Northwest Center for Public Health Practice University of Washington School of Public Health and...

Northwest Center for Public Health PracticeUniversity of Washington School of Public Health and Community Medicine

1

Preparing for and Responding to Preparing for and Responding to Bioterrorism: Bioterrorism:

Information for the Public Health Information for the Public Health WorkforceWorkforce

UW Northwest Center for Public Health Practice2

Acknowledgements Acknowledgements Acknowledgements Acknowledgements

This presentation, and the accompanying instructor’s manual, were prepared by Jennifer Brennan Braden, MD, MPH, at the Northwest Center for Public Health Practice in Seattle, WA, for thepurpose of educating public health employees in the general aspects of bioterrorism preparedness and response. Instructors are encouragedto freely use all or portions of the material for its intended purpose.

The following people and organizations provided information and/or support in the development of this curriculum. A complete list of resources can be found in the accompanying instructor’s guide.

Patrick O’Carroll, MD, MPH Project Coordinator Centers for Disease Control and Prevention

Judith YarrowDesign and Editing Health Policy and Analysis; University of WA

Washington State Department of Health

Jeff Duchin, MD Jane Koehler, DVM, MPHCommunicable Disease Control, Epidemiology and Immunization Section

Public Health - Seattle and King County

Ed Walker, MD; University of WADepartment of Psychiatry


Diseases of Bioterrorist Potential: Diseases of Bioterrorist Potential: Plague and Botulism Plague and Botulism

Diseases of Bioterrorist Potential: Diseases of Bioterrorist Potential: Plague and Botulism Plague and Botulism

CDC, AFIP


Diseases of Bioterrorist PotentialDiseases of Bioterrorist Potential Learning ObjectivesLearning Objectives

Diseases of Bioterrorist PotentialDiseases of Bioterrorist Potential Learning ObjectivesLearning Objectives

Describe the epidemiology, mode of Describe the epidemiology, mode of transmission, and presenting symptoms of transmission, and presenting symptoms of disease caused by the CDC-defined Category A disease caused by the CDC-defined Category A agents agents

Identify the infection control and prophylactic Identify the infection control and prophylactic measures to implement in the event of a measures to implement in the event of a suspected or confirmed Category A case or suspected or confirmed Category A case or outbreakoutbreak

Describe the epidemiology, mode of Describe the epidemiology, mode of transmission, and presenting symptoms of transmission, and presenting symptoms of disease caused by the CDC-defined Category A disease caused by the CDC-defined Category A agents agents

Identify the infection control and prophylactic Identify the infection control and prophylactic measures to implement in the event of a measures to implement in the event of a suspected or confirmed Category A case or suspected or confirmed Category A case or outbreakoutbreak


PlaguePlagueHistory & SignificanceHistory & Significance

PlaguePlagueHistory & SignificanceHistory & Significance

1414thth Century: “Black Death” responsible for Century: “Black Death” responsible for >20million deaths in Europe>20million deaths in Europe

Used as a BW agent by Japan in WW IIUsed as a BW agent by Japan in WW II

Studied by Soviet and, to a smaller extent, U.S. Studied by Soviet and, to a smaller extent, U.S. BW programs BW programs

1995: Larry Wayne Harris arrested for illicit 1995: Larry Wayne Harris arrested for illicit procurement of culture via mailprocurement of culture via mail

1414thth Century: “Black Death” responsible for Century: “Black Death” responsible for >20million deaths in Europe>20million deaths in Europe

Used as a BW agent by Japan in WW IIUsed as a BW agent by Japan in WW II

Studied by Soviet and, to a smaller extent, U.S. Studied by Soviet and, to a smaller extent, U.S. BW programs BW programs

1995: Larry Wayne Harris arrested for illicit 1995: Larry Wayne Harris arrested for illicit procurement of culture via mailprocurement of culture via mail


PlaguePlagueEpidemiologyEpidemiology

PlaguePlagueEpidemiologyEpidemiology

Caused by Caused by Yersinia pestisYersinia pestis

About 10-15 cases/year U.S.About 10-15 cases/year U.S. Mainly SW statesMainly SW states

Human plague occurs from bite of an infected Human plague occurs from bite of an infected flea (bubonic)flea (bubonic)

Only pneumonic form of plague is spread Only pneumonic form of plague is spread person-to-personperson-to-person Last case of person-to-person transmission in U.S. Last case of person-to-person transmission in U.S.

occurred in 1924occurred in 1924

Caused by Caused by Yersinia pestisYersinia pestis

About 10-15 cases/year U.S.About 10-15 cases/year U.S. Mainly SW statesMainly SW states

Human plague occurs from bite of an infected Human plague occurs from bite of an infected flea (bubonic)flea (bubonic)

Only pneumonic form of plague is spread Only pneumonic form of plague is spread person-to-personperson-to-person Last case of person-to-person transmission in U.S. Last case of person-to-person transmission in U.S.

occurred in 1924occurred in 1924


Yersinia PestisYersinia Pestis Yersinia PestisYersinia Pestis

Gram negative, non-Gram negative, non-motile, non-spore-motile, non-spore-forming bacillusforming bacillus

Resistant to freezing Resistant to freezing temperature and temperature and drying, killed by heat drying, killed by heat and sunlightand sunlight

Gram negative, non-Gram negative, non-motile, non-spore-motile, non-spore-forming bacillusforming bacillus

Resistant to freezing Resistant to freezing temperature and temperature and drying, killed by heat drying, killed by heat and sunlightand sunlight

Source: Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases, Fort Collins, CO


Plague Plague Case DefinitionCase Definition

Plague Plague Case DefinitionCase Definition

Characterized by fever, chills, headache, Characterized by fever, chills, headache, malaise, prostration, & leukocytosis that malaise, prostration, & leukocytosis that manifests in one or more of the following clinical manifests in one or more of the following clinical forms: forms: Regional lymphadenitis (bubonic)Regional lymphadenitis (bubonic) Septicemia w/o evident bubo (septicemic)Septicemia w/o evident bubo (septicemic) Plague pneumoniaPlague pneumonia Pharyngitis & cervical lymphadenitis Pharyngitis & cervical lymphadenitis

(pharyngeal)(pharyngeal)

Characterized by fever, chills, headache, Characterized by fever, chills, headache, malaise, prostration, & leukocytosis that malaise, prostration, & leukocytosis that manifests in one or more of the following clinical manifests in one or more of the following clinical forms: forms: Regional lymphadenitis (bubonic)Regional lymphadenitis (bubonic) Septicemia w/o evident bubo (septicemic)Septicemia w/o evident bubo (septicemic) Plague pneumoniaPlague pneumonia Pharyngitis & cervical lymphadenitis Pharyngitis & cervical lymphadenitis

(pharyngeal)(pharyngeal)MMWR 1997;46(RR-10)


PlaguePlagueCase Definition, cont.Case Definition, cont.

PlaguePlagueCase Definition, cont.Case Definition, cont.

Laboratory criteria for diagnosis: Laboratory criteria for diagnosis: PresumptivePresumptive

Elevated serum antibody titers to Elevated serum antibody titers to Y. pestisY. pestis F1 F1 antigen (w/o documented 4-fold change) in a antigen (w/o documented 4-fold change) in a patient with no history of plague vaccination patient with no history of plague vaccination OROR

Detection of F1 antigen in a clinical specimen by Detection of F1 antigen in a clinical specimen by fluorescent assayfluorescent assay

ConfirmatoryConfirmatory Isolation of Isolation of Y. pestisY. pestis from a clinical specimen from a clinical specimen OROR4-fold or greater change in serum antibody titer to 4-fold or greater change in serum antibody titer to

Y. pestisY. pestis F1 antigen F1 antigen

Laboratory criteria for diagnosis: Laboratory criteria for diagnosis: PresumptivePresumptive

Elevated serum antibody titers to Elevated serum antibody titers to Y. pestisY. pestis F1 F1 antigen (w/o documented 4-fold change) in a antigen (w/o documented 4-fold change) in a patient with no history of plague vaccination patient with no history of plague vaccination OROR

Detection of F1 antigen in a clinical specimen by Detection of F1 antigen in a clinical specimen by fluorescent assayfluorescent assay

ConfirmatoryConfirmatory Isolation of Isolation of Y. pestisY. pestis from a clinical specimen from a clinical specimen OROR4-fold or greater change in serum antibody titer to 4-fold or greater change in serum antibody titer to

Y. pestisY. pestis F1 antigen F1 antigen MMWR 1997;46(RR-10)


Plague: Case ClassificationPlague: Case ClassificationPlague: Case ClassificationPlague: Case Classification

SuspectedSuspected: Clinically compatible case w/o : Clinically compatible case w/o presumptive or confirmatory lab resultspresumptive or confirmatory lab results

ProbableProbable: Clinically compatible case with : Clinically compatible case with presumptive lab results presumptive lab results

ConfirmedConfirmed: Clinically compatible case with : Clinically compatible case with confirmatory lab results confirmatory lab results

SuspectedSuspected: Clinically compatible case w/o : Clinically compatible case w/o presumptive or confirmatory lab resultspresumptive or confirmatory lab results

ProbableProbable: Clinically compatible case with : Clinically compatible case with presumptive lab results presumptive lab results

ConfirmedConfirmed: Clinically compatible case with : Clinically compatible case with confirmatory lab results confirmatory lab results

MMWR 1997;46(RR-10)


PlaguePlagueClinical FormsClinical Forms

PlaguePlagueClinical FormsClinical Forms

Bubonic plagueBubonic plague Most common naturally-occurring formMost common naturally-occurring form Mortality 60% untreated, <5% treated Mortality 60% untreated, <5% treated

Primary or secondary septicemic plaguePrimary or secondary septicemic plague PneumonicPneumonic plague plague

Most likely BT presentationMost likely BT presentation From aerosol or septicemic spread to lungsFrom aerosol or septicemic spread to lungs Survival unlikely if treatment not initiated w/in Survival unlikely if treatment not initiated w/in

24 hours of the onset of symptoms 24 hours of the onset of symptoms

Bubonic plagueBubonic plague Most common naturally-occurring formMost common naturally-occurring form Mortality 60% untreated, <5% treated Mortality 60% untreated, <5% treated

Primary or secondary septicemic plaguePrimary or secondary septicemic plague PneumonicPneumonic plague plague

Most likely BT presentationMost likely BT presentation From aerosol or septicemic spread to lungsFrom aerosol or septicemic spread to lungs Survival unlikely if treatment not initiated w/in Survival unlikely if treatment not initiated w/in

24 hours of the onset of symptoms 24 hours of the onset of symptoms


Pneumonic PlaguePneumonic PlagueClinical PresentationClinical Presentation


Incubation: 1-6 days (usually 2-4 days)Incubation: 1-6 days (usually 2-4 days)

Acute onset of fever with cough, dyspnea, and Acute onset of fever with cough, dyspnea, and chest painchest pain

Hemoptysis characteristic; watery or purulent Hemoptysis characteristic; watery or purulent sputum also possible sputum also possible

Prominent GI symptoms may be present, Prominent GI symptoms may be present, including nausea, vomiting, diarrhea, and including nausea, vomiting, diarrhea, and abdominal pain abdominal pain

Incubation: 1-6 days (usually 2-4 days)Incubation: 1-6 days (usually 2-4 days)

Acute onset of fever with cough, dyspnea, and Acute onset of fever with cough, dyspnea, and chest painchest pain

Hemoptysis characteristic; watery or purulent Hemoptysis characteristic; watery or purulent sputum also possible sputum also possible

Prominent GI symptoms may be present, Prominent GI symptoms may be present, including nausea, vomiting, diarrhea, and including nausea, vomiting, diarrhea, and abdominal pain abdominal pain




Other symptoms include headache, chills, Other symptoms include headache, chills, malaise, myalgiasmalaise, myalgias

Rarely, cervical bubo present Rarely, cervical bubo present

Rapid progression to respiratory failure & shock Rapid progression to respiratory failure & shock

Other symptoms include headache, chills, Other symptoms include headache, chills, malaise, myalgiasmalaise, myalgias

Rarely, cervical bubo present Rarely, cervical bubo present

Rapid progression to respiratory failure & shock Rapid progression to respiratory failure & shock


Bubonic PlagueBubonic PlagueBubonic PlagueBubonic Plague

Incubation: 2-8 daysIncubation: 2-8 days Sudden onset nonspecific symptoms: fever, Sudden onset nonspecific symptoms: fever,

chills, malaise, muscle aches, headachechills, malaise, muscle aches, headache Regional lymphadenitis (buboes) Regional lymphadenitis (buboes)

Swollen, very painful lymph nodes Swollen, very painful lymph nodes Typically inguinal, femoral, axillary, or cervicalTypically inguinal, femoral, axillary, or cervical Erythema overlying skinErythema overlying skin May have surrounding edema May have surrounding edema Concurrent with or shortly after onset of other Concurrent with or shortly after onset of other

symptomssymptoms

Incubation: 2-8 daysIncubation: 2-8 days Sudden onset nonspecific symptoms: fever, Sudden onset nonspecific symptoms: fever,

chills, malaise, muscle aches, headachechills, malaise, muscle aches, headache Regional lymphadenitis (buboes) Regional lymphadenitis (buboes)

Swollen, very painful lymph nodes Swollen, very painful lymph nodes Typically inguinal, femoral, axillary, or cervicalTypically inguinal, femoral, axillary, or cervical Erythema overlying skinErythema overlying skin May have surrounding edema May have surrounding edema Concurrent with or shortly after onset of other Concurrent with or shortly after onset of other

symptomssymptoms


Septicemic & Bubonic PlagueSepticemic & Bubonic PlagueSepticemic & Bubonic PlagueSepticemic & Bubonic Plague

Source: CDC NVBID


PlaguePlagueInfection ControlInfection Control


Person-to-person transmission via respiratory Person-to-person transmission via respiratory

dropletsdroplets

Standard respiratory droplet precautions Standard respiratory droplet precautions

Treatment = 10 days antibiotics Treatment = 10 days antibiotics

Case isolation for at least the first 48 hrs of Case isolation for at least the first 48 hrs of

antibiotic treatmentantibiotic treatment

Bubonic plague - standard precautionsBubonic plague - standard precautions

Person-to-person transmission via respiratory Person-to-person transmission via respiratory

dropletsdroplets

Standard respiratory droplet precautions Standard respiratory droplet precautions

Treatment = 10 days antibiotics Treatment = 10 days antibiotics

Case isolation for at least the first 48 hrs of Case isolation for at least the first 48 hrs of

antibiotic treatmentantibiotic treatment

Bubonic plague - standard precautionsBubonic plague - standard precautions




Antibiotic prophylaxis for close contacts Antibiotic prophylaxis for close contacts Duration: 7 days or duration of risk of Duration: 7 days or duration of risk of

exposure + 7 days exposure + 7 days

Close contacts refusing prophylaxis: Close contacts refusing prophylaxis: Observe 7 days after last exposure and Observe 7 days after last exposure and

treat if fever or cough develop treat if fever or cough develop

Bubonic contacts: Bubonic contacts: Observe 7d and treat if symptoms Observe 7d and treat if symptoms

developdevelop

Antibiotic prophylaxis for close contacts Antibiotic prophylaxis for close contacts Duration: 7 days or duration of risk of Duration: 7 days or duration of risk of

exposure + 7 days exposure + 7 days

Close contacts refusing prophylaxis: Close contacts refusing prophylaxis: Observe 7 days after last exposure and Observe 7 days after last exposure and

treat if fever or cough develop treat if fever or cough develop

Bubonic contacts: Bubonic contacts: Observe 7d and treat if symptoms Observe 7d and treat if symptoms

developdevelop


Plague Plague Summary of Key PointsSummary of Key Points

Plague Plague Summary of Key PointsSummary of Key Points

The most likely presentation in a BT attack is pneumonic plague.

Unlike other forms of plague, pneumonic plague is transmitted person to person, and thus respiratory droplet precautions are indicated in suspected cases until 48 hours after the initiation of antibiotic therapy.

The most likely presentation in a BT attack is pneumonic plague.

Unlike other forms of plague, pneumonic plague is transmitted person to person, and thus respiratory droplet precautions are indicated in suspected cases until 48 hours after the initiation of antibiotic therapy.


Case ReportsCase ReportsCase ReportsCase Reports

Plague Plague Plague Plague

Plague Pneumonia - CA. MMWR 1984;33(34)

Pneumonic Plague -- Arizona, 1992. MMWR 41(40)


Clostridium BotulinumClostridium Botulinum Clostridium BotulinumClostridium Botulinum

C. botulinumC. botulinum spores found in soil worldwide spores found in soil worldwide Toxin causative agent of botulismToxin causative agent of botulism

Types A-G; A,B&E most commonly associated Types A-G; A,B&E most commonly associated with human diseasewith human disease

Most potent toxin known (lethal dose 1ng/kg)Most potent toxin known (lethal dose 1ng/kg) Inactivated by chlorine (~20min) and sunlight Inactivated by chlorine (~20min) and sunlight

(1-3hrs); destroyed by heat (5min at (1-3hrs); destroyed by heat (5min at 8585C)C)

Absorbed into circulation via mucosal surface Absorbed into circulation via mucosal surface or wound, not intact skinor wound, not intact skin

Interferes with nerve transmission Interferes with nerve transmission paralysis paralysis

C. botulinumC. botulinum spores found in soil worldwide spores found in soil worldwide Toxin causative agent of botulismToxin causative agent of botulism

Types A-G; A,B&E most commonly associated Types A-G; A,B&E most commonly associated with human diseasewith human disease

Most potent toxin known (lethal dose 1ng/kg)Most potent toxin known (lethal dose 1ng/kg) Inactivated by chlorine (~20min) and sunlight Inactivated by chlorine (~20min) and sunlight

(1-3hrs); destroyed by heat (5min at (1-3hrs); destroyed by heat (5min at 8585C)C)

Absorbed into circulation via mucosal surface Absorbed into circulation via mucosal surface or wound, not intact skinor wound, not intact skin

Interferes with nerve transmission Interferes with nerve transmission paralysis paralysis


Clostridium BotulinumClostridium BotulinumEpidemiologyEpidemiology

Clostridium BotulinumClostridium BotulinumEpidemiologyEpidemiology

Approximately 100 reported cases botulism/year Approximately 100 reported cases botulism/year in the U.S. in the U.S. Infant most common (72%)Infant most common (72%) Food-borne not common Food-borne not common

Incubation (food-borne): 12-72hrs (range 2hr-Incubation (food-borne): 12-72hrs (range 2hr-8d)8d) Dose dependentDose dependent Could be less following a BT attackCould be less following a BT attack

NoNo person-to-person transmission person-to-person transmission

Death 60% untreated; <5% treatedDeath 60% untreated; <5% treated

Approximately 100 reported cases botulism/year Approximately 100 reported cases botulism/year in the U.S. in the U.S. Infant most common (72%)Infant most common (72%) Food-borne not common Food-borne not common

Incubation (food-borne): 12-72hrs (range 2hr-Incubation (food-borne): 12-72hrs (range 2hr-8d)8d) Dose dependentDose dependent Could be less following a BT attackCould be less following a BT attack

NoNo person-to-person transmission person-to-person transmission

Death 60% untreated; <5% treatedDeath 60% untreated; <5% treated


Botulism & BioterrorismBotulism & BioterrorismBotulism & BioterrorismBotulism & Bioterrorism

Weaponized by former U.S. and Soviet Weaponized by former U.S. and Soviet offensive BW programsoffensive BW programs

Iran, Iraq, N. Korea, Syria believed to have Iran, Iraq, N. Korea, Syria believed to have developed/be developing toxin as a weapondeveloped/be developing toxin as a weapon

Aerosol use or food supply sabotage most Aerosol use or food supply sabotage most likelylikely

Weaponized by former U.S. and Soviet Weaponized by former U.S. and Soviet offensive BW programsoffensive BW programs

Iran, Iraq, N. Korea, Syria believed to have Iran, Iraq, N. Korea, Syria believed to have developed/be developing toxin as a weapondeveloped/be developing toxin as a weapon

Aerosol use or food supply sabotage most Aerosol use or food supply sabotage most likelylikely


BotulismBotulismClinical FormsClinical Forms

BotulismBotulismClinical FormsClinical Forms

Food-borneFood-borne Toxin produced anaerobically in improperly Toxin produced anaerobically in improperly

processed orprocessed or canned, low-acid foods contaminated canned, low-acid foods contaminated by sporesby spores

WoundWound Toxin produced by organisms contaminating woundToxin produced by organisms contaminating wound

InfantInfant TToxin produced by organisms in intestinal tractoxin produced by organisms in intestinal tract

Inhalation botulismInhalation botulism NoNo natural* occurrence, developed as BW weapon natural* occurrence, developed as BW weapon

Food-borneFood-borne Toxin produced anaerobically in improperly Toxin produced anaerobically in improperly

processed orprocessed or canned, low-acid foods contaminated canned, low-acid foods contaminated by sporesby spores

WoundWound Toxin produced by organisms contaminating woundToxin produced by organisms contaminating wound

InfantInfant TToxin produced by organisms in intestinal tractoxin produced by organisms in intestinal tract

Inhalation botulismInhalation botulism NoNo natural* occurrence, developed as BW weapon natural* occurrence, developed as BW weapon

*3 accidental cases in veterinary personnel, W. Germany, 1962


Botulism: Case Definition Botulism: Case Definition Botulism: Case Definition Botulism: Case Definition

Ingestion of botulinum toxin results in an illness Ingestion of botulinum toxin results in an illness of variable severity. Common symptoms are of variable severity. Common symptoms are diplopia, blurred vision and bulbar weakness. diplopia, blurred vision and bulbar weakness. Symmetric paralysis may progress rapidly. Symmetric paralysis may progress rapidly.

Laboratory* criteria for diagnosis: Laboratory* criteria for diagnosis: Detection of botulinum toxin in serum, stool or Detection of botulinum toxin in serum, stool or

patient’s food (food-borne) or other clinical patient’s food (food-borne) or other clinical specimen (“botulism, other”) specimen (“botulism, other”) OROR

Isolation of Isolation of Clostridium botulinumClostridium botulinum from stool from stool (food-borne) or other clinical specimen (food-borne) or other clinical specimen

Ingestion of botulinum toxin results in an illness Ingestion of botulinum toxin results in an illness of variable severity. Common symptoms are of variable severity. Common symptoms are diplopia, blurred vision and bulbar weakness. diplopia, blurred vision and bulbar weakness. Symmetric paralysis may progress rapidly. Symmetric paralysis may progress rapidly.

Laboratory* criteria for diagnosis: Laboratory* criteria for diagnosis: Detection of botulinum toxin in serum, stool or Detection of botulinum toxin in serum, stool or

patient’s food (food-borne) or other clinical patient’s food (food-borne) or other clinical specimen (“botulism, other”) specimen (“botulism, other”) OROR

Isolation of Isolation of Clostridium botulinumClostridium botulinum from stool from stool (food-borne) or other clinical specimen (food-borne) or other clinical specimen

MMWR 1997;46(RR-10)*Assay available at CDC

& some state public health labs


Botulism: Case ClassificationBotulism: Case ClassificationBotulism: Case ClassificationBotulism: Case Classification

Botulism, Food-borneBotulism, Food-borne ProbableProbable: Clinically compatible with an : Clinically compatible with an

epidemiologic link epidemiologic link ConfirmedConfirmed: Clinically compatible case that is : Clinically compatible case that is

laboratory confirmed or that occurs among laboratory confirmed or that occurs among persons who ate the same food as persons persons who ate the same food as persons who have laboratory-confirmed botulism who have laboratory-confirmed botulism

Botulism, OtherBotulism, Other ConfirmedConfirmed: Clinically compatible case that is : Clinically compatible case that is

laboratory confirmed in a patient laboratory confirmed in a patient 1 yr* who 1 yr* who has no history of ingestion of suspect food has no history of ingestion of suspect food and has no woundsand has no wounds

Botulism, Food-borneBotulism, Food-borne ProbableProbable: Clinically compatible with an : Clinically compatible with an

epidemiologic link epidemiologic link ConfirmedConfirmed: Clinically compatible case that is : Clinically compatible case that is

laboratory confirmed or that occurs among laboratory confirmed or that occurs among persons who ate the same food as persons persons who ate the same food as persons who have laboratory-confirmed botulism who have laboratory-confirmed botulism

Botulism, OtherBotulism, Other ConfirmedConfirmed: Clinically compatible case that is : Clinically compatible case that is

laboratory confirmed in a patient laboratory confirmed in a patient 1 yr* who 1 yr* who has no history of ingestion of suspect food has no history of ingestion of suspect food and has no woundsand has no wounds *age parameter may not apply in BT

MMWR 1997;46(RR-10)


BotulismBotulismTreatmentTreatment

BotulismBotulismTreatmentTreatment

Ventilatory assistance and supportive careVentilatory assistance and supportive care Standard precautions Standard precautions Botulinum antitoxinBotulinum antitoxin

Most effective if given early: does not reverse Most effective if given early: does not reverse effect of toxin already bound to nerve receptoreffect of toxin already bound to nerve receptor

Trivalent equine product against types A,B, Trivalent equine product against types A,B, and E currently available from CDC and E currently available from CDC

Heptavalent (A-G) antitoxin - investigationalHeptavalent (A-G) antitoxin - investigational Monovalent human anti-serum for infant Monovalent human anti-serum for infant

botulism -investigationalbotulism -investigational

Ventilatory assistance and supportive careVentilatory assistance and supportive care Standard precautions Standard precautions Botulinum antitoxinBotulinum antitoxin

Most effective if given early: does not reverse Most effective if given early: does not reverse effect of toxin already bound to nerve receptoreffect of toxin already bound to nerve receptor

Trivalent equine product against types A,B, Trivalent equine product against types A,B, and E currently available from CDC and E currently available from CDC

Heptavalent (A-G) antitoxin - investigationalHeptavalent (A-G) antitoxin - investigational Monovalent human anti-serum for infant Monovalent human anti-serum for infant

botulism -investigationalbotulism -investigational


BotulismBotulismProphylaxisProphylaxisBotulismBotulismProphylaxisProphylaxis

Pre-exposure Pre-exposure Prophylaxis for at-risk lab workers and Prophylaxis for at-risk lab workers and

military with investigational vaccinemilitary with investigational vaccine No pre-exposure prophylaxis No pre-exposure prophylaxis

recommended for general public recommended for general public

Post-exposure: close monitoring of those Post-exposure: close monitoring of those exposed; treat with antitoxin at first signs of exposed; treat with antitoxin at first signs of illnessillness

Pre-exposure Pre-exposure Prophylaxis for at-risk lab workers and Prophylaxis for at-risk lab workers and

military with investigational vaccinemilitary with investigational vaccine No pre-exposure prophylaxis No pre-exposure prophylaxis

recommended for general public recommended for general public

Post-exposure: close monitoring of those Post-exposure: close monitoring of those exposed; treat with antitoxin at first signs of exposed; treat with antitoxin at first signs of illnessillness


Botulism Botulism Summary of Key PointsSummary of Key Points


An outbreak of botulism occurring with a common geographic factor, but with no common food exposure, would suggest a deliberate aerosol exposure.

Inhalational botulism does not occur naturally, and any potential cases suggest a deliberate source of infection.

An outbreak of botulism occurring with a common geographic factor, but with no common food exposure, would suggest a deliberate aerosol exposure.

Inhalational botulism does not occur naturally, and any potential cases suggest a deliberate source of infection.




Gastrointestinal symptoms may not occur with inhalational botulism or with food-borne botulism (e.g., resulting from deliberate contamination of the food supply).

Botulinum antitoxin must be administered as soon as possible for optimum results.

Gastrointestinal symptoms may not occur with inhalational botulism or with food-borne botulism (e.g., resulting from deliberate contamination of the food supply).

Botulinum antitoxin must be administered as soon as possible for optimum results.


BotulismBotulismCase ReportsCase ReportsBotulismBotulism

Case ReportsCase Reports

MMWR Morb Mortal Wkly Rep 1995;44(48)

MMWR Morb Mortal Wkly Rep 1999;48(21)


Resources Resources Resources Resources

Centers for Disease Control & Prevention Centers for Disease Control & Prevention Bioterrorism Web page: Bioterrorism Web page: CDC Office of Health and Safety Information System CDC Office of Health and Safety Information System

(personal protective equipment)(personal protective equipment)

USAMRIID -- USAMRIID -- includes link to on-line version of includes link to on-line version of Medical Management of Biological Casualties HandbookMedical Management of Biological Casualties Handbook

Johns Hopkins Center for Civilian Biodefense Johns Hopkins Center for Civilian Biodefense StudiesStudies

Centers for Disease Control & Prevention Centers for Disease Control & Prevention Bioterrorism Web page: Bioterrorism Web page: CDC Office of Health and Safety Information System CDC Office of Health and Safety Information System

(personal protective equipment)(personal protective equipment)

USAMRIID -- USAMRIID -- includes link to on-line version of includes link to on-line version of Medical Management of Biological Casualties HandbookMedical Management of Biological Casualties Handbook

Johns Hopkins Center for Civilian Biodefense Johns Hopkins Center for Civilian Biodefense StudiesStudies

http://www.hopkins-biodefense.org

http://www.usamriid.army.mil/

http://www.bt.cdc.gov/

http://www.cdc.gov/od/ohs/



Office of the Surgeon General: Medical Office of the Surgeon General: Medical Nuclear, Biological and Chemical InformationNuclear, Biological and Chemical Information

St. Louis University Center for the Study of St. Louis University Center for the Study of Bioterrorism and Emerging Infections Bioterrorism and Emerging Infections

Public Health - Seattle & King CountyPublic Health - Seattle & King County

Office of the Surgeon General: Medical Office of the Surgeon General: Medical Nuclear, Biological and Chemical InformationNuclear, Biological and Chemical Information

St. Louis University Center for the Study of St. Louis University Center for the Study of Bioterrorism and Emerging Infections Bioterrorism and Emerging Infections

Public Health - Seattle & King CountyPublic Health - Seattle & King County

http://www.nbc-med.org

http://www.metrokc.gov/health

http://bioterrorism.slu.edu



Washington State Department of Health Washington State Department of Health

Communicable Disease EpidemiologyCommunicable Disease Epidemiology (206) 361-2914 (206) 361-2914 OROR (877) 539-4344 (24 hour emergency)(877) 539-4344 (24 hour emergency)

Association for Professionals in Infection Association for Professionals in Infection Control Control

MMWR Rec & Rep. Case definitions under MMWR Rec & Rep. Case definitions under public health surveillance.public health surveillance.

Washington State Department of Health Washington State Department of Health

Communicable Disease EpidemiologyCommunicable Disease Epidemiology (206) 361-2914 (206) 361-2914 OROR (877) 539-4344 (24 hour emergency)(877) 539-4344 (24 hour emergency)

Association for Professionals in Infection Association for Professionals in Infection Control Control

MMWR Rec & Rep. Case definitions under MMWR Rec & Rep. Case definitions under public health surveillance.public health surveillance. 1997;46(RR-10):1-55

http://www.apic.org/bioterror

http://www.doh.wa.gov

Northwest Center for Public Health Practice University of Washington School of Public Health and...

Documents

Transcript of Northwest Center for Public Health Practice University of Washington School of Public Health and...