Appendix a - Bioterrorism

7/27/2019 Appendix a - Bioterrorism

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Bioterrorism is the use of a biologic weapon to create terror

and panic. Bacteria, fungi, viruses, and biologic toxins maybe used.

The CDC has classified over 30 potential biologic weap-

ons into three broad categories lettered A through C. The

most lethal are category A agents.

Appendix A

Bioterrorism*

Agents with Potential for Use in Biological Terrorism

Category A

Easy to disseminate; cause high morbidity and mortality; and

require specific enhancements of CDCs diagnostic capacity and

enhanced disease surveillance

Anthrax

Plague

Smallpox

Hemorrhagic fevers

Botulism

Tularemia

Category B

Somewhat easy to disseminate; cause moderate morbidity and

low mortality; and require specific enhancements of CDCs diag-

nostic capacity and enhanced disease surveillance

Coxiella burnetii(Q fever)

Brucella species (brucellosis)

Burkholderia mallei(glanders)

AlphavirusesVenezuelan encephalomyelitis

Eastern and Western equine encephalomyelitis

Ricin toxin from Ricinus communis (castor beans)

Epsilon toxin of Clostridium perfringens

Staphylococcus enterotoxin B

Food or waterborne agents

Salmonella species

Shigella dysenteriae

Escherichia coliO157:H7

Vibrio cholerae

Cryptosporidium parvum

Category C

Emerging pathogens that could be engineered for mass dissemi-nation in the future because of availability; ease of production

and dissemination; and potential for high morbidity and mortality

and major health impact

Nipah virus

Hantaviruses

Tickborne hemorrhagic fever viruses

Tickborne encephalitis viruses

Yellow fever

Multidrug-resistant tuberculosis

Biological Terrorism: Infectious Disease Clinics of North America 22(1):2008.PMID: 18295687

Figure A-1 Inhalational anthrax. The incubation period is1 to 6 days. Signs and symptoms include fever, malaise, dys-pnea, cough, headache, chills, vomiting, weakness and chestpain. Chest films may show a widened mediastinum andpleural effusions.

*All photos courtesy CDC.

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http://www.ncbi.nlm.nih.gov/pubmed/18295687http://www.ncbi.nlm.nih.gov/pubmed/18295687http://www.ncbi.nlm.nih.gov/pubmed/18295687


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Appendix A

1020

AGENTS OF BIOTERRORISM

DiseaseClinicalpresentation Diagnostic tests

Person-to-persontransmission Treatment

Vaccine/prophylaxis

Anthrax Inhalation: fever,

malaise for 12 days

followed by respiratory

distress, shockMay have meningitis.

Highly fatal if untreated

Cutaneous: red papule

progressing to shallow

ulcer or blister, then

black eschar

CXR may show wide

mediastinum

Gram-positive bacilli in

blood, CSF, or skinlesion

CSF may be bloody

Blood culture is highest

yield for inhalation

anthrax

No Ciprofloxacin or

Doxycycline plus one

to two other drugs

Other active drugsinclude penicillin,

clindamycin, rifampin,

vancomycin, imipenem

Levofloxacin or moxi-

floxacin probably also

effective

Prophylaxis: ciprofloxa-

cin or doxycycline for

60 days (30 days if

given with vaccine)Bioport vaccine 0.5 mL

SC at 0, 2, 4 weeks; 6,

12, 18 months; then

annual boosters

Botulism Cranial nerve palsies

(particularly involving

eyes) progressing to

descending paralysis

Paralysis lasts for weeks

to months

Diagnosis mostly

clinical

Mouse bioassay using

patient serum takes

several days, not

widely available

No Primarily ventilator

support

Antitoxin can prevent

further progression,

but will not reverse

paralysis

None

Brucellosis Fever, chills, anorexia,

malaise

May last weeks to

months

Blood culture

(slow-growing;

notify laboratory if

suspected) or serology

Leukocyte counts

variable

CXR nonspecific

No

Culture speci-

mens may pose

risk to labora-

tory workers

Doxycycline or fluoro-

quinolone plus rifam-

pin

Doxycycline or

fluoroquinolone plus

rifampin for 6 weeks

No vaccine available

Cholera Severe watery diarrhea Stool culture with

special media

Rare

Use body fluid

precautions

Fluids, ciprofloxacin or

doxycycline

Prophylaxis: ciprofloxa-

cin or doxycycline

Two-dose vaccine, not

highly effective

Glanders

(Burkholderiamallei)

Tender skin nodules,

septicemia, pneumonia

Serology (not widely

available)

Blood culture often

negative

Low risk, but

respiratory

isolation

recommendedCulture speci-

mens may pose

risk to labora-

tory workers

Doxycycline, TMP/SMX,

chloramphenicol,

fluoroquinolones, or

aminoglycosides

Doxycycline, TMP/SMX,

macrolides, or fluoro-

quinolones can be

used for prophylaxisNo vaccine

Pneumonic

plague

Fever, chills, malaise,

cough, respiratory dis-

tress, hemoptysis, men-

ingitis, sepsis

Highly fatal if untreated

Gram-negative cocco-

bacilli in blood, spu-

tum, lymph node

aspirate

Safety-pin appearance

with Wright or Giemsa

stain

ELISA antigen test and

serology using ELISA or

IFA also available

High risk

Use respiratory

droplet

isolation

Streptomycin, gentami-

cin, doxycycline, or

chloramphenicol

Doxycycline or quino-

lone for 6 days

Killed vaccine for

bubonic plague, not

effective against aero-

sol exposure (no longer

manufactured)

Q fever

(Coxiella

burnetii)

Fever, chills, headache,

sometimes pneumonia

Mortality is low

Serology

Titers may not be ele-

vated until 23 weeks

into illness

No

Culture or

tissue speci-

mens may

pose risk to

lab workers

Tetracycline or

doxycycline

Tetracycline or

doxycycline for 5 days

for prophylaxis

Single dose inactivated

whole cell vaccine,

not licensed in

United States

Ricin Fever, dyspnea, vomit-

ing, diarrhea, shock

CXR may show pulmo-

nary edema

Serology (not widely

available)

No Supportive No vaccine or prophy-

laxis available


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Appendix A

1021

AGENTS OF BIOTERRORISMcontd

DiseaseClinicalpresentation Diagnostic tests

Person-to-persontransmission Treatment

Vaccine/prophylaxis

Smallpox Fever, malaise, head-

ache for 12 days, fol-

lowed by papular rash

progressing to vesiclesand pustules

Scabs or pustular fluid

can be forwarded to

CDC through local

public health depart-ment

Can test vesicular fluid

locally to exclude

varicella

High risk

Use strict

respiratory

isolationIdentify any

possible

contacts

Specimens can

pose risk to

laboratory

workers

Supportive

Cidofovir may be

useful, but not tested

Vaccinia vaccine can

prevent illness in

contacts up to several

days after exposure

Staphylococcal

enterotoxin B

Sudden onset of fever,

headache, myalgias,

vomiting, diarrhea, dry

cough

Usually resolves within

a day

Urine antigen, ELISA of

nasal swab (not widely

available)

No Supportive No vaccine

Tularemia Fever, malaise, prostra-

tion, headache, weight

loss and non-productive

cough

CXR may show infil-

trate, hilar adenopathy,

or effusion

Culture and gram stain

of blood or sputum

may show small, faintly

staining, slow growing

gram-negative

coccobacilli

Serology usually posi-

tive after 12 weeks

No

Culture speci-

mens may pose

risk to labora-

tory workers

Streptomycin, gentami-

cin, doxycycline,

chloramphenicol, or

fluoroquinolones

Doxycycline or cipro-

floxacin for 14 days

Investigational live

attenuated vaccine

Venezuelan,

Eastern, or

Western

equineencephalitis

Most have mild

syndrome of fever,

headache, and myalgia

Rarely progresses toencephalitis

Serology of CSF or

serum

Only via vector

Isolation not

necessary

Supportive Inactive vaccines for

VEE, EEE, WEE are

poorly effective

Live vaccine for VEEhas high incidence of

side effects

Viral hemor-

rhagic fevers

(e.g., Ebola)

Fever, prostration,

myalgia, conjunctival

infection, petechial

rash, bleeding

Most are highly fatal

Thrombocytopenia

Identification of virus

requires special testing

at CDC

Moderate risk

Primarily trans-

mitted through

body fluids, but

strict respira-

tory isolation is

recommended

Primarily supportive

Ribavirin may be effec-

tive for some, includ-

ing Congo-Crimean

HF, Lassa fever

No prophylaxis or

vaccine available

Biological Terrorism Infectious Disease Clinics of North America 22(1): 2008. PMID: 18295687CDC, Centers for Disease Control and Prevention; CSF, cerebrospinal fluid; CXR, chest x-ray; EEE, Eastern equine encephalomyelitis; ELISA, enzyme-linked immuno-

sorbent assay; HF, hemorrhagic fever; IFA, indirect fluorescent antibody; SC, subcutaneous; TMP/SMX, trimethoprim-sulfamethoxazole; VEE, Venezuelan equine

encephalomyelitis; WEE, Western equine encephalomyelitis.


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Appendix A

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Figure A-2 Anthrax lesion on the arm. Cutaneous lesionsoccur from 1 to 12 days after exposure with a mean incuba-

tion period of 5 days. The spores germinate in the skin wheretoxin production results in local edema and falls off.

Figure A-3 Anthrax lesion. Edema forms on exposed ar-eas of skin where the organism is deposited. Then a malig-

nant pustule or cutaneous anthrax occurs. The eschar ispainless. There is lymphangitis and painful lymphadenopathy.After 1 to 2 weeks, the anthrax eschar dries, loosens andfalls off.

Figure A-4 Smallpox (child). The rash appears on the faceand extremities and spreads centrally. Lesions evolve frommacules to papules to vesicles to pustules, with each stagelasting 1 to 2 days. Unlike chickenpox, all smallpox lesions areat the same stage of development. Vesicles and pustules arefirm or hard and feel like objects embedded under the skin.

Figure A-5 Smallpox. Late stage confluent. As lesionsevolve they become umbilicated or confluent and will scabover in 1 to 2 weeks, leaving scars.

BIOTERRORISM


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Appendix A

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Figure A-6 Plague buboe. Bubonic plague begins as pain-ful adenopathy several days after the infecting flea bite.

Figure A-7 Plague cutaneous hemorrhage. Patients de-velop septicemia with ecchymoses.

Figure A-8 Plague pneumonia. Aerosol dispersal causespneumonic plague. After an incubation period of 2 to 3 days,patients develop a fulminant pneumonia, with malaise, highfever, cough, hemoptysis, and septicemia with ecchymosesand extremity necrosis. The disease progresses rapidly, leadingto dyspnea, stridor, cyanosis, and septic shock. Death is nor-mally the result of respiratory failure and circulatory collapse.

Figure A-9 Plague extremity necrosis.Patients developsepticemia with extremity necrosis.

BIOTERRORISM

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