Learning Objectives
After completion of the course you’ll be able to:
Chapter 3: The Prospect of Domestic Bioterrorism
Chapter 5: Epidemiology of Bioterrorism
Define indication of intentional release of biologic agent.
Describe the precautions laboratory personnel should take when collecting or handling clinical specimens.
Discuss the epidemiology of bioterrorism and differentiate between a natural outbreak an intentional attack.
List 10 clues that together may constitue proof of intentional use of biological agent.
Chapter 7: Anthrax
Describe the side effects of taking ciprofloxacin and doxycycline.
Describe recommendations made by the CDC for worker safety under engineering controls, administrative controls, housekeeping controls, and personal protective equipment.
Implement anthrax worker safety guidelines issued by the CDC.
Describe the epidemiology of naturally occurring anthrax.
Discuss the diagnosis of inhalational anthrax.
Discuss the therapeutic options of anthrax infection.
Discuss infection control and decontamination protocols for anthrax.
Describe the procedure for handling suspicious packages or envelopes.
Provide medication information to patients about ciprofloxacin, doxycycline, penicillin, and amoxicillin.
Discuss clinical issues in the prophylaxis, diagnosis, and treatment of anthrax.
Chapter 8: Smallpox
Describe various phases of the smallpox disease, symptoms, and degree of infectiousness.
Answer questions about the smallpox disease and the vaccine.
List the categories of people who should not get vaccine.
List the steps that one should take after vaccination to minimize the risk of spreading vaccinia.
Chapter 9: Botulism
Describe three main kinds of botulism and their mode of transmission.
Answer frequently asked questions about botulism.
List symptoms of botulism.
Describe infant botulism, its epidemiology, source of C. botulinum , and prevention and control.
Describe the clinical syndrome of botulism and provide a diagnosis of the disease.
Put the use of botulinum toxin as a bioweapon in historical perspective.
Describe the pathogenesis and clinical manifestations of botulism.
List typical symptoms and signs of foodborne botulism.
Identify features of an outbreak that would indicate a bioterrorist attack with botulinum toxin.
Describe the therapy, prophylaxis and decontamination for botulinum toxin.
Chapter 10: Plague
Answer frequently asked questions about pneumonic and bubonic plague, their signs and symptoms, and treatment.
Describe the role fleas play in the spread of plague to humans.
Explain the epidemiology of plague.
Describe clinical manifestations of bubonic, septicemic, pneumonic, and pharyngeal plague.
Discuss signs and symptoms and laboratory confirmation that can establish the diagnosis of plague.
Describe the treatment for plague.
Outline the strategies for the prevention of plague.
Chapter 11: Tularemia
Answer frequently asked questions about tularemia.
Describe the signs and symptoms of tularemia.
Identify epidemiological indicators that would suggest a bioterrorism act of inhalational tularemia.
Describe the pathogenesis and clinical manifestations of F. tularensis .
Provide a diagnosis of inhalational tularemia following its use as a biological weapon.
Describe the treatment of tularemia in adults and children.
Chapter 12: Viral Hemorrhagic Fevers
Answer frequently asked questions about the etiology and epidemiology of viral hemorrhagic fevers.
Describe various ways of preventing and controlling viral hemorrhagic fevers.
Describe the history and potential of HFVs as biological weapons.
Describe the clinical manifestations of diseases caused by hemorrhagic fever viruses.
Provide a diagnosis of viral hemorrhagic fevers and treatment options including drug therapy.
Chapter 13: Ricin
Chapter 14: Nerve Agents
Answer frequently asked questions about nerve agents, GA, GB, GD and VX.
Describe the signs and symptoms of nerve agents GA, GB, GD and VX, and their effects on health.
List the things people can do to protect themselves against VX and things they should do if they are exposed to VX.
Describe the health effects of nerve agents, GA, GB, GD, and VX.
Describe the prehospital management of victims of nerve agent attack.
Chapter 15: Blister Agents
Describe the health effects of sulfur mustard on various body systems.
Describe prehospital management of victims exposed to sulfur mustard.
List general principles of triage for chemical exposures.
Describe triage for mustard agent casualties.
Chapter 16: Foodborne Illness
Describe some of the most common foodborne diseases.
Identify instances when a doctor should be consulted for a diarrheal illness.
Describe how outbreaks of foodborne disease are detected and investigated.
Describe the ways food can become contaminated.
List foods that are most associated with foodborne illness.
State five simple precautions one can take to reduce the risk of foodborne diseases.
Identify persons who are at particularly high risk to contract a foodborne illness.
Chapter 17: Escherichia coli O157:H7
List various ways Escherichia coli O157:H7 is spread.
Describe the illness caused by Escherichia coli O157:H7.
Chapter 18: Salmonellosis
Answer frequently asked questions about salmonellosis, including how people can catch Salmonella, its health consequences and treatment.
List eight things one can do to prevent salmonellosis.
Chapter 19: Cholera
Chapter 20: Shigellosis
Answer frequently asked questions about shigellosis.
List eight tips for preventing the spread of shigellosis.
Chapter 21: Brucellosis
Chapter 22: Typhoid Fever
Answer frequently asked questions about typhoid fever.
List steps one can take to avoid typhoid fever.
Chapter 24: Injuries and Mass Trauma Events
Describe symptoms of posttraumatic stress disorder.
Identify the kind of injuries that occur in mass trauma events.
List the things health departments should do to prepare for and subsequent to mass trauma events.
Identify various steps one should plan to escape from home, workplace or hotel.
Describe 3 types of burns, their symptoms and early treatment.
List signs and symptoms after a mild traumatic brain injury (MTBI).
Describe the procedure for personal cleaning and disposal of contaminated clothing.
Describe the evacuation procedure in the event of a chemical accident or attack.
Describe how to prepare to shelter in place in case of a chemical accident or attack.
Allay general public’s concerns about the safety of drinking water.
Describe emergency room procedures in chemical hazard emergencies.
Chapter 25: Bioterrorism Readiness Plan: A Template for Healthcare Facilities
Develop and implement a bioterrorism readiness plan appropriate for a particular healthcare facility.
Identify 6 features that should alert healthcare providers to the possibility of a bioterrorism-related outbreak.
Describe clinical features of anthrax infection, infection control practices for patient management, and post-exposure management.
Describe clinical features of botulism infection, infection control practices for patient management and post-exposure management.
Describe clinical features of pneumonic plague, infection control practices for patient management, and post-exposure management.
Learning Objectives
To assess the effectiveness of the course material, we ask that you evaluate your achievement of each learning objective on a scale of A to D (A=excellent, B=good, C=fair, D=unsatisfactory). Please indicate your responses next to each learning objective and return it to us with your completed exam.
Contents
1. Bioterrorism as a Public Health Threat
References
Figure 1. Effects of a nuclear and biological weapons release.
2. The Threat of Biological Attack: Why Concern Now?
Figure 1. Effects of a nuclear and biological weapons release
Vulnerability to Biological Attack
Perpetrator Capability
Technical Capability
Institutional Capability
Intention to Use Biological Weapons
Nonintentional Pathogen Releases
Table 1. New and reemerging viruses
Conclusions
References
3. The Prospect of Domestic Bioterrorism
Motivational Factors
Getting Attention
Economic Terrorism
Millenarianism
Premillennial Tension
Exacting Revenge or Creating Chaos
Mimicking God
The Aura of Science
The Copycat Phenomenon
Technical Factors
Table. Anthrax incidents in the United States, 1992-1999
Organizational Factors
The Likeliest Perpetrators
Conclusions
Acknowledgments
4. Biologic Terrorism–Responding to the Threat
v Bioterrorism: How Prepared Are We?
5. Epidemiology of Bioterrorism
Differential Diagnosis
Epidemiologic Approach
Epidemic Curve
Epidemiologic Clues
Recommendations for Preparedness
References
6. Medical Aspects of Biological Terrorism
Health-Care Providers
Clinical Case
Clinical Questions
What is a biological weapon?
How does biological terrorism pertain to medicine?
Who should be contacted if biological terrorism is suspected?
When should a physician suspect biological terrorism?
What are the most serious biological weapons?
What are the clinical and epidemiological features of smallpox, inhalational anthrax, pneumonic plague?
Smallpox
Anthrax
Plague
Key Points
Clinical Laboratory Personnel
Infection-Control Professionals
State Health Departments
References
Bibliography
7. Anthrax
v Questions and Answers About Anthrax
What is anthrax?
What is the difference between exposure to anthrax and disease caused by anthrax?
Transmission
How is anthrax transmitted?
What are the types of anthrax infection?
What are the case fatality rates for the various forms of anthrax?
Symptoms
What are the symptoms for anthrax?
How can I know my cold or flu is not anthrax?
Testing
Can I get screened or tested to find out whether I have been exposed to anthrax?
Does CDC collect samples to test the bacteria?
When an area is tested for the presence of Bacillus anthracis, how long does it take to get the results?
Does CDC recommend the use of home test kits for anthrax?
Are health department laboratories capable of conducting testing?
How effective and reliable are anthrax tests?
What is subtyping?
Is subtyping different from polymerase chain reaction (PCR)?
What method does CDC use to subtype Bacillus anthracis?
How does MLVA (multi-locus variable-number of tandem [consecutive] repeat analysis) identify different strains of anthrax?
When is environmental sampling performed?
Why is environmental sampling performed?
What is the turnaround time for an anthrax test of an environmental sample?
Is the Mayo Clinic/Roche Rapid Anthrax Test a new test?
Is the Mayo Clinic assay the same as the assay available to Laboratory Response Network (LRN) laboratories?
What are the limitations of the Mayo Clinic test?
Is CDC going to validate this assay?
Are you aware of any sensitivity or specificity issues with the Mayo Clinic test? Should we expect a large number of false positive/negative results?
Are you furnishing CDC-tested equipment and reagents to laboratories?
If a laboratory asks your opinion on whether to use Mayo Clinic/Roche Rapid test, what is your answer?
Will CDC accept results from laboratories that use this assay?
Diagnosis
How is anthrax diagnosed?
What are the standard diagnostic tests used by the laboratories?
What is a nasal swab test?
When is a nasal swab indicated?
Why were nasal swabs used to screen individuals in the Florida investigation for anthrax?
Is there an X-ray for detecting anthrax?
Preventive/Vaccine
What is the therapy for preventing inhalational anthrax?
Is there a vaccination for anthrax?
Is the anthrax vaccine available to the public?
Who should be vaccinated against anthrax?
Treatment
What is the treatment for patients with inhalational and cutaneous anthrax?
If an anthrax event occurs, should people buy and store antibiotics?
What drugs are FDA-approved for postexposure prophylaxis (PEP) and treatment?
Who should receive antibiotics for 60 days?
If patients are suspected of being exposed to anthrax, should they be quarantined or should other family members be tested?
What if I develop side effects from the antibiotic?
Has CDC tested the anthrax isolates for sensitivity to different antibiotics?
What are the risks of using tetracyclines and fluoroquinolones in children? Are alternatives available?
Are there special instructions for taking ciprofloxacin or doxycycline?
After I have started taking ciprofloxacin to protect me from developing anthrax, what side effects could I get from taking this antibiotic?
After I have started taking doxycycline to protect me from developing anthrax, what side effects could I get from taking this antibiotic?
Why is CDC recommending doxycycline instead of ciprofloxacin for the treatment and prevention of anthrax?
Why are people who have been exposed to B. anthracis being given antibiotics for different amounts of time?
Are there different strains of B. anthracis? Do they all respond to antibiotics?
What is the FDA telling physicians and other health professionals about prescriptions for ciprofloxacin?
Can other fluoroquinolones be used instead of ciprofloxacin for postexposure prophylaxis (PEP)/treatment?
Why do I need 60 days of antibiotics?
What happens if I take ciprofloxacin, doxycycline, or amoxicillin for a few days, stop, and then restart the antibiotics?
The ciprofloxacin I am taking gives me headaches. Is there anything I can do to help this?
The ciprofloxacin, doxycycline, or amoxicillin I am taking makes me feel sick to my stomach. Is there anything I can do to help this?
The ciprofloxacin, doxycycline, or amoxicillin I am taking gives me diarrhea. Is there anything I can do to help this?
If taking one of the recommended antibiotics makes me feel terrible, can I switch to another of these antibiotics?
I am having terrible yeast infections while taking ciprofloxacin, doxycycline, or amoxicillin. Is there anything I can take for this?
I feel much better if I take only one pill of ciprofloxacin, doxycycline, or amoxicillin each day. Is that okay?
My prescription says to take one pill every 12 hours. If 15 hours have passed since my last dose, is it still okay to take the pill?
What side effects are serious enough that I should go to a doctor?
Can I drink alcohol if I am taking ciprofloxacin, doxycycline, or amoxicillin?
The ciprofloxacin, doxycycline, or amoxicillin I am taking makes me feel itchy all over. Is there anything I can do to help this?
The ciprofloxacin, doxycycline, or amoxicillin gave me an allergic reaction and I stopped taking it. What should I do? 1
Why can’t I take a shot, wear a patch, or take one large dose of the medicine instead of taking it for 60 days?
Ciprofloxacin and doxycycline look different and come in different doses. Is one better than the other?
Should all patients who have flu-like symptoms be treated with antibiotics?
Does a patient have immunity after recovering from anthrax infection?
How do doctors treat inhalational anthrax to reduce the risk of death in patients?
I was told that I had been exposed to Bacillus anthracis and prescribed antibiotics. I took the medicine for a couple weeks. Wouldn’t that weaken any anthrax that’s in my body?
Why was ciprofloxacin ever publicized as the best drug for anthrax? How can we know which antibiotic is best?
Besides anthrax, what else is ciprofloxacin prescribed for? Has there been resistance to ciprofloxacin when used in other instances (historically)?
Is there a generic form of ciprofloxacin?
Pregnancy
I’m taking medication to prevent anthrax, and I just found out that I’m pregnant. What should I do?
I’m pregnant. What medicine should I take to prevent anthrax?
I’ve heard that doctors don’t generally prescribe ciprofloxacin to pregnant women. Why is that? Why are they recommending it for anthrax prevention?
I was started on ciprofloxacin to prevent anthrax. I’ve heard that amoxicillin may be a safer drug for me to take during my pregnancy. How do I know if I can be switched to amoxicillin?
Doxycycline is being recommended for my coworkers who aren’t pregnant . Is doxycycline a better medicine against anthrax than ciprofloxacin?
I’m having a lot of heartburn during my pregnancy. Can I take ciprofloxacin at the same time as I take antacids?
I’ve been trying to get pregnant and have just started taking medication to prevent anthrax. Can I continue to try to get pregnant while taking this medication?
I just recently found out I’m pregnant, and I was exposed to anthrax at work. I want to take the best medication for my fetus and me, but I don’t yet want my employer to know that I’m pregnant. What should I do?
Risk
What is the risk for an individual if he or she is treated with antibiotics and is exposed to Bacillus anthracis again?
Can the spores that cause anthrax multiply outside of a human or animal host?
What are the odds of my getting anthrax? (What is the average risk of contracting anthrax in the United States?)
Can anthrax affect pregnancy? Should pregnant women exposed to anthrax take antibiotics?
Can anthrax be transmitted by handling money?
What is the risk for anthrax in employees of a facility with a positive environmental sample?
Anthrax and Influenza
Influenza (flu) and inhalation anthrax can have similar symptoms. Does CDC recommend that I get a flu shot to help diagnose anthrax?
Is there a way to distinguish between early inhalational anthrax and flu?
Is there a quick test that doctors can do to tell whether I have anthrax or an illness like the flu?
Safety Issues/Mail
How can mail get cross-contaminated with anthrax?
Can the presence of Bacillus anthracis spores be detected by a characteristic appearance, odor, or taste?
How long do anthrax spores live?
What is the importance of knowing the genetic information about anthrax?
Does the similarity in strains from Florida, New York, and Washington, D.C. mean that they came from the same source or are these just the most common strains?
When there is a known incident, how can I prevent anthrax exposure from cross- contaminated mail?
What kind of mail should be considered suspicious?
What should people do when they get a letter or package with powder?
What is the risk for getting anthrax from handling my own mail?
As a postal employee, am I at risk for getting anthrax from handling mail on the job when there is an anthrax cross-contaminated mail event?
When the possibility of cross-contamination of the mail exists, should I take antibiotics?
What should I do to protect my family and myself if a dangerous chemical agent were released in my community?
Should I purchase a gas mask as protection from any chemical agent release such as anthrax?
What kinds of anthrax worker safety guidelines have been issued?
Worker Safety
If these recommendations are followed does it mean workers will stop getting sick with anthrax?
Is CDC telling all mail handling operations to adopt these anthrax worker safety guidelines immediately?
What kinds of engineering controls should mail-handling/processing operations consider implementing for detecting anthrax spores?
What administrative controls should mail-handling/processing sites consider implementing to protect workers from exposure to B. anthracis spores?
What housekeeping controls in mail-handling/processing sites are recommended to protect workers from exposure to B. anthracis spores?
What personal protective equipment for workers in mail-handling/processing sites is recommended to protect workers from exposure to B. anthracis spores?
What are some examples of personal protective equipment and clothing that could be used to protect workers who handle mail from exposure to B. anthracis spores?
Are there some areas in the postal setting that present a greater risk to some workers than others for anthrax exposure?
How can I recognize suspicious packages that have anthrax?
What can the consumer buy to protect against germ or chemical warfare such as anthrax?
What should be done with clothing contaminated with anthrax? Is washing in a regular home washer and dryer ok? Does CDC recommend adding bleach to the wash?
Are other solutions used at hospitals for cleaning blood spills also effective against anthrax?
What actions need to be taken if a facility is found to have an environmental sample positive for anthrax?
Reporting
If tests confirm that I was potentially exposed to Bacillus anthracis or have anthrax, how will it be reported to the proper authorities?
How should healthcare workers respond to suspected exposure to a bioterrorist agent? Who should healthcare workers call first, second, third? CDC, FBI, local police, local health department?
v Anthrax as a Biological Weapon
Introduction
History of Current Threat
Epidemiology
Microbiology
Figure 1. Gram Stain of Bacillus anthracis
Pathogenesis and Clinical Manifestations
Inhalational Anthrax
Figure 2. Chest radiograph of a patient with inhalational anthrax.
Figure 3. Cutaneous Anthrax
Cutaneous Anthrax
Gastrointestinal Anthrax
Diagnosis 96
Table 1. Diagnosis of Inhalational Infection
Vaccination
Therapy
Table 2. Working Group Recommendations for Medical Therapy for Patients With Clinically Evident Inhalational Anthrax Infection in the Contained Casualty Setting
Table 3. Working Group Recommendations for Medical Therapy for Patients With Clinically Evident Anthrax Infection in the Mass Casualty Setting or for Postexposure Prophylaxis
Postexposure Prophylaxis
Management of Special Groups
Children
Pregnant Women
Immunosuppressed Persons
Infection Control
Decontamination
Figure 4. Day of Onset of Inhalation Anthrax Following Sverdlovsk Accident
Additional Research
Author Information
Acknowledgment
References
v Update: Investigation of Bioterrorism-Related Anthrax and Interim Guidelines for Exposure Management and Antimicrobial Therapy, October 2001
Florida
New York
New Jersey
District of Columbia
Susceptibility Testing of B. anthracis Isolates
Managing Threats
Box 1. Handling of Suspicious Packages or Envelopes
Managing Exposures
Antimicrobial Treatment
Table 1. Inhalational anthrax treatment protocol for cases associated with this bioterrorism attack
References
v Children and Anthrax: A Fact Sheet for Clinicians
Vaccination
Prophylaxis
Drug Recommendations For Pediatric Anthrax Cases
v Anthrax Technical Information
v Fact Sheet: Anthrax Information for Health Care Providers
v Drug Therapy
Patient Information: Ciprofloxacin 500 MG Oral Tablet
Patient Information: Doxycycline 100 MG Oral Tablet
Patient Information: Penicillin VK 500 MG Oral Tablet
Patient Information: Amoxicillin 250 MG – Oral Capsules Or Amoxicillin 250 MG/5 ML– Oral Suspension
v Clinical Issues in the Prophylaxis, Diagnosis, and Treatment of Anthrax
Prophylaxis
Clinical Recognition and Diagnosis
Inhalational Anthrax
Cutaneous Anthrax
Treatment
References
v Additional Options for Preventive Treatment For Those Exposed to Inhalational Anthrax
Background
Options
8. Smallpox
v Smallpox Overview
The Disease
Where Smallpox Comes From
Transmission
v Smallpox Disease
Rash distribution
v Smallpox Questions and Answers: The Disease and the Vaccine
In General
What should I know about smallpox?
How serious is the smallpox threat?
How dangerous is the smallpox threat?
If I am concerned about a smallpox attack, can I go to my doctor and get the smallpox vaccine?
The Disease
What are the symptoms of smallpox?
If someone comes in contact with smallpox, how long does it take to show symptoms?
Is smallpox fatal?
How is smallpox spread?
If smallpox is released in aerosol form, how long does the virus survive?
How many people would have to get smallpox before it is considered an outbreak?
Is smallpox contagious before the smallpox symptoms show?
Is there any treatment for smallpox?
The Vaccine
What is the smallpox vaccine, and is it still required?
Should I get vaccinated against smallpox?
How is the vaccine given?
Many vaccinations are required. Why don’t people have to get the smallpox vaccine?
If someone is exposed to smallpox, is it too late to get a vaccination?
How long does a smallpox vaccination last?
Are diluted doses of smallpox vaccine as effective?
Vaccinia
What is the smallpox vaccine made of?
Is it possible for people to get smallpox from the vaccination?
Is it possible to get vaccinia, the virus in the vaccine, from someone who has recently been vaccinated?
After Vaccination: What You Should Know
After Vaccination: Taking Care
Reactions After Vaccination
Vaccine Safety
How safe is the smallpox vaccine?
Who should NOT get the vaccine?
Should you get the smallpox vaccine if you have a weakened immune system (e.g., you are immunocompromised)?
Pregnant women are discouraged from getting the vaccine. Is there a danger to them (or to an unborn child) if broader vaccination occurs, increasing the potential for contact with vaccinated people?
Why has CDC advised that people with known cardiac disease not receive the smallpox vaccine?
What is CDC doing to respond to reports of cardiac-related events?
Is there any way to treat bad reactions to the vaccine?
Is a child under the age of 1 year in the household a contraindication to vaccination?
Are there any eye conditions that would preclude vaccination?
9. Botulism
v Facts About Botulism
v Botulism–Technical Information
v Frequently Asked Questions
What is botulism?
What kind of germ is Clostridium botulinum?
How common is botulism?
What are the symptoms of botulism?
How is botulism diagnosed?
How can botulism be treated?
Are there complications from botulism?
How can botulism be prevented?
What are public health agencies doing to prevent or control botulism?
v Botulism in the United States
Introduction
Foodborne Botulism
A. Incidence
B. Mortality
Figure 1. Outbreaks of foodborne botulism by state, 1950-1996
C. Geographic distribution
D. Food sources and products causing outbreaks
E. Prevention and control
Infant Botulism
A. Epidemiology
B. Source of C. botulinum
C. Prevention and control
Wound Botulism
Child or Adult Botulism From Intestinal Colonization
Clinical Syndrome
Diagnosis
Treatment
Public Health Response
References
v Botulinum Toxin as a Biological Weapon–Medical and Public Health Management
Introduction
History of Current Threat
Microbiology and Virulence Factors
Figure 1. Mechanism of Action of Botulinum Toxin
Pathogenesis and Clinical Manifestations
Figure 2. Seventeen-year-old patient with mild botulism
Epidemiology
Table 1. Symptoms and Signs of Foodborne Botulism, Types A and B
Table 2. Symptoms and Signs of Inhalational Botulism in Order of Onset
Incubation Period
Age and Sex
Agent and Vehicles
Figure 3. Fifty-nine cases of botulism, by interval between eating at a restaurant and onset of first neurologic symptoms
Incidence and Outbreak Size
Toxin Types
Distribution
Bioterrorism Considerations
Box 1. Features of an Outbreak That Would Suggest a Deliberate Release of Botulism Toxin
Diagnosis and Differential Diagnosis
Box 2. Clinicians Caring for Patients With Suspected Botulism Should Immediately Contact Their:
Differential Diagnosis
Diagnostic Testing
Table 3. Selected Mimics and Misdiagnoses of Botulism
Therapy
Figure 4. Preferred Positioning of Nonventilated Botulism Patients
Special Populations
Prophylaxis
Decontamination
Infection Control
Research Needs
Author Information
REFERENCES
10.Plague
v Facts About Plague
v Frequently Asked Questions (FAQ) About Plague
What is plague?
Why are we concerned about pneumonic plague as a bioweapon?
How is plague transmitted?
What is the basic transmission cycle?
What is the incubation period for plague?
What is the mortality rate of plague?
How many cases of plague occur in the U.S.?
Is pneumonic plague different from bubonic plague?
What are the signs and symptoms of pneumonic plague?
How do people become infected with pneumonic plague?
Does plague occur naturally?
Can a person exposed to pneumonic plague avoid becoming sick?
How quickly would someone get sick if exposed to plague bacteria through the air?
Can pneumonic plague be treated?
Would enough medication be available in the event of a bioterrorism attack involving pneumonic plague?
What should someone do if they suspect they or others have been exposed to plague?
How can someone reduce the risk of getting pneumonic plague from another person or giving it to someone else?
How is plague diagnosed?
How long can plague bacteria exist in the environment?
Is a vaccine available to prevent pneumonic plague?
How Can People Get More Information About Pneumonic Plague?
v Introduction
v History
The First Pandemic
The Black Death (The Second Pandemic)
The Third Pandemic
v Plague as a Biological Warfare Agent
World War II
Since World War II
Figure 1. The oriental rat flea
v Epidemiology
Figure 2. Known mammalian reservoirs of plague in the United States (noninclusive)
Exhibit 1: Mammals Known to Harbor Plague in the United States.
v Clinical Manifestations
Bubonic Plague
Septicemic Plague
Figure 3. A femoral bubo
Figure 4. Purpuric lesions can be seen on the upper chest of this girl with plague
Figure 7. This child has left axillary bubonic plague.
Figure 5. This patient is recovering from bubonic plague that disseminated to the blood (septicemic form) and the lungs (pneumonic form)
Figure 6. This chest roentgenogram shows right middle and lower-lobe involvement in a patient with pneumonic plague.
Figure 7. This child has left axillar bubonic plague
Pneumonic Plague
Plague Meningitis
Pharyngeal Plague
Cutaneous Manifestations
v Diagnosis
Signs and Symptoms
Laboratory Confirmation
Figure 9. (a) Small femoral bubo and presumed inoculation site (on the inferior thigh) in a patient with tularemia.
Figure 10. These Yersinia pestis fluorescent cells are from infected mouse spleen
v Treatment
Isolation
Antibiotics
v Prevention
Postexposure Prophylaxis
Immunization
v Summary
References
11.Tularemia
v Facts about Tularemia
v Frequently Asked Questions (FAQ) About Tularemia
What is tularemia?
How do people become infected with the tularemia bacteria?
Does tularemia occur naturally in the United States?
Why are we concerned about tularemia as a bioweapon?
Can someone become infected with the tularemia bacteria from another person?
How quickly would someone become sick if they were exposed to the tularemia bacteria?
What are the signs and symptoms of tularemia?
What should someone do if they suspect they or others have been exposed to the tularemia bacteria?
How is tularemia diagnosed?
Can tularemia be effectively treated with antibiotics?
How long can Francisella tularensis exist in the environment?
Is there a vaccine available for tularemia?
v Tularemia as a Biological Weapon–Medical and Public Health Management
v Introduction
v History and Potential Biological Weapon
v Epidemiology
Geographic Distribution and Human Exposures
Incidence
Natural Occurrences of Inhalational Tularemia
Inhalational Tularemia Following Use as a Biological Weapon
Table 1. Diagnosis of Inhalational Tularemia Following Use of a Biological Weapon
v Micribiology and Virulence Factors
v Pathogenesis and Clinical Manifestations
Pathogenesis
Clinical Manifestations
Figure 1. Cervical lymphadenitis in a patient with pharyngeal tularemia
Figure 2. Chest radiograph of a patient with pulmonary tularemia
v Diagnosis
Figure 3. Gram stain smears of the agents of anthrax (bacillus anthracis), plague (yersinia pestis), and tularemia (francisella tularensis), demonstrating comparative morphology, size, and staining characteristics.
Box. Clinicians Caring for Patients With Suspected Tularemia Should Immediately Contact Their:
Figure 4. Francisella tularensis growth at 72 hours after inoculation.
v Vaccination
Treatment
Contained Casualty Situation
Mass Casualty Situation
Management of Special Groups
v Post-Exposure Antibiotic Recommendations
Table 2. Working Group Consensus Recommendations for Treatment of Patients With Tularemia in a Contained Casualty Setting*
Table 3. Working Group Consensus Recommendations for Treatment of Patients With Tularemia in a Mass Casualty Setting and for Postexposure Prophylaxis*
v Infection Control
v Environmental Decontamination and Protection
Additional Research
Author Information
Additional Articles
Author Affiliations
References
12. Viral Hemorrhagic Fevers
What are viral hemorrhagic fevers?
How are hemorrhagic fever viruses grouped?
What carries viruses that cause viral hemorrhagic fevers?
Where are cases of viral hemorrhagic fever found?
How are hemorrhagic fever viruses transmitted?
What are the symptoms of viral hemorrhagic fever illnesses?
How are patients with viral hemorrhagic fever treated?
How can cases of viral hemorrhagic fever be prevented and controlled?
What needs to be done to address the threat of viral hemorrhagic fevers?
v Management of Patients with Suspected Viral Hemorrhagic Fever
Background
Recommendations
References
v Hemorrhagic Fever Viruses as Biological Weapons
Introduction
Table 1. Hemorrhagic Fever Viruses
Consensus Methods
History and Potential as Biological Weapons
Epidemiology of Disease Transmission
Filoviridae: Ebola and Marburg
Arenaviridae: Lassa Fever and New World Arenaviruses
Bunyaviridae: Rift Valley Fever
Flaviviridae: Yellow Fever, Omsk Hemorrhagic Fever, and Kyasanur Forest Disease
Microbiology and Pathogenesis
Table 2. Microbiology of Hemorrhagic Fever Viruses
Clinical Manifestations
Figure 1. Maculopapular Rash in Marburg Disease
Table 3. Clinical Characteristics of Hemorrhagic Fever Viruses Noted in Past Case Outbreaks
Figure 2. Erythematous Rash in Bolivian Hemorrhagic Fever
Figure 3. Ocular Manifestations in Bolivian Hemorrhagic Fever
Diagnosis
Box 1. Key Medical and Public Health Interventions After Identification of Suspected Index Case of VHF
Treatment
Drug Therapy
Table 4. Recommendations for Ribavirin Therapy in Patients With Clinically Viral Hemorrhagic Fever of Unknown Etiology or Secondary to Arenaviruses or Bunyaviruses
Passive Immunization
Postexposure Prophylaxis
Vaccine
Infection Control
Isolation Precautions
Box 2. Recommendations for Protective Measures Against Nosocomial Transmission of Hemorrhagic Fever Viruses
Personal Protective Equipment
Laboratory Testing
Postmortem Practices
Environmental Decontamination
Ongoing Research and Proposed Agenda
Author Affiliations
References
13. Ricin
v Frequently Asked Questions (FAQs) About Ricin
What is ricin?
Where is ricin found, and how is it used?
How can people be exposed to ricin?
How does ricin work?
What are the signs and symptoms of ricin exposure?
How is ricin poisoning treated?
How do we know for sure whether people have been exposed to ricin?
What can people do if they think they may have been exposed to ricin?
How can people get more information about ricin?
v Biotoxin Ricin
14. Nerve Agents
v Tox FAQs™ for Nerve Agents (GA, GB, GD, VX)
What are nerve agents GA, GB, GD, and VX?
What happens to nerve agents GA, GB, GD, and VX when they enter the environment?
How might I be exposed to nerve agents GA, GB, GD, and VX?
How can nerve agents GA, GB, GD, and VX affect my health?
How likely are nerve agents GA, GB, GD, and VX to cause cancer?
How can nerve agents GA, GB, GD, and VX affect children?
How can families reduce the risk of exposure to nerve agents GA, GB, GD and VX?
Is there a medical test to show whether I’ve been exposed to nerve agents GA, GB, GD, and VX?
Has the federal government made recommendations to protect human health?
Where can I get more information?
v Facts About VX
What VX is
Where VX is found and how it is used
How people can be exposed to VX
How VX works
Immediate signs and symptoms of VX exposure
The long-term health effects are
How people can protect themselves, and what they should do if they are exposed to VX
How VX exposure is treated
How can people get more information about VX
v Technical Information About Nerve Agents
v Nerve Agent VX
v Health Effects
v Prehospital Management
Table 2. Triage for Nerve Agent Casualties
Table 3. Recommendations for Nerve Agent Therapy Antidotes–Prehospital Management
v Emergency Department Management
Table 4. Recommendations for Nerve Agent Therapy–Emergency Department Management.
Nerve Agents Patient Information Sheet
What are nerve agents?
What immediate health effects can result from exposure to nerve agents?
Can nerve agent poisoning be treated?
Are any future health effects likely to occur?
What tests can be done if a person has been exposed to nerve agents?
Where can more information about nerve agents be found?
Follow-up Instructions
15. Blister Agents
v Blister Agents
Table 1. Physical Properties of Sulfur Mustards
v Health Effects
Table 2. Clinical Effects and Time of Onset by Severity of Exposure to Sulfur Mustard
v Prehospital Management
Table 3. Triage for Mustard Agent Casualties
v Emergency Department Management
v General Medical Management
v Blister Agents Sulfur Mustard (H, HD, and HT)–Patient Information Sheet
What are sulfur mustards?
What immediate health effects can result from exposure to sulfur mustards?
Can sulfur mustard poisoning be treated?
Are any future health effects likely to occur?
What tests can be done if a person has been exposed to sulfur mustards?
Where can more information about sulfur mustards be found?
Follow-up Instructions
v Blister Agent Mustard
16. Foodborne Illness
What is foodborne disease?
What are the most common foodborne diseases?
Are the types of foodborne diseases changing?
What happens in the body after the microbes that produce illness are swallowed?
How are foodborne diseases diagnosed?
How are foodborne diseases treated?
When should I consult my doctor about a diarrheal illness?
How many cases of foodborne disease are there in the United States?
How do public health departments track foodborne diseases?
What are foodborne disease outbreaks and why do they occur?
Why do public health officials investigate outbreaks?
How are outbreaks of foodborne disease detected?
How is a foodborne disease outbreak investigated?
How does food become contaminated?
What foods are most associated with foodborne illness?
What can consumers do to protect themselves from foodborne illness?
Are some people more likely to contract a foodborne illness? If so, are there special precautions they should take?
What can consumers do when they eat in restaurants?
There is only so much the consumer can do. How can food be made safer in the first place?
What is CDC doing to control and prevent foodborne disease?
What are some unsolved problems in foodborne disease?
v Frequently Asked Consumer Questions About Food Safety and Terrorism
What is the Food and Drug Administration (FDA) doing to protect the food supply against terrorism?
Does FDA cooperate with industry in the defense against food terrorism?
Is anything being done to intensify the FDA surveillance of food imports and food production?
What can consumers do to protect themselves and their families from food tampering or other kinds of food contamination?
What should consumers do if they suspect a food product has been contaminated or tampered with?
Should consumers take antibiotics for protection against contaminated food?
What food handling practices should consumers follow on a day- to-day basis to help prevent foodborne illness?
Where can I get more information about food safety?
FDA’s Consumer Complaint Coordinators
Where can I learn more about food safety and foodborne diseases?
17. Escherichia coli O157:H7
v Frequently Asked Questions
What is Escherichia coli O157:H7?
How is E. coli O157:H7 spread?
What illness does E. coli O157 :H7 cause?
How is E. coli O157:H7 infection diagnosed?
How is the illness treated?
What are the long-term consequences of infection?
What can be done to prevent the infection?
What can you do to prevent E. coli O157:H7 infection?
v Technical Information
18. Salmonellosis
v Frequently Asked Questions
What is salmonellosis?
What sort of germ is Salmonella?
How can Salmonella infections be diagnosed?
How can Salmonella infections be treated?
Are there long-term consequences to a Salmonella infection?
How do people catch Salmonella?
What can a person do to prevent this illness?
How common is salmonellosis?
What else can be done to prevent salmonellosis?
What is the government doing about salmonellosis?
How can I learn more about this and other public health problems?
What can I do to prevent salmonellosis?
v Technical Information
19. Cholera
v Frequently Asked Questions
What is cholera?
How does a person get cholera?
What is the risk for cholera in the United States?
What should travelers do to avoid getting cholera?
Is a vaccine available to prevent cholera?
Can cholera be treated?
How long will the current epidemic last?
What is the U.S. government doing to combat cholera?
Where can a traveler get information about cholera?
v Technical Information
20. Shigellosis
v Frequently Asked Questions
What is shigellosis?
What sort of germ is Shigella?
How can Shigella infections be diagnosed?
How can Shigella infections be treated?
Are there long-term consequences to a Shigella infection?
How do people catch Shigella?
What can a person do to prevent this illness?
How common is shigellosis?
What else can be done to prevent shigellosis?
What is the government doing about shigellosis?
How can I learn more about this and other public health problems?
v Technical Information
21.Brucellosis
v Frequently Asked Questions
What is brucellosis?
How common is brucellosis?
Where is brucellosis usually found?
How is brucellosis transmitted to humans, and who is likely to become infected?
Can brucellosis be spread from person to person?
Is there a way to prevent infection?
My dog has been diagnosed with brucellosis. Is that a risk for me?
How is brucellosis diagnosed?
Is there a treatment for brucellosis?
I am a veterinarian, and I recently accidentally jabbed myself with the animal vaccine (RB-51 or B-19, or REV-1) while I was vaccinating cows (or sheep, goats). What do I need to do?
v Technical Information
22. Typhoid Fever
v Frequently Asked Questions
How is typhoid fever spread?
Where in the world do you get typhoid fever?
How can you avoid typhoid fever?
What are the signs and symptoms of typhoid fever?
What do you do if you think you have typhoid fever?
v Technical Information
23. Radiological Emergencies
v CDC’s Roles in the Event of a Radiological Terrorist Event
Lead Federal Agencies
CDC’s Roles
CDC’s Partners
CDC’s Actions
Radiation Exposure Registry
24. Injuries and Mass Trauma Events
v Coping With a Traumatic Event–Information for the Public
What is a traumatic event?
Why do these injuries occur in mass trauma events?
What are some common responses?
What is PTSD?
What can you do for yourself?
What can you do for your child?
When should you contact your doctor or mental health professional?
v Coping With a Traumatic Event–Information for Health Professionals
How do you interact with patients after a traumatic event?
What can you do to help patients cope with a traumatic event?
Common Responses to a Traumatic Event
Who is at risk for severe and longer lasting reactions to trauma?
What can you do to treat patients in response to a traumatic event?
What can health departments do to prepare for a mass trauma event?
What can health departments do after a mass trauma event?
Resources for Help and Information
v Burns
Background Information
Escape Information
Safeguard Your Home
Hotel and Workplace Fire Safety
If You Are Trapped in a Burning Building
First Aid
Types of Burns
First-Degree Burns
Second-Degree Burns
Third-Degree Burns
References
v Brain Injuries and Mass Trauma Event–Information for the Public
What is a brain injury?
Why are brain injuries a problem in mass trauma events?
What are some common signs of a brain injury?
What can you do to get help?
v Brain Injuries and Mass Trauma Events–Information for Clinicians
Brain Injury Facts
Signs and Symptoms after an MTBI
Diagnosis
Treatment
Additional Resources for Clinicians
v Chemical Agents: Facts About Personal Cleaning and Disposal of Contaminated Clothing
How to know if you need to wash yourself and dispose of your clothing
What to do
How you can get more information about personal cleaning and disposal of contaminated clothing
25. Bioterrorism Readiness Plan: A Template for Healthcare Facilities
v Introduction
v Section I: General Categorical Recommendations for Any Suspected Bioterrorism Event
A. Reporting Requirements and Contact Information
B. Potential Agents
C. Detection of Outbreaks Caused by Agents of Bioterrorism
1. Syndrome-based criteria
2. Epidemiological features
D. Infection Control Practices for Patient Management
1. Isolation Precautions
2. Patient Placement
3. Patient Transport
4. Cleaning, Disinfection, and Sterilization of Equipment and Environment
5. Discharge management
6. Post- Mortem Care
E. Post-Exposure Management
1. Decontamination of Patients and Environment
2. Prophylaxis and Post-Exposure Immunization
3. Triage and Management of Large-Scale Exposures and Suspected Exposures
4. Psychological Aspects of Bioterrorism
F. Laboratory Support and Confirmation
Obtaining Diagnostic Samples
Laboratory Criteria For Processing Potential Bioterrorism Agents
Transport Requirements
G. Patient, Visitor, and Public Information
v Section II: Agent- Specific Recommendations
A. Anthrax
1. Description of Agent/Syndrome
2. Preventive Measures
3. Infection Control Practices for Patient Management
Table1. Recommended post-exposure prophylaxis for exposure to Bacillus anthracis
4. Post-Exposure Management
5. Laboratory Support and Confirmation
6. Patient, Visitor, and Public Information
B. Botulism
1. Description of Agent/Syndrome
2. Preventive Measures
3. Infection Control Practices for Patient Management
4. Post-Exposure Management
5. Laboratory Support and Confirmation
6. Patient, Visitor, and Public Information
C. Plague
1. Description of Agent/Syndrome
2. Preventive Measures
3. Infection Control Practices for Patient Management
4. Post-Exposure Management
Table 2. Recommended post-exposure prophylaxis for exposure to Yersimia pestis
5. Laboratory Support and Confirmation
6. Patient, Visitor, and Public Information
D. Smallpox
1. Description of Agent/ Syndrome
2. Preventive Measures
3. Infection Control Practices for Patient Management
4. Post-Exposure Management
5. Laboratory Support and Confirmation
6. Patient, Visitor, and Public Information
References
Telephone Directory of State and Territorial Public Health Directors
Websites Relevant to Bioterrorism Readiness
Other Sources of Information
26. Mass Casualty Disaster Plan Checklist: A Template for Healthcare Facilities