Preparing for and Responding to Bioterrorism: Information for Primary Care Clinicians

Northwest Center for Public Health PracticeUniversity of Washington School of Public Health and Community Medicine, July 2002

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

Primary Care CliniciansPrimary Care Clinicians

UW Northwest Center for Public Health Practice

Acknowledgements Acknowledgements Acknowledgements Acknowledgements

This presentation, and the accompanying instructor’s manual (current as of 7/02), were prepared by Jennifer Brennan Braden, MD, MPH, at the Northwest Center for Public Health Practice in Seattle, WA, and Jeff Duchin, MD with Public Health – Seattle & King County and the Division of Allergy & Infectious Diseases, University of WA, for thepurpose of educating primary care clinicians in relevant 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 The Centers for Disease Control and PreventionProject Manager

Judith YarrowHealth Policy & Analysis, University of WADesign and Editing

Jane Koehler, DVM, MPHCommunicable Disease Control, Epidemiology and Immunization section, Public Health - Seattle & King County

Ed Walker, MD; University of WADepartment of Psychiatry


Diseases of Bioterrorist PotentialDiseases of Bioterrorist PotentialPlague & BotulismPlague & Botulism

Diseases of Bioterrorist PotentialDiseases of Bioterrorist PotentialPlague & BotulismPlague & Botulism

CDC, AFIP


Diseases of BT Potential Diseases of BT Potential Learning ObjectivesLearning Objectives

Diseases of BT Potential Diseases of BT Potential Learning ObjectivesLearning Objectives

Be familiar with the agents most likely to be Be familiar with the agents most likely to be used in a biological weapons attack and the used in a biological weapons attack and the most likely mode of disseminationmost likely mode of dissemination

Know the clinical presentation(s) of the Know the clinical presentation(s) of the Category A agents and features that may Category A agents and features that may distinguish them from more common diseases distinguish them from more common diseases

Be familiar with diagnosis, treatment Be familiar with diagnosis, treatment recommendations, infection control, and recommendations, infection control, and preventive therapy for management of infection preventive therapy for management of infection with or exposure to Category A agents. with or exposure to Category A agents.

Be familiar with the agents most likely to be Be familiar with the agents most likely to be used in a biological weapons attack and the used in a biological weapons attack and the most likely mode of disseminationmost likely mode of dissemination

Know the clinical presentation(s) of the Know the clinical presentation(s) of the Category A agents and features that may Category A agents and features that may distinguish them from more common diseases distinguish them from more common diseases

Be familiar with diagnosis, treatment Be familiar with diagnosis, treatment recommendations, infection control, and recommendations, infection control, and preventive therapy for management of infection preventive therapy for management of infection with or exposure to Category A agents. with or exposure to Category A agents.


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Biological Agents of Highest Concern

Plague

Botulism

Summary and Resources

Biological Agents of Highest ConcernBiological Agents of Highest ConcernCategory A AgentsCategory A Agents

Biological Agents of Highest ConcernBiological Agents of Highest ConcernCategory A AgentsCategory A Agents

““Easily disseminated,” infectious via aerosolEasily disseminated,” infectious via aerosol Susceptible civilian populationsSusceptible civilian populations Cause high morbidity and mortality Cause high morbidity and mortality Person-to-person transmission Person-to-person transmission Unfamiliar to physiciansUnfamiliar to physicians – – difficult to difficult to

diagnose/treatdiagnose/treat Cause panic and social disruptionCause panic and social disruption Previous development for BWPrevious development for BW

““Easily disseminated,” infectious via aerosolEasily disseminated,” infectious via aerosol Susceptible civilian populationsSusceptible civilian populations Cause high morbidity and mortality Cause high morbidity and mortality Person-to-person transmission Person-to-person transmission Unfamiliar to physiciansUnfamiliar to physicians – – difficult to difficult to

diagnose/treatdiagnose/treat Cause panic and social disruptionCause panic and social disruption Previous development for BWPrevious development for BW

Biological Agents of Highest ConcernBiological Agents of Highest Concern Category A AgentsCategory A Agents

Biological Agents of Highest ConcernBiological Agents of Highest Concern Category A AgentsCategory A Agents

Variola major (Smallpox)Variola major (Smallpox) Bacillus anthracisBacillus anthracis (Anthrax) (Anthrax) Yersinia pestisYersinia pestis (Plague) (Plague) Francisella tularensisFrancisella tularensis (Tularemia) (Tularemia) Botulinum toxin (Botulism)Botulinum toxin (Botulism) Filoviruses & Arenaviruses (Viral hemorrhagic Filoviruses & Arenaviruses (Viral hemorrhagic

fevers)fevers) Report ANY Report ANY suspected suspected illness due to these illness due to these

agents to Public Health agents to Public Health immediatelyimmediately..

Variola major (Smallpox)Variola major (Smallpox) Bacillus anthracisBacillus anthracis (Anthrax) (Anthrax) Yersinia pestisYersinia pestis (Plague) (Plague) Francisella tularensisFrancisella tularensis (Tularemia) (Tularemia) Botulinum toxin (Botulism)Botulinum toxin (Botulism) Filoviruses & Arenaviruses (Viral hemorrhagic Filoviruses & Arenaviruses (Viral hemorrhagic

fevers)fevers) Report ANY Report ANY suspected suspected illness due to these illness due to these

agents to Public Health agents to Public Health immediatelyimmediately..

Biological Agents of 2nd Highest ConcernBiological Agents of 2nd Highest ConcernCategory B AgentsCategory B Agents

Biological Agents of 2nd Highest ConcernBiological Agents of 2nd Highest ConcernCategory B AgentsCategory B Agents

Coxiella burnettiCoxiella burnetti (Q-fever) (Q-fever) BrucellaBrucella species (brucellosis) species (brucellosis) Burkholderia malleiBurkholderia mallei (glanders) (glanders) Alphaviruses (Venezuelan, Western and Alphaviruses (Venezuelan, Western and

Eastern encephalomyelitis viruses)Eastern encephalomyelitis viruses) Ricin toxin from Ricin toxin from Ricinus communisRicinus communis (castor (castor

bean)bean) Epsilon toxin from Epsilon toxin from Clostridium perfringensClostridium perfringens StaphlococcusStaphlococcus enterotoxin B enterotoxin B

Coxiella burnettiCoxiella burnetti (Q-fever) (Q-fever) BrucellaBrucella species (brucellosis) species (brucellosis) Burkholderia malleiBurkholderia mallei (glanders) (glanders) Alphaviruses (Venezuelan, Western and Alphaviruses (Venezuelan, Western and

Eastern encephalomyelitis viruses)Eastern encephalomyelitis viruses) Ricin toxin from Ricin toxin from Ricinus communisRicinus communis (castor (castor

bean)bean) Epsilon toxin from Epsilon toxin from Clostridium perfringensClostridium perfringens StaphlococcusStaphlococcus enterotoxin B enterotoxin B

Biological Agents of 2nd Highest ConcernBiological Agents of 2nd Highest ConcernFood- or Water-borne Category B AgentsFood- or Water-borne Category B Agents

Biological Agents of 2nd Highest ConcernBiological Agents of 2nd Highest ConcernFood- or Water-borne Category B AgentsFood- or Water-borne Category B Agents

Salmonella speciesSalmonella species

Shigella dysenteriaeShigella dysenteriae

Escherichia coli Escherichia coli 0157:H70157:H7

Vibrio choleraVibrio cholera

Cryptosporidium parvumCryptosporidium parvum

Salmonella speciesSalmonella species

Shigella dysenteriaeShigella dysenteriae

Escherichia coli Escherichia coli 0157:H70157:H7

Vibrio choleraVibrio cholera

Cryptosporidium parvumCryptosporidium parvum


Biological Agents of 3rd Highest ConcernBiological Agents of 3rd Highest ConcernCategory C AgentsCategory C Agents

Biological Agents of 3rd Highest ConcernBiological Agents of 3rd Highest ConcernCategory C AgentsCategory C Agents

Emerging pathogens that could be Emerging pathogens that could be engineered for mass dissemination in the engineered for mass dissemination in the futurefuture Nipah virus Nipah virus Hantaviruses Hantaviruses Tick-borne hemorrhagic fever virusesTick-borne hemorrhagic fever viruses Tickborne encephalitis viruses Tickborne encephalitis viruses Yellow fever Yellow fever Multidrug-resistant tuberculosisMultidrug-resistant tuberculosis

Emerging pathogens that could be Emerging pathogens that could be engineered for mass dissemination in the engineered for mass dissemination in the futurefuture Nipah virus Nipah virus Hantaviruses Hantaviruses Tick-borne hemorrhagic fever virusesTick-borne hemorrhagic fever viruses Tickborne encephalitis viruses Tickborne encephalitis viruses Yellow fever Yellow fever Multidrug-resistant tuberculosisMultidrug-resistant tuberculosis


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Biological Agents of Highest ConcernBiological Agents of Highest Concern

PlaguePlague

BotulismBotulism



PlaguePlagueHistory and SignificanceHistory and Significance

PlaguePlagueHistory and SignificanceHistory and 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


PlaguePlagueClinical FormsClinical Forms

PlaguePlagueClinical FormsClinical Forms

Bubonic plagueBubonic plague Most common naturally-occurring formMost common naturally-occurring form >80% bacteremic; ~25% clinically septic>80% bacteremic; ~25% clinically septic Mortality 60% untreated, <5% treated Mortality 60% untreated, <5% treated

Primary or secondary septicemic plaguePrimary or secondary septicemic plague Pneumonic plaguePneumonic 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 within Survival unlikely if treatment not initiated within

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 >80% bacteremic; ~25% clinically septic>80% bacteremic; ~25% clinically septic Mortality 60% untreated, <5% treated Mortality 60% untreated, <5% treated

Primary or secondary septicemic plaguePrimary or secondary septicemic plague Pneumonic plaguePneumonic 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 within Survival unlikely if treatment not initiated within

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


Bubonic PlagueBubonic PlagueBubonic PlagueBubonic Plague

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

malaise, myalgias, headachemalaise, myalgias, headache Nausea/vomiting/abdominal pain in some casesNausea/vomiting/abdominal pain in some cases Liver and spleen often tender and palpableLiver and spleen often tender and palpable

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

malaise, myalgias, headachemalaise, myalgias, headache Nausea/vomiting/abdominal pain in some casesNausea/vomiting/abdominal pain in some cases Liver and spleen often tender and palpableLiver and spleen often tender and palpable

Source: CDC NVBIDThis link will take you away from the educational site


Bubonic PlagueBubonic PlagueBubonic PlagueBubonic Plague

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

Cutaneous findings (~25% of patients)Cutaneous findings (~25% of patients) Possible papule, vesicle, or pustule at inoculation Possible papule, vesicle, or pustule at inoculation

sitesite Purpuric lesions Purpuric lesions –– late late

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

Cutaneous findings (~25% of patients)Cutaneous findings (~25% of patients) Possible papule, vesicle, or pustule at inoculation Possible papule, vesicle, or pustule at inoculation

sitesite Purpuric lesions Purpuric lesions –– late late


Septicemic Plague Septicemic Plague Septicemic Plague Septicemic Plague

Primary occurs in absence of buboes Primary occurs in absence of buboes

Secondary from bubonic or pneumonic disease Secondary from bubonic or pneumonic disease

Presentation similar to other gram negative Presentation similar to other gram negative septicemias with endotoxin production septicemias with endotoxin production

Primary occurs in absence of buboes Primary occurs in absence of buboes

Secondary from bubonic or pneumonic disease Secondary from bubonic or pneumonic disease

Presentation similar to other gram negative Presentation similar to other gram negative septicemias with endotoxin production septicemias with endotoxin production


Septicemic Plague Septicemic Plague Septicemic Plague Septicemic Plague

Can cause DIC, vascular Can cause DIC, vascular necrosis, and purpuranecrosis, and purpura

Gangrene of acral digits Gangrene of acral digits = Black Death (late = Black Death (late complication)complication)

Secondary pneumonia, Secondary pneumonia, meningitis may occurmeningitis may occur

Can cause DIC, vascular Can cause DIC, vascular necrosis, and purpuranecrosis, and purpura

Gangrene of acral digits Gangrene of acral digits = Black Death (late = Black Death (late complication)complication)

Secondary pneumonia, Secondary pneumonia, meningitis may occurmeningitis may occur

Source: Centers for Disease Control and Prevention,

Division of Vector-Borne Infectious Diseases, Fort Collins, CO.


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 and dyspnea, Acute onset of fever with cough and dyspnea, 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 and dyspnea, Acute onset of fever with cough and dyspnea, 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 and Rapid progression to respiratory failure and shock 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 and Rapid progression to respiratory failure and shock shock


Pneumonic PlaguePneumonic Plague Radiological & Lab FindingsRadiological & Lab Findings Pneumonic PlaguePneumonic Plague Radiological & Lab FindingsRadiological & Lab Findings

CXR: variable, but CXR: variable, but frequently bilateral frequently bilateral infiltrates, patchy or infiltrates, patchy or consolidated consolidated

Leukocytosis Leukocytosis w/bandemia (PMNs)w/bandemia (PMNs)

Often fibrin split Often fibrin split products; liver products; liver enzymes may be enzymes may be

CXR: variable, but CXR: variable, but frequently bilateral frequently bilateral infiltrates, patchy or infiltrates, patchy or consolidated consolidated

Leukocytosis Leukocytosis w/bandemia (PMNs)w/bandemia (PMNs)

Often fibrin split Often fibrin split products; liver products; liver enzymes may be enzymes may be Source: Centers for Disease Control and Prevention,

Division of Vector-Borne Infectious Diseases,

Fort Collins, CO


PlaguePlagueDifferential DiagnosisDifferential Diagnosis

PlaguePlagueDifferential DiagnosisDifferential Diagnosis

PneumonicPneumonic Bioterrorism threatsBioterrorism threats

AnthraxAnthrax TularemiaTularemia

Other severe Other severe community-acquired community-acquired pneumonias (influenza, pneumonias (influenza, hantavirus)hantavirus)

Hemorrhagic Hemorrhagic leptospirosisleptospirosis

PneumonicPneumonic Bioterrorism threatsBioterrorism threats

AnthraxAnthrax TularemiaTularemia

Other severe Other severe community-acquired community-acquired pneumonias (influenza, pneumonias (influenza, hantavirus)hantavirus)

Hemorrhagic Hemorrhagic leptospirosisleptospirosis

SepticemicSepticemic Other causes of gram-Other causes of gram-

negative sepsisnegative sepsis MeningococcemiaMeningococcemia Rocky Mt Spotted feverRocky Mt Spotted fever TTPTTP

BubonicBubonic Staph/strep adenitis Staph/strep adenitis Glandular tularemiaGlandular tularemia Cat scratch diseaseCat scratch disease STD’s: LGV, chancroidSTD’s: LGV, chancroid

SepticemicSepticemic Other causes of gram-Other causes of gram-

negative sepsisnegative sepsis MeningococcemiaMeningococcemia Rocky Mt Spotted feverRocky Mt Spotted fever TTPTTP

BubonicBubonic Staph/strep adenitis Staph/strep adenitis Glandular tularemiaGlandular tularemia Cat scratch diseaseCat scratch disease STD’s: LGV, chancroidSTD’s: LGV, chancroid


PlaguePlagueDiagnosisDiagnosisPlaguePlague

DiagnosisDiagnosis

Initially based on clinical suspicion Initially based on clinical suspicion

Gram stain of sputum or blood: gram negative Gram stain of sputum or blood: gram negative bacilli or coccobacilli bacilli or coccobacilli

Bipolar staining with Wright, Giemsa or Wayson Bipolar staining with Wright, Giemsa or Wayson stainstain

Immunofluorescent antibody testImmunofluorescent antibody test

Initially based on clinical suspicion Initially based on clinical suspicion

Gram stain of sputum or blood: gram negative Gram stain of sputum or blood: gram negative bacilli or coccobacilli bacilli or coccobacilli

Bipolar staining with Wright, Giemsa or Wayson Bipolar staining with Wright, Giemsa or Wayson stainstain

Immunofluorescent antibody testImmunofluorescent antibody test


PlaguePlagueDiagnosisDiagnosisPlaguePlague

DiagnosisDiagnosis

Confirmatory testing at state health Confirmatory testing at state health department labs and CDC department labs and CDC

Culture of lymph node aspirate and blood Culture of lymph node aspirate and blood Automated culture systems may misidentify Automated culture systems may misidentify

Y.pestis Y.pestis Inform labs of suspicion for plague Inform labs of suspicion for plague

Confirmatory testing at state health Confirmatory testing at state health department labs and CDC department labs and CDC

Culture of lymph node aspirate and blood Culture of lymph node aspirate and blood Automated culture systems may misidentify Automated culture systems may misidentify

Y.pestis Y.pestis Inform labs of suspicion for plague Inform labs of suspicion for plague


When to Think (BT) Plague? When to Think (BT) Plague? History/Epi CluesHistory/Epi Clues

When to Think (BT) Plague? When to Think (BT) Plague? History/Epi CluesHistory/Epi Clues

Other recent cases of plague Other recent cases of plague Claims* by a terrorist or aggressor of a release of Claims* by a terrorist or aggressor of a release of

plagueplague Illness in persons with common ventilation Illness in persons with common ventilation

system or other exposuresystem or other exposure Cluster of similar or unusual syndrome Cluster of similar or unusual syndrome

compatible with plaguecompatible with plague More severe disease than is usually expected or More severe disease than is usually expected or

failure to respond to standard therapy failure to respond to standard therapy Unusual season for pneumonia in presenting age Unusual season for pneumonia in presenting age

groupgroup

Other recent cases of plague Other recent cases of plague Claims* by a terrorist or aggressor of a release of Claims* by a terrorist or aggressor of a release of

plagueplague Illness in persons with common ventilation Illness in persons with common ventilation

system or other exposuresystem or other exposure Cluster of similar or unusual syndrome Cluster of similar or unusual syndrome

compatible with plaguecompatible with plague More severe disease than is usually expected or More severe disease than is usually expected or

failure to respond to standard therapy failure to respond to standard therapy Unusual season for pneumonia in presenting age Unusual season for pneumonia in presenting age

groupgroup

*a ‘credible threat’ as determined by law enforcement and/or public health officials


PlaguePlagueInfection ControlInfection Control


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

Standard respiratory droplet precautions include Standard respiratory droplet precautions include disposable surgical masks, gown, gloves and disposable surgical masks, gown, gloves and eye protectioneye protection

Case isolation for at least the first 48 hrs of Case isolation for at least the first 48 hrs of antimicrobial therapyantimicrobial therapy

Bubonic plague Bubonic plague –– standard precautions standard precautions Strict precautions when handling bodies of Strict precautions when handling bodies of

plague victims plague victims Use HEPA respirators and negative pressure rooms, Use HEPA respirators and negative pressure rooms,

if availableif available

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

Standard respiratory droplet precautions include Standard respiratory droplet precautions include disposable surgical masks, gown, gloves and disposable surgical masks, gown, gloves and eye protectioneye protection

Case isolation for at least the first 48 hrs of Case isolation for at least the first 48 hrs of antimicrobial therapyantimicrobial therapy

Bubonic plague Bubonic plague –– standard precautions standard precautions Strict precautions when handling bodies of Strict precautions when handling bodies of

plague victims plague victims Use HEPA respirators and negative pressure rooms, Use HEPA respirators and negative pressure rooms,

if availableif available




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 7 days and treat if symptoms Observe 7 days 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 7 days and treat if symptoms Observe 7 days and treat if symptoms

developdevelop


Recommendations for Treatment of Patients With Pneumonic Recommendations for Treatment of Patients With Pneumonic Plague in a Contained Casualty Setting*Plague in a Contained Casualty Setting*

Recommendations for Treatment of Patients With Pneumonic Recommendations for Treatment of Patients With Pneumonic Plague in a Contained Casualty Setting*Plague in a Contained Casualty Setting*

Adults Adults Streptomycin 1gm IM BID x 10dStreptomycin 1gm IM BID x 10d Gentamicin 5mg/kg IM/IV qd, or 2mg/kg Gentamicin 5mg/kg IM/IV qd, or 2mg/kg

loading followed by 1.7mg/kg IM/IV TID x 10dloading followed by 1.7mg/kg IM/IV TID x 10d ChildrenChildren

Streptomycin 15mg/kg IM BID x 10d (max Streptomycin 15mg/kg IM BID x 10d (max 2g/d)2g/d)

Gentamicin 2.5mg/kg IM/IV TID x 10dGentamicin 2.5mg/kg IM/IV TID x 10d Pregnant women – gentamicin, doxycycline, Pregnant women – gentamicin, doxycycline,

ciprofloxacin ciprofloxacin Alternates: ciprofloxacin, doxycycline, chloramphenicolAlternates: ciprofloxacin, doxycycline, chloramphenicol

Adults Adults Streptomycin 1gm IM BID x 10dStreptomycin 1gm IM BID x 10d Gentamicin 5mg/kg IM/IV qd, or 2mg/kg Gentamicin 5mg/kg IM/IV qd, or 2mg/kg

loading followed by 1.7mg/kg IM/IV TID x 10dloading followed by 1.7mg/kg IM/IV TID x 10d ChildrenChildren

Streptomycin 15mg/kg IM BID x 10d (max Streptomycin 15mg/kg IM BID x 10d (max 2g/d)2g/d)

Gentamicin 2.5mg/kg IM/IV TID x 10dGentamicin 2.5mg/kg IM/IV TID x 10d Pregnant women – gentamicin, doxycycline, Pregnant women – gentamicin, doxycycline,

ciprofloxacin ciprofloxacin Alternates: ciprofloxacin, doxycycline, chloramphenicolAlternates: ciprofloxacin, doxycycline, chloramphenicol

*Working Group on Civilian Biodefense consensus-based recommendationsSource: JAMA. 2000;283:2281-2290This link will take you away from the educational site


Recommendations for Treatment of Patients With Pneumonic Recommendations for Treatment of Patients With Pneumonic Plague in Mass Casualty Settings and for Postexposure Plague in Mass Casualty Settings and for Postexposure

Prophylaxis*Prophylaxis*

Recommendations for Treatment of Patients With Pneumonic Recommendations for Treatment of Patients With Pneumonic Plague in Mass Casualty Settings and for Postexposure Plague in Mass Casualty Settings and for Postexposure

Prophylaxis*Prophylaxis*

Adults & Pregnant womenAdults & Pregnant women Doxycycline 100mg po BID x 7-10dDoxycycline 100mg po BID x 7-10d Ciprofloxacin 500mg po BID x 7-10dCiprofloxacin 500mg po BID x 7-10d

Children <45kgChildren <45kg Doxycycline 2.2mg/kg po BID x 7-10d Doxycycline 2.2mg/kg po BID x 7-10d

(if 45+ kg, give adult dosage) (if 45+ kg, give adult dosage) Ciprofloxacin 20mg/kg po BID x 7-10dCiprofloxacin 20mg/kg po BID x 7-10d

Alternate: ChloramphenicolAlternate: Chloramphenicol

Adults & Pregnant womenAdults & Pregnant women Doxycycline 100mg po BID x 7-10dDoxycycline 100mg po BID x 7-10d Ciprofloxacin 500mg po BID x 7-10dCiprofloxacin 500mg po BID x 7-10d

Children <45kgChildren <45kg Doxycycline 2.2mg/kg po BID x 7-10d Doxycycline 2.2mg/kg po BID x 7-10d

(if 45+ kg, give adult dosage) (if 45+ kg, give adult dosage) Ciprofloxacin 20mg/kg po BID x 7-10dCiprofloxacin 20mg/kg po BID x 7-10d

Alternate: ChloramphenicolAlternate: Chloramphenicol *Working Group on Civilian Biodefense consensus-based recommendationsSource: JAMA. 2000;283:2281-2290

This link will take you away from the educational site


PlaguePlagueOther Treatment/Prophylactic MeasuresOther Treatment/Prophylactic Measures

PlaguePlagueOther Treatment/Prophylactic MeasuresOther Treatment/Prophylactic Measures

Supportive Care --e.g., IV crystalloids; heparin & Supportive Care --e.g., IV crystalloids; heparin & pressor agents rarely neededpressor agents rarely needed

Buboes – aspiration, and not I&D, Buboes – aspiration, and not I&D, recommendedrecommended

Vaccine - none currently availableVaccine - none currently available Old killed whole cell vaccine effective against Old killed whole cell vaccine effective against

bubonic, not pneumonic formbubonic, not pneumonic form F1-V antigen vaccine in development at USAMRIIDF1-V antigen vaccine in development at USAMRIID

Supportive Care --e.g., IV crystalloids; heparin & Supportive Care --e.g., IV crystalloids; heparin & pressor agents rarely neededpressor agents rarely needed

Buboes – aspiration, and not I&D, Buboes – aspiration, and not I&D, recommendedrecommended

Vaccine - none currently availableVaccine - none currently available Old killed whole cell vaccine effective against Old killed whole cell vaccine effective against

bubonic, not pneumonic formbubonic, not pneumonic form F1-V antigen vaccine in development at USAMRIIDF1-V antigen vaccine in development at USAMRIID


Plague Plague Summary of Key PointsSummary of Key Points


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

In addition to the epidemiologic clues noted in Module 1 (Introduction to Bioterrorism), clinical clues suggesting pneumonic plague include an abrupt onset of pneumonia with bloody sputum and a fulminant course.

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

In addition to the epidemiologic clues noted in Module 1 (Introduction to Bioterrorism), clinical clues suggesting pneumonic plague include an abrupt onset of pneumonia with bloody sputum and a fulminant course.




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.

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.


PlaguePlagueCase Studies and ReportsCase Studies and Reports

PlaguePlagueCase Studies and ReportsCase Studies and Reports

Clin Infect Dis 2000;30:893-900 (abstract)

MMWR Morb Mortal Wkly Rep 1997;46(27)

MMWR Morb Mortal Wkly Rep 1992;41(40)

These links will take you away from the educational site


Navigation Page Navigation Page Click the Section to Which You Want to GoClick the Section to Which You Want to Go

Navigation Page Navigation Page Click the Section to Which You Want to GoClick the Section to Which You Want to Go


PlaguePlague

BotulismBotulism



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)

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)


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

Therapeutic botox impractical BT weaponTherapeutic botox impractical BT weapon Licensed vial of type A only 0.3% estimated human lethal Licensed vial of type A only 0.3% estimated human lethal

inhalational dose inhalational dose

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

Therapeutic botox impractical BT weaponTherapeutic botox impractical BT weapon Licensed vial of type A only 0.3% estimated human lethal Licensed vial of type A only 0.3% estimated human lethal

inhalational dose inhalational dose

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


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): 12-72 hrs Incubation (food-borne): 12-72 hrs (range 2hr-8d)(range 2hr-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): 12-72 hrs Incubation (food-borne): 12-72 hrs (range 2hr-8d)(range 2hr-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


Clostridium BotulinumClostridium Botulinum Pathogenesis Pathogenesis

Clostridium BotulinumClostridium Botulinum Pathogenesis Pathogenesis

Toxin absorbed into circulation via mucosal Toxin absorbed into circulation via mucosal surface or wound, not intact skinsurface or wound, not intact skin

Binds acetylcholine receptor irreversibly Binds acetylcholine receptor irreversibly and blocks release of acetylcholine into and blocks release of acetylcholine into neuromuscular junctionneuromuscular junction

Toxin absorbed into circulation via mucosal Toxin absorbed into circulation via mucosal surface or wound, not intact skinsurface or wound, not intact skin

Binds acetylcholine receptor irreversibly Binds acetylcholine receptor irreversibly and blocks release of acetylcholine into and blocks release of acetylcholine into neuromuscular junctionneuromuscular junction


BotulismBotulismClinical PresentationClinical Presentation


Acute, afebrile, symmetric descending flaccid Acute, afebrile, symmetric descending flaccid paralysisparalysis Always begins in bulbar musculature --> Always begins in bulbar musculature -->

cranial nerve palsiescranial nerve palsies Skeletal muscle paralysis followsSkeletal muscle paralysis follows Respiratory failure can occur in as little as Respiratory failure can occur in as little as

24 hrs24 hrs Clear sensorium: sensation and mental status Clear sensorium: sensation and mental status

normalnormal Afebrile patient Afebrile patient

Acute, afebrile, symmetric descending flaccid Acute, afebrile, symmetric descending flaccid paralysisparalysis Always begins in bulbar musculature --> Always begins in bulbar musculature -->

cranial nerve palsiescranial nerve palsies Skeletal muscle paralysis followsSkeletal muscle paralysis follows Respiratory failure can occur in as little as Respiratory failure can occur in as little as

24 hrs24 hrs Clear sensorium: sensation and mental status Clear sensorium: sensation and mental status

normalnormal Afebrile patient Afebrile patient




Gastrointestinal symptomsGastrointestinal symptoms May precede neurological symptoms in May precede neurological symptoms in

food-borne botulismfood-borne botulism Thought to be secondary to other Thought to be secondary to other

substances contaminating the food substances contaminating the food May not occur in BT attackMay not occur in BT attack

Autonomic effects Autonomic effects –– dry mouth, ileus, dry mouth, ileus, constipation, urinary retentionconstipation, urinary retention

Gastrointestinal symptomsGastrointestinal symptoms May precede neurological symptoms in May precede neurological symptoms in

food-borne botulismfood-borne botulism Thought to be secondary to other Thought to be secondary to other

substances contaminating the food substances contaminating the food May not occur in BT attackMay not occur in BT attack

Autonomic effects Autonomic effects –– dry mouth, ileus, dry mouth, ileus, constipation, urinary retentionconstipation, urinary retention


BotulismBotulismSymptomsSymptomsBotulismBotulismSymptomsSymptoms

DiplopiaDiplopia

Blurry visionBlurry vision

DysphagiaDysphagia

DysarthriaDysarthria

DiplopiaDiplopia

Blurry visionBlurry vision

DysphagiaDysphagia

DysarthriaDysarthria

FatigueFatigue

DizzinessDizziness

DyspneaDyspnea

GI symptomsGI symptoms

FatigueFatigue

DizzinessDizziness

DyspneaDyspnea

GI symptomsGI symptoms


BotulismBotulismSignsSigns

BotulismBotulismSignsSigns

PtosisPtosis

Gaze paralysisGaze paralysis

Fixed or dilated pupilsFixed or dilated pupils

Facial palsiesFacial palsies

PtosisPtosis

Gaze paralysisGaze paralysis

Fixed or dilated pupilsFixed or dilated pupils

Facial palsiesFacial palsies

Diminished gag reflexDiminished gag reflex

Tongue weaknessTongue weakness

Arm and leg weaknessArm and leg weakness

Decreased reflexesDecreased reflexes

Diminished gag reflexDiminished gag reflex

Tongue weaknessTongue weakness

Arm and leg weaknessArm and leg weakness

Decreased reflexesDecreased reflexes


BotulismBotulismDifferential DiagnosisDifferential Diagnosis


Condition Features that distinguish condition from botulism

Guillain-Barre and variants

H/o antecedent infection; paresthesias; often ascending paralysis, early areflexia; eventual CSF protein increase; EMG* findings

Myasthenia gravis Recurrent paralysis; EMG findings; sustained response to anticholinesterase therapy

Stroke Paralysis often asymmetric; abnormal CNS image


Guillain-Barre and variants

H/o antecedent infection; paresthesias; often ascending paralysis, early areflexia; eventual CSF protein increase; EMG* findings

Myasthenia gravis Recurrent paralysis; EMG findings; sustained response to anticholinesterase therapy

Stroke Paralysis often asymmetric; abnormal CNS image

Source: Arnon et al. JAMA 2001;285:1059-1070*ElectromyogramThis link will take you away from the educational site





Intoxication w/depressants

H/o exposure; excessive drug levels in body fluids

Lambert-Eaton syndrome

Increased strength w/sustained contraction; evidence of lung carcinoma; EMG findings similar to botulism

Tick paralysis Paresthesias; ascending paralysis; tick attached to skin


Intoxication w/depressants

H/o exposure; excessive drug levels in body fluids

Lambert-Eaton syndrome

Increased strength w/sustained contraction; evidence of lung carcinoma; EMG findings similar to botulism

Tick paralysis Paresthesias; ascending paralysis; tick attached to skin

Source: Arnon et al. JAMA 2001;285:1059-1070



BotulismBotulismDiagnosisDiagnosis


Mouse bioassay: available at CDC and certain Mouse bioassay: available at CDC and certain public health labs public health labs In King County, call Public Health – Seattle & In King County, call Public Health – Seattle &

King County: (206) 296-4774King County: (206) 296-4774

EMG findings – nonspecific but may be helpful EMG findings – nonspecific but may be helpful Normal nerve conduction velocity and Normal nerve conduction velocity and

sensory nerve function; brief small amplitude sensory nerve function; brief small amplitude motor potentials, facilitation with repetitive motor potentials, facilitation with repetitive stimulationstimulation

Mouse bioassay: available at CDC and certain Mouse bioassay: available at CDC and certain public health labs public health labs In King County, call Public Health – Seattle & In King County, call Public Health – Seattle &

King County: (206) 296-4774King County: (206) 296-4774

EMG findings – nonspecific but may be helpful EMG findings – nonspecific but may be helpful Normal nerve conduction velocity and Normal nerve conduction velocity and

sensory nerve function; brief small amplitude sensory nerve function; brief small amplitude motor potentials, facilitation with repetitive motor potentials, facilitation with repetitive stimulationstimulation




Exclusionary tests to rule out other causesExclusionary tests to rule out other causes Normal CSF Normal CSF Edrophonium (“Tensilon test”) Edrophonium (“Tensilon test”)

Reverses paralysis in myasthenia gravisReverses paralysis in myasthenia gravis May have false positive with botulismMay have false positive with botulism

Normal imaging Normal imaging Evaluate for presence of ticks Evaluate for presence of ticks

Exclusionary tests to rule out other causesExclusionary tests to rule out other causes Normal CSF Normal CSF Edrophonium (“Tensilon test”) Edrophonium (“Tensilon test”)

Reverses paralysis in myasthenia gravisReverses paralysis in myasthenia gravis May have false positive with botulismMay have false positive with botulism

Normal imaging Normal imaging Evaluate for presence of ticks Evaluate for presence of ticks


Specimen CollectionSpecimen CollectionC. botulinumC. botulinum

Specimen CollectionSpecimen CollectionC. botulinumC. botulinum

In Washington, call local (in King County: (206) 296-4774) or State Department of Health (206-361-2914) for prior approval

Serum Collect 10 -15 ml serum as soon as possible after the onset of symptoms and before administration of antitoxin; use red top or separator type tubes; ship cold

Feces 10-50 g of stool should be collected in sterile container; sterile enema water enema material (20ml) o.k.; ship cold

Food sample Food should be left in original container if possible or placed in a sterile unbreakable container. Place containers in leak-proof plastic bags. Do not freeze. Ship cold

Wound or tissue

Place in an anaerobic collection device. Transport at room temperature.

Gastric material/vomit (50gm)

Ship same as serum

In Washington, call local (in King County: (206) 296-4774) or State Department of Health (206-361-2914) for prior approval

Serum Collect 10 -15 ml serum as soon as possible after the onset of symptoms and before administration of antitoxin; use red top or separator type tubes; ship cold

Feces 10-50 g of stool should be collected in sterile container; sterile enema water enema material (20ml) o.k.; ship cold

Food sample Food should be left in original container if possible or placed in a sterile unbreakable container. Place containers in leak-proof plastic bags. Do not freeze. Ship cold

Wound or tissue

Place in an anaerobic collection device. Transport at room temperature.

Gastric material/vomit (50gm)

Ship same as serum

Sources: CDC, ASM & APHL. “Basic Protocols for Level A Laboratories”; Michigan Department of Community Health ;Washington State Department of Health Public Health Laboratories


BotulismBotulismTreatmentTreatment


Ventilatory assistance and supportive careVentilatory assistance and supportive care Recovery depends on regeneration of new motor Recovery depends on regeneration of new motor

axons and may take weeks to monthsaxons and may take weeks to months

Botulinum antitoxinBotulinum antitoxin Most effective if given early: does not reverse Most effective if given early: does not reverse

action of already-bound toxinaction of already-bound toxin 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 Recovery depends on regeneration of new motor Recovery depends on regeneration of new motor

axons and may take weeks to monthsaxons and may take weeks to months

Botulinum antitoxinBotulinum antitoxin Most effective if given early: does not reverse Most effective if given early: does not reverse

action of already-bound toxinaction of already-bound toxin 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




Botulinum antitoxinBotulinum antitoxin Single 10ml vial per patient, diluted 1:10 in 0.9% Single 10ml vial per patient, diluted 1:10 in 0.9%

saline & administered by slow IV infusionsaline & administered by slow IV infusion Screen for hypersensitivity before administering Screen for hypersensitivity before administering

equine antitoxin and desensitize if necessaryequine antitoxin and desensitize if necessary Monitor closely during treatmentMonitor closely during treatment Diphenhydramine and epinephrine on hand to Diphenhydramine and epinephrine on hand to

treat hypersensitivity reactionstreat hypersensitivity reactions

Antibiotics for secondary infectionAntibiotics for secondary infection Aminoglycosides and clindamycin contraindicated: Aminoglycosides and clindamycin contraindicated:

exacerbate neuromuscular blockade exacerbate neuromuscular blockade

Botulinum antitoxinBotulinum antitoxin Single 10ml vial per patient, diluted 1:10 in 0.9% Single 10ml vial per patient, diluted 1:10 in 0.9%

saline & administered by slow IV infusionsaline & administered by slow IV infusion Screen for hypersensitivity before administering Screen for hypersensitivity before administering

equine antitoxin and desensitize if necessaryequine antitoxin and desensitize if necessary Monitor closely during treatmentMonitor closely during treatment Diphenhydramine and epinephrine on hand to Diphenhydramine and epinephrine on hand to

treat hypersensitivity reactionstreat hypersensitivity reactions

Antibiotics for secondary infectionAntibiotics for secondary infection Aminoglycosides and clindamycin contraindicated: Aminoglycosides and clindamycin contraindicated:

exacerbate neuromuscular blockade exacerbate neuromuscular blockade


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 publicrecommended 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 publicrecommended 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 DecontaminationDecontamination

Botulism Botulism DecontaminationDecontamination

Wash exposed surfaces with soap and water.Wash exposed surfaces with soap and water.

Decontaminate environmental surfaces with Decontaminate environmental surfaces with 0.1% bleach solution, if necessary.0.1% bleach solution, if necessary. Without intervention, toxin will degrade or dissipate Without intervention, toxin will degrade or dissipate

over hours to days.over hours to days.

Wash exposed surfaces with soap and water.Wash exposed surfaces with soap and water.

Decontaminate environmental surfaces with Decontaminate environmental surfaces with 0.1% bleach solution, if necessary.0.1% bleach solution, if necessary. Without intervention, toxin will degrade or dissipate Without intervention, toxin will degrade or dissipate

over hours to days.over hours to days.


Botulism Botulism Summary of Key PointsSummary of Key Points


Botulism presents as symmetric bilateral weakness or paralysis with cranial nerve abnormalities and a clear sensorium.

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

Botulism presents as symmetric bilateral weakness or paralysis with cranial nerve abnormalities and a clear sensorium.

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).

A careful dietary and activity/travel history is important when evaluating potential botulism cases.

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

A careful dietary and activity/travel history is important when evaluating potential botulism cases.




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

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

Contact your local health department for any suspicion of botulism.

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

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

Contact your local health department for any suspicion of botulism.


BotulismBotulismCase Studies and ReportsCase Studies and Reports

BotulismBotulismCase Studies and ReportsCase Studies and Reports

J Paediatr Child Health 2000;36(2):193-5 (abstract)

MMWR Morb Mortal Wkly Rep. 1995;44(48)






PlaguePlague

BotulismBotulism



Summary - Category A Critical AgentsSummary - Category A Critical AgentsSummary - Category A Critical AgentsSummary - Category A Critical Agents

Disease Transmit Man to Man

Infective Dose* (Aerosol)

Incubation Period

Duration of Illness Approx. case fatality rate

Inhalation anthrax

No

8,000-50,000 spores

1-6 days 3-5 days (usually fatal if untreated)

High

Pneumonic Plague

High 100-500 organisms

2-3 days 1-6 days (usually fatal)

High unless treated within 12-24 hours

Tularemia No 10-50 organisms

2-10 days (average 3-5)

> 2 weeks Moderate if untreated

Smallpox High Assumed low (10-100 organisms)

7-17 days (average 12)

4 weeks High to moderate

Viral Hemorrhagic Fevers

Moderate 1-10 organisms 2-21 days Death between 7-16 days

High for Zaire strain, moderate with Sudan

Botulism No 0.001 g/kg is LD50 for type A

1-5 days Death in 24-72 hours; lasts months if not lethal

High without respiratory support

Modified from: USAMRIID’s Medical Management of Biological Casualties Handbook

*infectious dose may be less in certain circumstances



SummarySummaryCategory A Critical AgentsCategory A Critical Agents

SummarySummaryCategory A Critical AgentsCategory A Critical Agents

Decontamination of exposed persons Decontamination of exposed persons Showering or washing thoroughly with soap and Showering or washing thoroughly with soap and

water adequate for most; bleach not necessary water adequate for most; bleach not necessary

Infection controlInfection control Standard precautions – all cases Standard precautions – all cases Airborne and contact precautions – smallpox and Airborne and contact precautions – smallpox and

viral hemorrhagic feversviral hemorrhagic fevers Droplet precautions – pneumonic plagueDroplet precautions – pneumonic plague

Decontamination of exposed persons Decontamination of exposed persons Showering or washing thoroughly with soap and Showering or washing thoroughly with soap and

water adequate for most; bleach not necessary water adequate for most; bleach not necessary

Infection controlInfection control Standard precautions – all cases Standard precautions – all cases Airborne and contact precautions – smallpox and Airborne and contact precautions – smallpox and

viral hemorrhagic feversviral hemorrhagic fevers Droplet precautions – pneumonic plagueDroplet precautions – pneumonic plague


Resources Resources Resources Resources Centers for Disease Control and Prevention Centers for Disease Control and 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 – includes link to on-line version of Medical USAMRIID – includes link to on-line version of Medical Management of Biological Casualties Handbook Management of Biological Casualties Handbook

Johns Hopkins Center for Civilian Biodefense Studies Johns Hopkins Center for Civilian Biodefense Studies fact sheets and links to fact sheets and links to other info, including JAMA series from Working Group other info, including JAMA series from Working Group on Civilian Biodefense and BT-related anthrax case on Civilian Biodefense and BT-related anthrax case studiesstudies

Centers for Disease Control and Prevention Centers for Disease Control and 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 – includes link to on-line version of Medical USAMRIID – includes link to on-line version of Medical Management of Biological Casualties Handbook Management of Biological Casualties Handbook

Johns Hopkins Center for Civilian Biodefense Studies Johns Hopkins Center for Civilian Biodefense Studies fact sheets and links to fact sheets and links to other info, including JAMA series from Working Group other info, including JAMA series from Working Group on Civilian Biodefense and BT-related anthrax case on Civilian Biodefense and BT-related anthrax case studiesstudieshttp://www.hopkins-biodefense.org

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

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

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



Resources Resources Resources Resources

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 –– fact fact sheets and links sheets and links

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 –– fact fact sheets and links sheets and links

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

http://www.nbc-med.org

http://www.metrokc.gov/health

http://bioterrorism.slu.edu



Resources Resources Resources Resources

American College of Physicians – links to BT American College of Physicians – links to BT resources, including decision support tools and resources, including decision support tools and palm documents palm documents

Self-Assessment (case scenarios – chemical Self-Assessment (case scenarios – chemical and biological)and biological)

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

American College of Physicians – links to BT American College of Physicians – links to BT resources, including decision support tools and resources, including decision support tools and palm documents palm documents

Self-Assessment (case scenarios – chemical Self-Assessment (case scenarios – chemical and biological)and biological)

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

http://www.acponline.org

http://www.acponline.org/bioterro/self_assessment.htm

1997;46(RR-10):1-55



In Case of An Event…In Case of An Event…Web Sites with Up-to-Date Information and Web Sites with Up-to-Date Information and

InstructionsInstructions



Centers for Disease Control and Prevention Centers for Disease Control and Prevention Saint Louis University, CSB & EISaint Louis University, CSB & EI WA State Local Health Departments/DistrictsWA State Local Health Departments/Districts

Level A Lab Protocols: Presumptive Agent IDLevel A Lab Protocols: Presumptive Agent ID

Centers for Disease Control and Prevention Centers for Disease Control and Prevention Saint Louis University, CSB & EISaint Louis University, CSB & EI WA State Local Health Departments/DistrictsWA State Local Health Departments/Districts

Level A Lab Protocols: Presumptive Agent IDLevel A Lab Protocols: Presumptive Agent ID

http://www.bt.cdc.gov/EmContact/index.asphttp://www.bt.cdc.gov/EmContact/index.asp

http://bioterrorism.slu.edu/hotline.htmhttp://bioterrorism.slu.edu/hotline.htm

http://www.bt.cdc.gov/LabIssues/index.asphttp://www.bt.cdc.gov/LabIssues/index.asp

http://www.doh.wa.gov/LHJMap/LHJMap.htmhttp://www.doh.wa.gov/LHJMap/LHJMap.htm







FBI Terrorism Web PageFBI Terrorism Web Page

WA State Emergency Mgt Division – Hazard Analysis WA State Emergency Mgt Division – Hazard Analysis UpdateUpdate

Mail Security Mail Security

Links to your state health departmentLinks to your state health department

NIOSH – Worker Safety and Use of PPE NIOSH – Worker Safety and Use of PPE

FBI Terrorism Web PageFBI Terrorism Web Page

WA State Emergency Mgt Division – Hazard Analysis WA State Emergency Mgt Division – Hazard Analysis UpdateUpdate

Mail Security Mail Security

Links to your state health departmentLinks to your state health department

NIOSH – Worker Safety and Use of PPE NIOSH – Worker Safety and Use of PPE

http://www.fbi.gov/terrorism/terrorism.htmhttp://www.fbi.gov/terrorism/terrorism.htm

http://www.usps.com/news/2001/press/serviceupdates.htmhttp://www.usps.com/news/2001/press/serviceupdates.htm

http://www.cdc.gov/niosh/emres01.htmlhttp://www.cdc.gov/niosh/emres01.html

http://www.wa.gov/wsemhttp://www.wa.gov/wsem

http://www.astho.org/state.htmlhttp://www.astho.org/state.html


Preparing for and Responding to Bioterrorism: Information for Primary Care Clinicians

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