages: macules, papules, vesicles, pustules, scabsStages: macules, papules, vesicles, pustules, scabs- Pustules raised, round, firm - like small beads in the Pustules raised, round, firm - like small beads in the

skin (“shotty”)skin (“shotty”)- Umbilication commonUmbilication common

• Begins and most dense on face and extremities Begins and most dense on face and extremities (centrifugal distribution)(centrifugal distribution)

• Lesions on palms and soles (Lesions on palms and soles (>>50% of cases)50% of cases)

• Lesions in same stage and evolve slowly (1-2 Lesions in same stage and evolve slowly (1-2 days/stage)days/stage)

Smallpox RashSmallpox Rash

Day 4 of rash

Ordinary SmallpoxOrdinary Smallpox

Pustular lesions on palms

Flattened lesionson soles

SmallpoxOrdinary Type (Discreet

lesions)

SmallpoxSmallpox

Ordinary Type (Dense lesions)Ordinary Type (Dense lesions)

SmallpoxSmallpox

Flat-typeFlat-type

SmallpoxSmallpox

Hemorrhagic TypeHemorrhagic Type

Varicella

SMALLPOXSMALLPOX

Deep, hard lesionsDeep, hard lesions

Round, well Round, well circumscribedcircumscribed

Confluent or umbilicatedConfluent or umbilicated

Lesions at same stage of Lesions at same stage of

developmentdevelopment

CHICKEN POXCHICKEN POX

SuperficialSuperficial

Not well circumscribedNot well circumscribed

Confluence and umbilication Confluence and umbilication uncommonuncommon

Lesions at all stages of Lesions at all stages of developmentdevelopment

Differential DiagnosisDifferential Diagnosis

SMALLPOX SMALLPOX

CHICKENPOX

SmallpoxSmallpox

ChickenpoxChickenpox

Smallpox

Varicella

Smallpox Outbreak Control Smallpox Outbreak Control Activities and Strategies Activities and Strategies

Surveillance and Containment Surveillance and Containment (Ring Vaccination)(Ring Vaccination)

Case(s)

Contacts of Case(s)

Contacts of Contacts

• Search for casesSearch for cases

• Provide a ring of immunity Provide a ring of immunity around each casearound each case

- Vaccinate close contactsVaccinate close contacts- Vaccinate close contacts of Vaccinate close contacts of

contactscontacts

• Required to control diseaseRequired to control disease- most efficient use of vaccinemost efficient use of vaccine

- minimize adverse reactionsminimize adverse reactions

SurveillanceSurveillancePre-Event SurveillancePre-Event Surveillance– Identify cases with typical presentationIdentify cases with typical presentation– Rapid laboratory confirmation Rapid laboratory confirmation – Confirmation initiates contact vaccination Confirmation initiates contact vaccination – Passive with more specificityPassive with more specificity

Post-Event SurveillancePost-Event Surveillance– Identify Identify allall potential cases (typical/atypical) potential cases (typical/atypical)– Clinical diagnosis can initiate contact vaccinationClinical diagnosis can initiate contact vaccination– Active with increased sensitivityActive with increased sensitivity

Epidemiologic InvestigationEpidemiologic InvestigationIdentify source of initial introduction(s)Identify source of initial introduction(s)

Identify contacts and other population(s) at riskIdentify contacts and other population(s) at risk

Characterize and define outbreakCharacterize and define outbreak– Identify unusual/unexpected featuresIdentify unusual/unexpected features– Scope Scope

Monitor effectiveness of control measuresMonitor effectiveness of control measures

Communicate information and define public Communicate information and define public health recommendationshealth recommendations

Contact TracingContact Tracing

Goal is to find as many contacts as possibleGoal is to find as many contacts as possible– Contact with patient after onset of feverContact with patient after onset of fever– Prioritize based on closeness, length, and date Prioritize based on closeness, length, and date

of exposure of exposure – If too many to find quickly, consider all people in If too many to find quickly, consider all people in

same room (or possibly facility) with smallpox same room (or possibly facility) with smallpox case after onset of fever as contactscase after onset of fever as contacts

ExamplesExamples::– Highest priority - people who live full-time in Highest priority - people who live full-time in

home and other face-to-face contacts after home and other face-to-face contacts after onset of feveronset of fever

– Next priority – non face-to-face contacts Next priority – non face-to-face contacts exposed in a medical care facility or in homeexposed in a medical care facility or in home

– Last priority – people in same facility after onset Last priority – people in same facility after onset of fever (other than home or hospital) but of fever (other than home or hospital) but without face-to-face contactwithout face-to-face contact

Contact TracingContact Tracing

Isolation and QuarantineIsolation and Quarantine

Goals of Smallpox IsolationGoals of Smallpox IsolationProtectProtect others from becoming infected others from becoming infected– Healthcare personnelHealthcare personnel– Response personnelResponse personnel– Other patientsOther patients

IsolateIsolate smallpox patient smallpox patient– Prevent sharing of airspace (respiratory isolation)Prevent sharing of airspace (respiratory isolation)– Prevent direct contact (protective clothing)Prevent direct contact (protective clothing)– Prevent contact with infectious materials Prevent contact with infectious materials

(decontamination)(decontamination)

Prevent sharing of airspacePrevent sharing of airspacewith potentially infectious patientswith potentially infectious patients

Negative pressure isolation rooms.Negative pressure isolation rooms.

Separate facilities for larger groups.Separate facilities for larger groups.

Respirators for unvaccinated care-Respirators for unvaccinated care-

providers.providers.

Personal Protective EquipmentPersonal Protective Equipment

Use disposable gloves, gowns, and shoe Use disposable gloves, gowns, and shoe covers.covers.

Reusable bedding and clothing should be Reusable bedding and clothing should be autoclaved or laundered in hot water with autoclaved or laundered in hot water with bleach.bleach.

Respiratory Protection - Respiratory Protection - SmallpoxSmallpox

•Airborne precautions

•Recommendation: fitted NIOSH N95 or greater respirators for personnel entering patient room

Properly Fitted – air goes through mask filter

Isolation StrategiesIsolation Strategies

3 groups to consider3 groups to consider– Confirmed or suspected smallpox casesConfirmed or suspected smallpox cases

– Febrile vaccinated contactsFebrile vaccinated contacts

– Asymptomatic (vaccinated) contacts Asymptomatic (vaccinated) contacts under surveillanceunder surveillance

Confirmed/SuspectedConfirmed/SuspectedSmallpox Cases (Few)Smallpox Cases (Few)

Known or presumed Known or presumed infectious individualsinfectious individuals

Hospital isolation room(s)Hospital isolation room(s)

Rooms under negative Rooms under negative pressurepressure

At least 6 to12 air At least 6 to12 air changes/hourchanges/hour

Air vented to outsideAir vented to outside

Air not re-circulated to other Air not re-circulated to other rooms or areasrooms or areas

Confirmed/Suspected Confirmed/Suspected Smallpox Cases (Many)Smallpox Cases (Many)

Designated Facility Designated Facility for smallpox patientsfor smallpox patientsAerosol precautions Aerosol precautions not needed if not needed if onlyonly potential smallpox potential smallpox cases in facility and cases in facility and no shared ventilationno shared ventilation systemsystem– AllAll people people

admitted/entering admitted/entering facility vaccinatedfacility vaccinated

Febrile Vaccinated ContactsFebrile Vaccinated Contacts

Vaccinated contacts with fever (no rash)Vaccinated contacts with fever (no rash)– Two successive temps > 101Two successive temps > 101ºº F (38 F (38ººC)C)

– Less need for medical careLess need for medical care

– No shared ventilationNo shared ventilation system system

– Can be housed in same facility with smallpox Can be housed in same facility with smallpox cases or separate facilitycases or separate facility

– All persons in facility require vaccination All persons in facility require vaccination

Asymptomatic Vaccinated Asymptomatic Vaccinated ContactsContacts

Not infectious Not infectious – Own home or other lodgingOwn home or other lodging– No special ventilation or medical requirementsNo special ventilation or medical requirements

All other persons staying in home must also be All other persons staying in home must also be vaccinatedvaccinated– Household members with contraindications stay Household members with contraindications stay

elsewhereelsewhere

Fever surveillance for 18 days from last Fever surveillance for 18 days from last exposure or 14 days from vaccinationexposure or 14 days from vaccination

DecontaminationDecontamination

Air:Air:– UV Light SensitiveUV Light Sensitive

– Exhaust, Good Air FlowExhaust, Good Air Flow

Surfaces:Surfaces:– Diluted bleach solution (Fresh every day)Diluted bleach solution (Fresh every day)

– Hospital disinfectantsHospital disinfectants

Blood, pus contaminated equipment:Blood, pus contaminated equipment:– Wash before disinfectingWash before disinfecting

DecontaminationDecontaminationLaundry:Laundry:– Contain separately Contain separately

– Dissolving laundry bags if availableDissolving laundry bags if available

– Don’t sort first, wash, then sortDon’t sort first, wash, then sort

– Hot water with detergent and/or bleachHot water with detergent and/or bleach

Household:Household:– Basic cleaningBasic cleaning

– Wash all clothing in hot w/ bleach if possibleWash all clothing in hot w/ bleach if possible

– Public health review of homePublic health review of home

PlaguePlague

ObjectivesObjectives

Identify plague bacteriumIdentify plague bacterium

EpidemiologyEpidemiology

Natural OccurrenceNatural Occurrence

Bio-Terror ThreatBio-Terror Threat

Plague can cause large numbers of Plague can cause large numbers of casescases

Could create panicCould create panic

Considered for use since 14Considered for use since 14thth century century

Clinical SyndromesClinical Syndromes

BubonicBubonic

PneumonicPneumonic

SepticemicSepticemic

Plague MeningitisPlague Meningitis

PharyngealPharyngeal

““Safety Pin” Y. Pestis in bloodSafety Pin” Y. Pestis in blood

Bubonic PlagueBubonic Plague

Infected flea biteInfected flea bite

Exposure through Exposure through break in skinbreak in skin

No person-to-personNo person-to-person

Untreated progresses Untreated progresses to pneumonicto pneumonic

Pneumonic PlaguePneumonic Plague

Inhalation of plague Inhalation of plague bacteriabacteria

Disease progressionDisease progression– Respiratory failureRespiratory failure– ShockShock– Rapid deathRapid death

Person-to-person Person-to-person transmissiontransmission

Septicemic PlagueSepticemic Plague

Primary FormPrimary Form– Direct inoculation in bloodstreamDirect inoculation in bloodstream

Secondary FormSecondary Form– Development of untreated pneumonic or Development of untreated pneumonic or

bubonic plaguebubonic plague

EpidemiologyEpidemiologyNatural ReservoirsNatural Reservoirs

Bites of infected fleaBites of infected flea

Blood meal from bacteremic animalBlood meal from bacteremic animal

Regurgitates into human/ animal hostRegurgitates into human/ animal host

Common reservoirsCommon reservoirs– Deer miceDeer mice– Ground squirrelsGround squirrels

EpidemiologyEpidemiologyTransmissionTransmission

Bite of infected fleaBite of infected fleaRespiratory dropletsRespiratory dropletsDirect contact (1,5-2 Direct contact (1,5-2 m)m)Direct skin/mucous Direct skin/mucous membrane less membrane less commoncommonBT event – BT event – Respiratory droplets Respiratory droplets or aerosolsor aerosols

Plague IncidencePlague IncidenceWorldwide, 1970 - 1998Worldwide, 1970 - 1998

All inhabited continents, but AustraliaAll inhabited continents, but Australia

1,500 to 3,000 cases annually1,500 to 3,000 cases annually

Greatest ConcentrationsGreatest Concentrations– Asia, South AmericaAsia, South America

Plague Bioterrorism ScenarioPlague Bioterrorism Scenario

Most dangerous as Most dangerous as aerosolaerosol

Outbreak of Outbreak of pneumonicpneumonic

Possibly pharyngeal Possibly pharyngeal or ocularor ocular

Report all suspect Report all suspect cases to public cases to public health immediatelyhealth immediately


Incubation: 2 to 6 daysIncubation: 2 to 6 days

SymptomsSymptoms– Lymphadenopathy, feverLymphadenopathy, fever– Buboes at site of inoculationBuboes at site of inoculation

Disease Progression - UntreatedDisease Progression - Untreated– SepticemiaSepticemia– Secondary Pneumonic PlagueSecondary Pneumonic Plague– Meningitis (rare)Meningitis (rare)





Incubation: 2 to 4 days (range 1 to 6 days)Incubation: 2 to 4 days (range 1 to 6 days)

SymptomsSymptoms– Acute fever, chills, malaise, myalgiasAcute fever, chills, malaise, myalgias– Productive coughProductive cough– Watery mucoid sputum, may be bloodyWatery mucoid sputum, may be bloody– Associated chest pain, increasing dyspneaAssociated chest pain, increasing dyspnea


Disease ProgressionDisease Progression– Adult Respiratory Distress SyndromeAdult Respiratory Distress Syndrome– Refractory pulmonary edemaRefractory pulmonary edema– Signs of shockSigns of shock– Without treatment in less than 24 hours, Without treatment in less than 24 hours,

almost universally fatalalmost universally fatal


Coughing patient can spreadCoughing patient can spread

Respiratory precautionsRespiratory precautions

Rapidly expanding infiltratesRapidly expanding infiltrates

Pulmonary parenchymal necrosis and Pulmonary parenchymal necrosis and hemorrhagehemorrhage

Occasional pulmonary abscessesOccasional pulmonary abscesses

Enlarged hilar nodes and pleural effusionsEnlarged hilar nodes and pleural effusions




Septicemic PlagueSepticemic Plague

Incubation: Most common as complication Incubation: Most common as complication of pneumonic or bubonic plagueof pneumonic or bubonic plagueSymptomsSymptoms– Acute fever, chills, prostration, abdominal Acute fever, chills, prostration, abdominal

pain, nausea, vomitingpain, nausea, vomiting

Disease ProgressionDisease Progression– PurpuraPurpura– DICDIC– Hypotension and other signs of shockHypotension and other signs of shock– Fatal if not treatedFatal if not treated

Infection ControlInfection Control

Large numbers of plague bacilliLarge numbers of plague bacilli

Respiratory droplet spread in close direct Respiratory droplet spread in close direct contactcontact

Respiratory droplet precautions with Respiratory droplet precautions with suspect casessuspect cases

Contact public healthContact public health

Bubonic PlagueBubonic PlagueDifferential DiagnosisDifferential Diagnosis

Streptococcal or Streptococcal or staphylococcal adenitisstaphylococcal adenitis ((Staphylococcal aureusStaphylococcal aureus, , Staphylococcal pyogenesStaphylococcal pyogenes) )

Purulent/ inflamed lesion often distal to Purulent/ inflamed lesion often distal to nodesnodes

Involved nodes more likely to be fluctuantInvolved nodes more likely to be fluctuant

Ascending lymphangitis or cellulitis may Ascending lymphangitis or cellulitis may be presentbe present

TularemiaTularemia

((Francisella tularensisFrancisella tularensis)) Ulcer or pustule distal to nodesUlcer or pustule distal to nodes

Rarely as fulminant as in plagueRarely as fulminant as in plague

Systemic toxicity uncommon Systemic toxicity uncommon

Cat scratch diseaseCat scratch disease

((B. henselaeB. henselae)) History of cat contact/scratchHistory of cat contact/scratch

Indolent clinical courseIndolent clinical course

Primary lesion at site of scratchPrimary lesion at site of scratch

No systemic toxicityNo systemic toxicity


Mycobacterial infection, including scrofula (Mycobacterium tuberculosis and other Mycobacterium species)

• Adenitis occurs in cervical region• Usually painless• Indolent clinical course• More likely to occur in immunocompromised patients

Lymphogranuloma venereum (Chlamydia trachomatis)

• Adenitis occurs in the inguinal region• Sexual exposure 10-30 days previously• Suppuration, fistula tracts common• Exquisite tenderness usually absent• Although patients may appear ill (headache, fever, myalgias), systemic toxicity not present


Chancroid Chancroid ((Hemophilus ducreyiHemophilus ducreyi) )

Adenitis occurs in inguinal region Adenitis occurs in inguinal region

Ulcerative lesion presentUlcerative lesion present

Systemic symptoms uncommon; toxicity Systemic symptoms uncommon; toxicity does not occur does not occur

Primary genital herpes Primary genital herpes Genital areaGenital area

Adenitis occurs in the inguinal region Adenitis occurs in the inguinal region

Severe systemic toxicity not present Severe systemic toxicity not present

Primary or secondary Primary or secondary syphilissyphilis

((Treponema pallidumTreponema pallidum) )

Enlarged lymph nodes in inguinal regionEnlarged lymph nodes in inguinal region

Lymph nodes generally painlessLymph nodes generally painless

Chancre may be notedChancre may be noted

Strangulated inguinal Strangulated inguinal hernias hernias

Evidence of bowel involvementEvidence of bowel involvement

Primary Pneumonic PlaguePrimary Pneumonic PlagueDifferential DiagnosisDifferential Diagnosis

Inhalational anthrax (Bacillus anthracis)

• Widened mediastinum and pleural effusions• Not true pneumonia• Minimal sputum production• Hemoptysis uncommon

Tularemia (Francisella tularensis)

Not as rapid or fulminant as in pneumonic plague


Community-acquired bacterial Community-acquired bacterial pneumoniapneumonia

Mycoplasmal pneumonia Mycoplasmal pneumonia ((Mycoplasma pneumoniaeMycoplasma pneumoniae))

Pneumonia caused by Pneumonia caused by Chlamydia Chlamydia pneumoniaepneumoniae

Legionnaires' disease (Legionnaires' disease (Legionella Legionella pneumophilapneumophila or other or other LegionellaLegionella species)species)

Psittacosis (Psittacosis (Chlamydia psittaciChlamydia psittaci))

Other bacterial agents (e.g., Other bacterial agents (e.g., Staphyloccocus aureusStaphyloccocus aureus, , Streptococcus Streptococcus pneumoniaepneumoniae, , Haemophilus influenzaeHaemophilus influenzae, , Klebsiella pneumoniaeKlebsiella pneumoniae, , Moraxella Moraxella catarrhaliscatarrhalis) )

Rarely as fulminantRarely as fulminant

Usually occur in persons with Usually occur in persons with underlying pulmonary or other underlying pulmonary or other disease or in the elderlydisease or in the elderly

Bird exposure with psittacosisBird exposure with psittacosis

Gram stain may be useful Gram stain may be useful

Community outbreaks not as Community outbreaks not as explosive as pneumonic plague explosive as pneumonic plague outbreakoutbreak

S. pneumoniaeS. pneumoniae usually usually institutionalinstitutional

Community outbreaks of Community outbreaks of Legionnaires' disease often involve Legionnaires' disease often involve exposure to cooling systems exposure to cooling systems


Viral pneumoniaViral pneumonia

InfluenzaInfluenza

HantavirusHantavirus

RSV RSV

CMV CMV

Influenza generally seasonal Influenza generally seasonal

History of recent cruise ship History of recent cruise ship travel or travel to tropics travel or travel to tropics

Exposure to excrement of mice Exposure to excrement of mice with Hantavirus with Hantavirus

RSV usually occurs in children RSV usually occurs in children

CMV usually occurs in CMV usually occurs in immunocompromised patients immunocompromised patients

Q feverQ fever((Coxiella burnetiiCoxiella burnetii) )

Exposure to infected parturient Exposure to infected parturient cats, cattle, sheep, goatscats, cattle, sheep, goats

Severe pneumonia not Severe pneumonia not prominentprominent

Laboratory confirmationLaboratory confirmation

Critical for first casesCritical for first cases

Collect immediately and before antibioticsCollect immediately and before antibiotics

Store appropriatelyStore appropriately

Presumptive diagnosesPresumptive diagnoses

SpecimensSpecimensRespiratoryRespiratory

Pharyngeal swabsPharyngeal swabs

Tracheal washes or aspiratesTracheal washes or aspirates

Sputum specimensSputum specimens

Trans-thoracic lung aspiratesTrans-thoracic lung aspirates

Pleural fluid collectionPleural fluid collection

Testing – Staining, culture, DNA Testing – Staining, culture, DNA amplificationamplification

SpecimensSpecimensTissuesTissues

Lung tissueLung tissue

Lymph node tissueLymph node tissue

SpleenSpleen

LiverLiver

Testing – Culture, Gram stainTesting – Culture, Gram stain

SpecimensSpecimensTissues (Autopsy)Tissues (Autopsy)

LungLungLiverLiverSpleenSpleenLymph nodesLymph nodesSkin lesionsSkin lesionsKidneyKidneyTesting – PCR (Specimens kept fresh Testing – PCR (Specimens kept fresh frozen, unpreserved)frozen, unpreserved)

SpecimensSpecimensBloodBlood

Baseline before antibioticsBaseline before antibiotics

ConvalescentConvalescent– Minimum 14 days apartMinimum 14 days apart– 3 to 4 weeks after symptom onset3 to 4 weeks after symptom onset

Two or more sequentially collected Two or more sequentially collected samples preferredsamples preferred

Laboratory TestingLaboratory TestingPneumonic PlaguePneumonic Plague

Collect before initiating Collect before initiating therapytherapySputum, blood, lymph node Sputum, blood, lymph node aspirateaspirateGram Stain and cultureGram Stain and culture– Gram-negative coccobacillusGram-negative coccobacillus– Bipolar (safety pin) stainingBipolar (safety pin) staining

Acute and convalescent Acute and convalescent bloods for public healthbloods for public health

Recommended Plague TreatmentRecommended Plague TreatmentContained Casualty - AdultsContained Casualty - Adults

PreferredPreferred

StreptomycinStreptomycin 1g IM BID1g IM BID

GentamicinGentamicin 5 mg/kg IM or IV daily OR 5 mg/kg IM or IV daily OR

2 mg/kg loading with 1.7 mg/kg 2 mg/kg loading with 1.7 mg/kg IM or IV TIDIM or IV TID

AlternativeAlternative

DoxycyclineDoxycycline 100mg IV BID or 200mg IV100mg IV BID or 200mg IV

CiprofloxacinCiprofloxacin 400mg IV BID400mg IV BID

ChloramphenicolChloramphenicol 25 mg/kg IV QID25 mg/kg IV QID

Recommended Plague TreatmentRecommended Plague TreatmentMass Casualty - AdultsMass Casualty - Adults

PreferredPreferred

DoxycyclineDoxycycline 100 mg PO BID100 mg PO BID

CiprofloxacinCiprofloxacin 500 mg PO BID500 mg PO BID

AlternativeAlternative

ChloramphenicolChloramphenicol 25 mg/kg PO QID25 mg/kg PO QID

Plague Infection Control Plague Infection Control PrecautionsPrecautions

Isolation for 48 hours of antibiotic Isolation for 48 hours of antibiotic treatment or until clinical improvementtreatment or until clinical improvement

Bubonic Standard

Pneumonic Standard and Respiratory

Septicemic Standard

Suspect Respiratory and Isolation

Plague Infection ControlPlague Infection Control

Cohort and Droplet precautions if no Cohort and Droplet precautions if no isolation availableisolation available

Isolation of contacts may increase in Isolation of contacts may increase in importance for outbreak controlimportance for outbreak control

Corpses – Standard PrecautionsCorpses – Standard Precautions

UN Hazard Class 6UN Hazard Class 6

UN Division 6.2UN Division 6.2

Shipping Biological SpecimensShipping Biological SpecimensInfectious SubstanceInfectious Substance

UN = United Nations

Shipping Biological SpecimensShipping Biological SpecimensInfectious SubstancesInfectious Substances

Primary ContainerPrimary Container– Positive SealPositive Seal

Absorbent MaterialAbsorbent Material

Secondary PackagingSecondary Packaging

Water-tightWater-tight

Leak proofLeak proof


Must be approved by the United Nations.Must be approved by the United Nations.

Designated as UN Certified Packaging or UN Designated as UN Certified Packaging or UN Specified Packaging. Specified Packaging.


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The concept of disease, controlled by the International Health Regulations Smallpox Plague Disease,...

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