EDUCATIONEVIDENCE
EVIDENCEENGAGEMENT
BIOTERRORISM AGENTS
EDUCATIONEVIDENCE
ENGAGEMENTEDUCATION
AND BARRIER PROTECTION
A SELF STUDY GUIDERegistered Nurses
®
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noverviewAnsell Healthcare Products LLC has an ongoing commitment to the development of quality hand barrier products and services for the healthcare industry. This self-study, Clinical Reference Manual: Bioterrorism Agents and Barrier Protection is one in a series of continuing educational services provided by Ansell. This educational module examines the history and evolution of bioterrorism, including an extensive review of the six primary biological agents and their respective clinical presentations, as well as prevention strategies and infection control measures and appropriate barrier protection for each of the agents.
ProgrAm oBjectivesUpon completion of this educational activity, the learner should be able to:
1. Discuss the history of bioterrorism.2. Discuss the disease caused by Bacillus anthracis, Anthrax.3. Discuss the disease caused by Variola virus, Smallpox.4. Discuss the disease caused by Clostridium botulinum, Botulism.5. Discuss the disease caused by Francisella.6. Discuss the diseases referred to as Hemorrhagic Fever Viruses.7. Discuss the disease caused by Yersinia pestis, Plague.8: Describe the characteristics of good barrier protection for the different gloving materials available.
intended AudienceThe information contained in this self-study guidebook is intended for use by healthcare professionals who are responsible for or involved in the following activities related to this topic:
• Educatinghealthcareworkers• Establishinginstitutionalordepartmentalpoliciesandprocedures• Decision-makingresponsibilitiesforhand-barrierproducts• MaintainingregulatorycompliancewithagenciessuchasOSHA,ADAandCDC• Managingemployeehealthandinfectioncontrolservices
instructionsAnsell Healthcare is a provider approved by the california Board of registered nursing, Provider # ceP 15538 for 3 contact hour(s). obtaining full credit for this offering depends on completion of the self-study materials online as directed below.Thiscontinuingeducationactivityisapprovedfor3.75CEcreditsbytheAssociationofSurgicalTechnologists,Inc., for continuing education for the Certified Surgical Technologist and Certified Surgical First Assistant. This recognition does not imply that AST approves or endorses any product or products that are included in the presentation.
Approval refers to recognition of educational activities only and does not imply endorsement of any product or company displayed in any form during the educational activity.
To receive contact hours for this program, please go to the “Program Tests” area and complete the post-test. You will receive your certificate via email.
An 85% PAssing score is reQuired For successFuL comPLetion
Allow 4 to 6 weeks for processing and issuance of a certificate. Any learner who does not successfully Any learner who does not successfully complete the post-test will be notified and given an opportunity to resubmit for certification.
For more information about our educational programs or hand-barrier-related topics, please contact Ansell Healthcare EducationalServicesat1-732-3452162ore-mailusatedu@ansellhealthcare.com.
Planning Committee Members: Lori Jensen, RN PamelaWerner,RN,BSN,CNOR,MBA
The planning committee members declare that they have an affiliation and financial relationship as employees of Ansell Healthcare, which could be perceived as posing a potential conflict of interest with development of this self-study module. This module will include discussion of commercial products referenced in generic terms only.
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contents
What is Bioterrorism? ..............................................................................................1
HistoryandEvolutionofBioterrorism ......................................................................1
Bacillus anthracis, Anthrax ......................................................................................3
Variola virus, Smallpox ............................................................................................5
Clostridium botulinum, Botulism .............................................................................8
Hemorrhagic Fever Viruses ...................................................................................10
Francisella tularensis, Tularemia ...........................................................................13
Yersinia pestis, Plague .........................................................................................15
PersonalProtectiveEquipment ..............................................................................17
Post-Test ...............................................................................................................20
Bibliography ..........................................................................................................21
Notes ...............................................................................................................22–23
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1
wHAt is Bioterrorism?
Bioterrorism is defined as the deliberate
or threatened use of bacteria, viruses, or
toxins to cause disease, death, disruption,
or fear. The most likely large-scale attack of
bioterrorism is expected to be an aerosolized
agent. Any of the Category A diseases have
the potential to be aerosolized: anthrax,
smallpox, botulism, viral hemorrhagic
fevers, tularemia, and plague.
HistorY And evoLution oF Bioterrorism
KeY BioTerrorisT eVenTs • GenevaProtocolsignedtoprohibitresearch
and development of biological weapons.
• UnitedStatesoffensivebiologicalweaponsprogram dismantled.
• BiologicalandToxinWeaponsConvention signed.
Bioterrorism is not a new phenomenon
and has been used as a weapon for
centuries. In 700 BC, the Assyrians
poisoned the water wells of their enemies
with the poison rye ergot. In the 1300s,
during the siege of Kaffa (now in Ukraine),
the Tartars catapulted plague-infected
corpses over the walls of the city, which
probably led to the Black Death plague
epidemic that followed. It has been said
that during Pizarro’s conquest of South
America in the 1600s, he ensured his
victory by giving the natives “gifts” of
clothing that had been tainted with the
smallpox virus. In 1763, during the French
and Indian War and under the guise of
friendship, Native Americans were given
gifts of blankets that had been previously
used by patients that died of the smallpox
virus. In 1797, Napoleon attempted to
force the surrender of Mantua by infecting
the citizens with swamp fever. During
the Civil War, Confederate troops left
carcasses of dead animals, usually horses,
in the Union soldiers’ source of drinking
water. During World War II, allegations
weremadeagainsttheGermansfor
attempting to spread cholera in Italy and
plague in Leningrad, and use biological
bombs over Britain. Also, it was alleged
thattheGermansdeployedanthraxagainst
their enemies in both World Wars I and II.
Othersignificanteventsinthehistoryof
bioterrorism include:
1925:TheGenevaProtocolwassigned.This document prohibited research and development of biological weapons, although history has proven that offensive biological programs continued despite the treaty.
1940: Japanese dropped plague, by planes, at Ninpo.
1969: President Nixon dismantled the United States offensive biological weapons program, although research related to defense against biological weapons continues to this day.
1972: The Biological and Toxin Weapons Convention was signed and ratified by 140 nations. This agreement required termination of all offensive weapons research and destruction of existing stockpiles of agents.
Protection against Bioterrorism
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1978:InLondon,anallegedKGBagent assassinated a Bulgarian exile using ricin toxin.
1984: To alter the outcome of a local election, Rajneesh cult members sprayed salmonellaonsaladbarsinOregon,causing more than 700 people to become ill.
1995: A sarin nerve agent attack aimed at subway passengers in Tokyo.
2001: Letters laden with anthrax were mailed to media, news organizations, and politicians.
The threat of biologic weapons (BW) has
increased over the last two decades with a
number of countries working on offensive
weapons (USAMRIID). Biological weapons
have distinct advantages over traditional
weapons. First, they can attack a very
large area in a very short period of time
using aerosolized biological agents.
The detection of the biological release
would most likely be delayed since
these agents are odorless, colorless,
and tasteless. Unless the terrorists call
and announce the agent they released,
the public will not be aware until victims
become ill, which is usually days or weeks
later. Using biological agents as weapons
also has the advantage of a delayed
recognition in the medical community.
The diseases produced by biological
agents all present with very similar
symptoms in the beginning, usually
non-specific flu-like symptoms that
make early diagnosis difficult. Further,
many physicians have not seen these
diseases in their medical practice and
have only read about them in medical
textbooks. Another reason that the threat
of using biological agents as weapons has
increased is that biological weapons are
very inexpensive to create.
At a cost of $2000 or more for
conventional weapons, a $1 in biological
weapons could produce similar results.
(AORN2004)Whilenuclearweapons
production requires specific facilities,
anthrax can be germinated in a basement
laboratory. Also, the knowledge to produce
and disseminate these agents is easily
accessible through current technology,
such as the Internet. Furthermore, at
the end of the Cold War, many Russian
scientists working in offensive biological
programs lost their jobs. The whereabouts
of these Soviet scientists is an unknown
factor and the whereabouts of their
products is unclear.
Biological agents can be delivered in
several different ways, including orally
in food, and through water or air. Today,
most experts predict the most likely
method of biological attack would be a
large-scale attack using an aerosolized
agent that may or may not be contagious.
Which biological agents would pose the
greatest threat when used as a weapon?
Potentially, thousands of agents could be
used in a bioterrorism attack. However,
the Centers for Disease Control (CDC) and
the US Army Medical Research Institute of
Infectious Diseases (USAMRIID) narrowed
the list based on a number of criteria,
including how easy it is to obtain and
produce the agent, the agent’s stability in
the environment, and whether the agent
is contagious and/or lethal. Next, the CDC
grouped the agents into three categories
based on the likelihood of their use as a
biological weapon. The categories are A,
B, and C. The CDC identified the Category
A agents as high priority agents that pose
a risk to national security.
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Category A consists of six diseases:
anthrax, smallpox, botulism, viral
hemorrhagic fevers, tularemia, and
plague. This study guide will review
the six Category A diseases, providing
a description, clinical manifestations,
diagnosis, treatment, post-exposure
prophylaxis, and infection control,
including appropriate barrier protection.
Bacillus anthracis, AntHrAx
DeFiniTionAnthrax is caused by Bacillus anthracis,
a gram-positive spore-forming bacterium,
and is found in soil worldwide. Humans
contract the disease from close contact
with animals or animal products infected
withthebacteria.Ofthethreeroutesof
exposure – inhalation, cutaneous, and
gastrointestinal – inhalational anthrax
is the one that is of greatest concern as
a bioweapon. (USAMRIID 2005) Inhaled
spores typically germinate 1-6 days but
there have been reports of illness up to 6
weeks after exposure in the mediastinal
lymph nodes; therefore, the time period
between exposure and onset of symptoms
may be as long as several weeks.
There are three forms of anthrax:
Cutaneous Most common natural form. Mortality of 10% to 20% if untreated; less than 1% when treated.
Inhalation Most lethal form, with mortality of 45% to 87% following inhalation of spores. Inhalation anthrax may be complicated by hemorrhagic meningitis in 50% of cases andGIhemorrhagein80%ofcases. Most likely form of the disease to occur in a bioterrorist event.
Gastrointestinal Results from the ingestion of large numbers of vegetative bacilli from poorly cooked infected meat. Due to difficulty in early diagnosis, mortality is high.
ANTHRAX INCUB A TIO N PERIOD
EARLY SIGNS/SYMPTOMS
LATER SIGNS/SYMPTOMS
Inhalational (primary involvement is the mediastinum)
Cutaneous
Gastrointestinal 1-6 days.
1-6 up to 40 days.
1-2 days.
Non-specific febrile syndrome including fever, malaise, headache, fatigue and drenching sweats.
Small papular or vesicular rash that may be pruritic.
Fever, focal abdominal pain, vomiting.
Hematemisis.
Same as above.
Abrupt development of severe respiratory distress with dyspnea, stridor, cyanosis, septicemia, shock and death.
CliniCAl mAniFesTATions oF THe THree Forms oF AnTHrAx
Scanning electron micrograph (SEM) of bacillus anthracis in lung tissue
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DiAGnosisRapid field tests results have
uncertain sensitivity and specificity
for inhalation anthrax, but a widened
mediastinum with or without infiltrates
on chest x-ray is highly suggestive in
a young or otherwise healthy person
with the typical presentation. Bloody
pleural effusions are also common.
Basic diagnostic testing should include
gram stain and culture of blood, which
can be obtained following your facility’s
standard routine. Confirmatory tests
must be performed by special reference
laboratory in the Laboratory Response
Network (LRN) (JAMA 2002). The state
laboratory needs to be notified ahead of
time that anthrax is a possibility. The local
health department will investigate and
give directions on how to obtain and send
the cultures. B. anthracis can be cultured
from the lesion for laboratory confirmation
in the cutaneous form. The local health
department will need to be notified and
provide directions to obtain and send
these cultures.
TreATmenTTreatment consists of hospitalization, intravenous antibiotics, and intensive supportive care. Antibiotic treatment should be administered as soon as the diagnosis issuspected.Earlyinitiationcanreducemortality, which approaches 100% when treatment is delayed.
PosT-exPosUre ProPHYlAxisAntibiotics should be administered to all persons that have been exposed or potentially exposed to the release of anthrax before symptoms have occurred. Patient contacts (family, friends, and healthcare workers) who were not originally exposed to the release do not require prophylaxis.
VACCinATion The Department of Defense (DoD) and the Department of Health and Human Services have purchased a stockpile of vaccine doses. Vaccination is currently required for most military deployed to Iraq, Afghanistan and S. Korea. It is not currently being used on the general public. Researchers continue to develop and test new Anthrax vaccine(s) (USAMRIID 2005).
inFeCTion ConTrolAll precautions are utilized to decrease the spread of recognized and unrecognized infection and to prevent exposure to all bodily fluids.
Standard Precautions – Is recommended for all forms of B. Anthrax1. Handwashing
Wash hands immediately after gloves areremoved, between patient contacts, andwhen otherwise indicated to avoid transferof microorganisms to other patients orenvironments. Hand wash with soap and wateror2%CHGaftersporecontact.(Weber2003)
Anthrax lesion on the skin caused by the bacterium Bacillus anthracis
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2. GlovesWear gloves when touching blood,bodily fluids, secretions, excretions, andcontaminated items; put on clean gloves justbefore touching mucous membranes andnonintact skin.
Change gloves between tasks andprocedures on the same patient aftercontact with material that may contain ahigh concentration of microorganisms.
Remove gloves promptly after use, beforetouching noncontaminated items andenvironmental surfaces, and before goingto another patient. Wash hands immediatelyto avoid transfer of microorganisms to otherpatients or environments.
3. Masks, Eye Protection, Face ShieldsWear a standard surgical mask and eyeprotection or a face shield to protect mucousmembranes of the eyes, nose, and mouthduring procedures and activities that arelikely to generate splashes or sprays.
Transmission Based PrecautionsSeveral sources recommend contact precautions for cutaneous anthrax for persons with draining lesions.
Contact Precautions• Placepatientinaprivateroom.
• Glovesshouldbewornwhenenteringthe room and removed before leaving theroom. Hands should be washed with anantimicrobial agent or soap and water withspore contact.
• Gownsshouldbewornwhenenteringtheroom if it is anticipated that clothing willhave contact with the patient, environmentalsurfaces, or items in the room. The gownshould be removed before leaving thepatient’s room.
• Patienttransportshouldbelimitedtoessential purposes only.
• Noncriticalpatient-careequipmentshouldbededicated whenever possible.
Variola Virus, smALLPoxDeFiniTionSmallpox is the most devastating infectious disease in the history of mankind. This “ancient scourge” threatened 60% of the world population even in 1967 when World Health Organization(WHO)launchedan intensified plan to eradicate smallpox. (AORN2004)Thevariolavirusthatemerged in human populations dates back to the 12th Century BC.
Literature dating from approximately 3700BCinEgyptand1100BCinChinasuggests that the original sources of smallpox were in Asia and Africa. There is evidence that a major smallpox epidemic occurred at the end of the eighteenth Egyptiandynasty.Researchfromthemummy of Pharaoh Ramses V, who died in 1157 BC, indicates that he most likely diedofsmallpox.FromancientEgypt,traders spread the disease to India, and thentoEuropeduringtheMiddleAges.
Spanish colonists brought smallpox to the United States in the fifteenth and sixteenth centuries. After an extensive andsuccessfuleradicationprogram,WHO declaredEndemicsmallpoxeradicatedin 1980. There was a suspected report of smallpox in NYC in 2002, (cnn.com) Successful efforts to prevent the spread of smallpox through vaccination changed the course of history of Western medicine. Most people think that since smallpox was eradicated, it is no longer a threat.
Gloves should be worn as standard procedure when handling contaminated items
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However, when smallpox was eradicated, two samples were maintained for research purposes. These samples were kept at the CDC and in a research facility in Russia.
The potential for secret stockpiles to exist outside these facilities continues to be an unknown factor. In the aftermath oftheeventsofSeptemberandOctober2001, there is heightened concern that the variola virus might be used as a bioterrorism agent. (USAMRIID)
Variola Major Is a severe and more common form of smallpox, with a more extensive rash and higher fever. The fatality rate is around 30%. There are four types of variola major smallpox:
1. Ordinary:themostfrequentform,accounting for 90% of all cases.
2. Modified: a mild form occurring in personspreviously vaccinated for smallpox.
3. Malignant/ Flat: Characterized by lesionsthat do not develop to the pustular stage.
4. Hemorrhagic: a very rare and veryfatal form.
Variola Minor This is a much less severe and less common form of smallpox, with death rates of 1% or less.
CliniCAl mAniFesTATionsoF smAllPox
Exposuretothevirusisfollowedbyan
incubation period during which people
do not have any symptoms, may feel fine
and do not shed the virus. The incubation
period averages about 12 to 14 days,
with a range from 7 to 17 days. During
this time people are not contagious
and cannot spread the virus to others.
Typically, a two-stage illness will follow.
First is the Prodrome stage, lasting from
2 to 4 days. During this stage, the person
will present with “flu-like” symptoms
including fever, malaise, head and body
aches, and sometimes vomiting. The fever
is usually high, in the range of 101° to
104° Fahrenheit. During this stage the
person may be contagious. Two to three
days later the affected person moves to
the eruptive stage. The smallpox rash is
very characteristic. The rash emerges
first as small red spots on the tongue and
in the mouth. These spots develop into
sores that break open and spread large
amounts of the virus into the mouth and
throat. At this time, a rash will also appear
on the skin starting on the face hands and
forearms. The rash will usually spread
to all parts of the body within 24 hours.
The fever usually breaks as the skin rash
appears and the patient may feel better.
Around the third day of the skin rash, the
rash becomes raised bumps. By the fourth
day, the bumps fill with thick, opaque fluid
and have a depression in the center that
looks like a belly button (this is a major
distinguishing characteristic of smallpox).
Transmission electron micrograph (TEM) of the smallpox virus
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Fever will rise again and stay high until scabs form over the bumps. The bumps will become pustules that are raised, round, and firm to the touch. The pustules then begin to form a crust and then scab over. The pustules and scab portion takes approximately 5 days, and the person remains very contagious during this time. At this time the scabs begin to fall off, leaving pitted scars. This takes another 6 to 7 days, and the person remains contagious. About 3 weeks after the rash first appeared, the scabs fall off and the person is no longer contagious.
TrAnsmissionPerson-to-person transmission of smallpox occurs through aerosol droplets expelled from the oropharynx of infected persons, or by direct contact with an infected person. It is the highest after face-to-face contact with a patient after developing fever and during the first week of the rash. The virus can also be spread through contaminated bedding and clothing, and through direct contact with infected bodily fluids. It is not known to be transmitted by insects or animals.
DiAGnosisSmallpox is most frequently misdiagnosed as varicella, or chickenpox, which is caused by the herpes virus. The most effective criteria for distinguishing the two infections is an examination of the following characteristics of the lesions:
Time and Pattern of Appearance The most obvious distinction between smallpox and chickenpox is the manner in which the skin lesions appear. In chickenpox, the lesions occur in successive “crops.” It is possible to determine several different stages of lesion maturation and development at the same time. In smallpox, the lesions appear simultaneously. All lesions have the same maturation.
Density and Location Chickenpox lesions tend to be denser over the trunk, while smallpox lesions are denser on the face and extremities. Smallpox is almost always seen on the palms and soles of the feet, which is unusual for chickenpox.
Smallpox can be confirmed in the laboratory by electron microscopic examination of vesicular or pustule liquid or scabs. Definitive laboratory identification and characterization involves growth of the virus in the cell culture, and characterization of strains by use of biologic assays, including polymerase chain reaction, restriction fragment-length polymorphismanalysis,andEnzyme-LinkedImmunoabsorbentAssay(ELISA).Culture for smallpox is available only at the LRN National Labs, at the CDC and USAMRIID and are performed under BLS-4 conditions. Notification of the local and state health departments is necessary.
The eruptive stage of smallpox
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TreATmenTCurrently, there are no known effective antivirals. Provide the patient supportive care and antibiotics for secondary infections. The discovery of a single suspected case of smallpox must be treated as an international health emergency and immediately brought to the attention of national officials through local and state health authorities.
PosT-exPosUre ProPHYlAxis
All contacts must be vaccinated within 3 to 5 days. Contacts include all household members, patients, staff, and visitors to the hospital at the same time as the smallpox case.7 Monitor all patient contacts for 17 days, and if one of the contacts starts showing signs of a fever, they should be isolated as soon as possible. Patients become infectious the day before the rash, so conduct a thorough history of all contacts the day before they broke out, and monitor all of those contacts.
inFeCTion ConTrol
Patient(s) should be isolated and all precautions used until all scabs separate.
Standard Precautions
1. Handwashing
Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments.
2. Gloves Wear gloves when touching blood, bodily fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin.
Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching
noncontaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.
3. Masks, Eye Protection, Face Shields
Wear a standard surgical mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and activities that are likely to generate splashes or sprays.
Transmission Based PrecautionsAirborne Precautions • Placepatientinasingleoccupancy,Airborne
Infection Isolation Room (AIIR) (formally – Negative Pressure Isolation Room)
• For mass exposure contain those exposed in a designated area and utilize barrier precautions.
• Useexternalairexhaustorhighefficiencyparticulate air filters if the air is recirculated.(CDC 2007)
Contact Precautions• Placepatientinaprivateroom.
• Glovesshouldbewornwhenenteringthe room and removed before leaving the room. Hands should be washed with an antimicrobial agent or a waterless handwashing agent immediately after removing gloves.
• Gownsshouldbewornwhenenteringtheroom if it is anticipated that clothing will have contact with the patient, environmental surfaces, or items in the room. The gown should be removed before leaving the patient’s room.
• Patienttransportshouldbelimitedtoessential purposes only.
• Noncriticalpatient-careequipmentshouldbe dedicated whenever possible.
clostridium Botulinum, BotuLismDeFiniTionBotulism is a rare but serious paralytic illness caused by a nerve toxin produced by the bacterium Clostridium botulinum,
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the most potent neuro toxin known to humans. There are seven (7) neurotoxins produced by this spore-forming bacillus. Thetoxins,AthroughG,arethemostpotent neurotoxins known. There are three (3) main types of botulism that effecthumans: foodborne, infant and wound.In the US an average of 145 cases a yearare reported:
• Foodborne-15%• Infantbotulism-65%• Wound-20%(CDCposted2009)
It is possible that the aerosolized form of botulism could be used as a biological weapon. The paralytic symptoms would appear after inhalation or the contamination of food or water supplies. (USAMRIID)
The clinical manifestations are similar for each of the botulism routes and are dependent on the route of exposure and dose received.
DiAGnosisThe patient’s clinical history and physical examination can be an indicator of botulism, patient(s) seeking medical services that exhibit progressive symmetrical descending flaccid paralysis strongly suggests botulism. The most sensitive testing for botulism is mouse neutralization (bioassay) of the patient serum.
TreATmenTTreatment consists of mechanical ventilation support if necessary and supportive care. Respiratory failure due to paralysis is the most serious concern and is usually the cause of death. Antitoxin is available, and is particularly effective infoodbornecases.Earlyadministrationof antitoxin can neutralize the circulating toxins in the body. This can prevent patients from worsening, but recovery still takes many weeks.
ProPHYlAxis A toxiod of C. Botulism for types A, B, C, D&EisavailableunderInvestigationalNew Drug (IND) therapy only. The vaccine has several contraindications due to hypersensitivities inherent in its production.
BOTULISM INCUB A TIO N PERIOD
EARLY SIGNS/SYMPTOMS
LATER SIGNS/SYMPTOMS
Botulism (all forms) 12-36 hours, longer if exposed to low doses of toxin
Generally no fever. Symmetric cranial neuropathies, such as drooping eyelids, difficulty swallowing or speaking. Mental status generally alert.
Sensory exam generally normal.
Blurred vision.
Symmetric descending weakness — generalized weakness and progressive to respiratory failure
CliniCAl mAniFesTATions oF BoTUlism
Botulism bacteria, 80x on 35mm film
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inFeCTion ConTrolStandard precautions are adequate for
HCW as B. Toxin is not dermally active
and secondary aerosols are not a hazard
(USADRIIM).
Standard Precautions1. Handwashing
Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments.
2. Gloves Wear gloves when touching blood, bodily fluids, secretions, excretions, and contaminated items; put on clean gloves just before touching mucous membranes and nonintact skin.
Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.
Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.
3. Masks, Eye Protection, Face Shields Wear a standard surgical mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and activities that are likely to generate splashes or sprays.
HemorrHAgic Fever viruses
DeFiniTionViral hemorrhagic fevers (VHFs) refer
to a group of illnesses that are caused
by several distinct families of viruses.
These viruses occur in different endemic
locations. Their transmission if from
rodent reservoir, dust contaminated
excreta, ticks, body fluid or contaminated
meats of infected animals and mosquito
borne.Eachdiseasecausesafebrile
syndrome characterized by hemorrhagic
complications, but mortality rates,
incubation periods, and susceptibility
to antiviral therapy vary depending on
the etiologic agent. While some types of
hemorrhagic fever can cause relatively
mild illnesses, many of these viruses
cause severe, life-threatening disease.
These organisms pose a biological threat
due to their potential to cause severe
morbidity.Exceptfordenguevirus,allthe
VHFs are laboratory infectious by aerosol.
The four (4) viral family of viruses considered dangerous due to their potential for weaponization by aerosol are:
Arenaviridae•LassaFever•Argentine,Bolovian,VenezuelanVHF Caused by Tuninvirus, machupo, Guanarito and sabia viruses
Bunyaviridae•Hantavirusgenus•CongoCrimeanVHF(Nairovirusgenus)•Rift Valley Fever virus (Phlebovirus genus)
Filoviridae•Ebola•Marburg
Flaviviridae•Dengue•Yellow
DiAGnosisDefinitive diagnosis requires the resources
found at reference laboratories that have
biocontainment capability.
Patients presenting with an acute febrile
illness and indications of vascular
involvement, especially if a detailed history
includes travel to an endemic area should
have VHF as a presumptive diagnosis.
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Notification of the local health department
is necessary. For decisions regarding
obtaining and processing diagnostic
specimens, contact local, state, and
regional laboratory authorities or the CDC.
TreATmenTPatients receive supportive therapy
because there is no established cure for
VHFs. Ribavirin, an antiviral drug, has been
effective in treating some individuals with
Lassa fever. Treatment with convalescent-
phase plasma has been used with success
for some VHFs.
PosT-exPosUre ProPHYlAxisThere is no post-exposure prophylaxis
currently available for VHFs. There is
a licensed live attenuated yellow fever
vaccine and presently no other VHF agents
available for use in USA. (USAMRIID)
inFeCTion PreVenTionPatients with VHF have large quantities
of infectious viruses in their blood and
bodyfluidsandsecretions.Extremecare
should be taken to avoid sharps injuries.
Strict adherence to all infection control
precautions, in addition to increased barrier
ComPArison oF VHF AGenTs & DiseAses (UsAmriiD)
Virus Disease Endemic Area Mortality Nosocomial
transmissionCharacteristic
features Countermeasures
Flavivirus
Yellow fever virus
Yellow fever Africa, South America
Overall3-12%, 20-50% if severe second phase develops
No
Oftenbiphasic,severe second phase with bleeding, very high bilirubin and transaminases, jaundice, renal failure
17-D live attenuated vaccine very effective in prevention, no post-exposure countermeasure available
KFD virusKyasanur Forest Disease
Southern India 3-5% No
Flu-like syndrome with additionofcough,GIsymptoms, hemorrhage, bradycardia
Formalin - inactivated vaccine available in India
OHFvirusOMSKhemorrhagic fever
Siberia 0.2-3% NoFrequent sequelae of hearing loss, neuropsych complaints, alopecia
TBEvaccines(notavail.in US) may offer some cross-protection
Filoviruses
EbolavirusEbolahemorrhagic fever
Africa, Phillipines (EbolaReston)
50-90% for Sudan/Zaire Common
Severe illness, maculopapular rash, profuse bleeding and DIC
Anecdotal success with immune serum transfusion
Marburg virus
Marburg hemorrhagic fever
Africa 23-70% Yes
Bunyaviruses
CCHFCrimean-Congo hemorrhagic fever
Africa,SEEurope,Central Asia, India
30% Yes Oftenprominentpetechial/ecchymotic rash
Anectotal success with Ribavirin
RVF Rift Valley fever Africa <0.5% No
Hemorrhagic disease rare, classically associated with retinitis and encephalitis. Significant threat to livestock - epidemics of abortion and death of young
Human killed vaccine - DODIND,liveattenuatedvaccine in clinical trials
Hantavirus (Hantaan, Dobrava, Seoul, Puumala)
Hemorrhagic fever with renal syndrome (HFRS)
Europe,Asia, South America (rare)
5% for Asian HFRS No
Prominent renal disease, marked polyuric phase during recovery, usually elevated WBC
Effectivelocallyproducedvaccines in Asia (not avail inU.S.).Experimentalvaccine at USAMRIID. Ribavirin effective in randomized, controlled clinical trial
Arenaviruses
Lassa virus Lassa fever West Africa 1-2% Yes
Frequent inapparent/mild infection, hearing loss in convalescence common
Ribavirin effective in clinical trial with non-randomized controls
JuninArgentine hemorrhagic fever
Argentinean pampas 30% Rare ProminentGIcomplaints,
late neurologic syndromeImmune plasma, Ribavirin effective Candid 1 vaccine
Machupo Bolivian hemorrhagic Bolivia 25-35% Rare Similar to AHF
Protective but not avail. in U.S. Immune plasma effective, Ribavirin probably effective, Candid 1 vaccine protects monkeys
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precautions as suggested by USAMRIID,
should be taken when VHFs are suspected.
Additional measures may include:
• AIIRwith6-12airexchanges
• Allenteringroomshouldwear:
– Double gloves
– Impermeable gowns
– Leg and shoe coverings
– Eyeprotection
– N-95(HEPA)maskorpositivepressure
air-purifying respirators (PAPR’s)
• Accessrestrictedtonecessary
caregivers
Person-to-person spread of VHF is via
direct contact with body fluids, cadavers,
and symptomatic patients. Inadequate use
of infection precaution methods also can
be the cause of spread. All precautions
should be employed
inFeCTion ConTrol Appropriate isolation precautions for patients
with suspected or confirmed VHF include a
combination of airborne, contact, droplet,
and standard precautions. Although airborne
transmission of these agents appears to
be rare, airborne transmission theoretically
may occur; therefore, airborne precautions
should be instituted for all patients with
suspected VHF.
TRANSMISSION BASED PRECAUTIONS
Airborne Precautions • PlacethepatientinaprivateroomwithAIIR.
• Useexternalairexhaustorhigh-efficiencyparticulate air filters if the air is recirculated.
• Keepthedoortotheroomclosed.
• N-95respirator.
Contact Precautions
• Placepatientinaprivateroom.
• Glovesshouldbewornwhenenteringthe room and removed before leaving
the room. Hands should be washed with an antimicrobial agent or a waterless handwashing agent immediately after removing gloves.
• Gownsshouldbewornwhenenteringtheroom if it is anticipated that clothing willhave contact with the patient, environmentalsurfaces, or items in the room. The gownshould be removed before leaving thepatient’s room.
• Patienttransportshouldbelimitedtoessential purposes only.
• Noncriticalpatient-careequipmentshouldbe dedicated whenever possible.
Droplet Precautions
• Placethepatientinaprivateroomorinaroom with other patients who have the sameinfection.
• Whenaprivateroomandlikeinfectionpatients are unavailable, spatial separationof a least three feet should be maintained.
• Healthcareworkersshouldwearastandardsurgical mask when working within threefeet of the patient.
Standard Precautions
1. HandwashingWash hands immediately after gloves areremoved, between patient contacts, andwhen otherwise indicated to avoid transferof microorganisms to other patients orenvironments.
2. GlovesWear gloves when touching blood, bodily fluids,secretions, excretions, and contaminateditems; put on clean gloves just beforetouching mucous membranes and nonintactskin. Change gloves between tasks andprocedures on the same patient after contactwith material that may contain a highconcentration of microorganisms. Removegloves promptly after use, before touchingnoncontaminated items and environmentalsurfaces, and before going to anotherpatient, and wash hands immediately toavoid transfer of microorganisms to otherpatients or environments.
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3. Masks, Eye Protection, Face ShieldsWear a standard surgical mask and eyeprotection or a face shield to protect mucousmembranes of the eyes, nose, and mouthduring procedures and activities that arelikely to generate splashes or sprays. Placeall persons who have had close or high-riskcontact with a patient suspected of havingVHF during the 21 days following onset ofsymptoms under medical surveillance. Ifmultiple patients with suspected VHF areadmitted to one healthcare facility, groupthem in the same part of the hospital tominimize exposure to other patients andhealthcare workers.
Francisella tularensis, tuLAremiA
DeFiniTionTularemia is an acute onset infectious disease caused by Francisella tularensis.
There are several forms of the disease; Typhoidal tularemia with pneumonia, and rarely ulceroglandular or oculoglandular forms of the disease, as well as others. The natural occurring form of the disease may present in infected animals and is transmitted by bites of infected ticks, deerflies or mosquitos. Inhaling or ingesting, as may be delivered by dry aerosol or sprayed over food and water sources as a potential BW may cause the disease. The potential use of this Category A agent is of grave concern because it
can be extremely virulent at low doses. Inhalation of, as low as 10 colony-forming units can cause disease.
Tularemia occurs throughout much of NorthAmerica,Europe,andAsia.
It is resistant for months in cold temperatures below freezing.
CliniCAl mAniFesTATions oF TUlAremiATularemia is mostly a disease of rural exposure due to its animal hosts. Persons that hunt and farm are more likely to be exposed to naturally occurring disease. Most cases occur June to September. Winter cases occur among hunters and trappers when they handle infected animal hides and carcasses.
Cases occurring in urban areas or in
those with no risk factors should alert
TULAREMIA INCUB A TIO N PERIOD
EARLY SIGNS/SYMPTOMS
LATER SIGNS/SYMPTOMS
Pneumonic tularemia 3-5 days; can range from 1-14 days.
Abrupt onset, fever, headache, chills, rigors, body aches, sore throat, dry cough, dyspnea, tachypnea, pleuritic pain, or hemoptysis.
Illness may be rapidly progressive and severe or may be indolent with progressive weakness and weight loss over several weeks to months. The progression of pneumonia tends to be slower than that of pneumonic plague. If untreated, can progress to respiratory failure, meningitis, sepsis, shock, and death.
CliniCAl mAniFesTATions oF TUlAremiA
Tularemia is commonly transmitted through tick bites
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healthcare personnel to the possibility of a
biological attack. Treatment of tularemia is
critical to avoid progression to respiratory
failure; meningitis; kidney, spleen, or liver
involvement; sepsis; shock; and death.
DiAGnosisThere is no rapid diagnostic testing
available for tularemia. F. tularensis
may be diagnosed through recovery
of organisms in culture from blood, ulcers,
conjunctival exudates, sputum, gastric
washings and throat swabs. It requires
the use the use of special diagnostic and
safety procedures. Results can be read
out in several hours if the designated
reference laboratory in the National
PH Laboratory Network is notified and
receives the appropriate collected
specimens. Notify local health department.
TreATmenTThe disease can be fatal if not treated
with the right antibiotics. Administration of
parenteral antibiotics.
PosT-exPosUre ProPHYlAxis Post-exposure prophylaxis with antibiotics
should be initiated following confirmed or
suspected bioterrorism exposure, and for
post-exposure management of healthcare
workers and others who had unprotected
face-to-face contact with symptomatic
patients. There is an investigational live
attenuated vaccine. Research to find and
evaluate new and better vaccine is on going.
inFeCTion ConTrolPerson-to-person transmission of tularemia has not been documented; therefore, standard precautions would be appropriate for patients with tularemia.
Standard Precautions
1. HandwashingWash hands immediately after gloves areremoved, between patient contacts, andwhen otherwise indicated to avoid transferof microorganisms to other patients orenvironments.
2. GlovesWear gloves when touching blood,bodily fluids, secretions, excretions, andcontaminated items; put on clean gloves justbefore touching mucous membranes andnonintact skin. Change gloves between tasksand procedures on the same patient aftercontact with material that may contain a highconcentration of microorganisms. Removegloves promptly after use, before touchingnoncontaminated items and environmentalsurfaces, and before going to anotherpatient, and wash hands immediately toavoid transfer of microorganisms to otherpatients or environments.
3. Masks, Eye Protection, Face ShieldsWear a standard surgical mask and eye
Wearing gloves is an effective precaution against infection
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protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and activities that are likely to generate splashes or sprays
Yersinia pestis, PLAgue
DeFiniTionPlague is a disease caused by Yersinia pestis, a bacterium found in rodents and their fleas in many areas around the world. Under natural conditions, plague is transmitted to humans via rodent fleas infected with the bacterium, although humans can also contract it by direct contact with infected animal body tissues or by inhaling infected droplets.
There are three (3) forms of plague that may affect humans:
• Bubonic• Septicemic• Primary pneumonic (USAMRIID 2005)
Y. Pestis is contagious in the pneumonicform of the disease which makes it anideal form for use as a biological weapon.The mortality for untreated pneumonicplague approaches 100%. The organismincubates for up to six (6) days and is dosedependent.Onsetofprimarypneumonicplague is acute and fulminent. See chartbelow for specifics. Pneumonic plaguecan be readily spread person-to-person.Most of the secondary cases are to homecaregivers (80%), medical professionals(14%), and persons in close contact up tosix (6) feet.
CliniCAl mAniFesTATions oF PlAGUePneumonic plague will infect the lungs as a result of inhalation of the organisms (primary pneumonic) or spread there due to septicemic (secondary pneumonic) plague.
DiAGnosisFrom an epidemiological perspective the arrival of an increasing number of patients with rapidly progressing pneumonia accompanied by bloody sputum should create a high degree of suspicion. This would be the manifestation of the intentional release of pneumonic plague. A delay in diagnosis and treatment is associated with high fatality rates. There are no readily available rapid tests to detect plague. Definitive diagnosis is made by culture from clinical specimen.
PLAGUE INCUB A TIO N PERIOD
EARLY SIGNS/SYMPTOMS
LATER SIGNS/SYMPTOMS
Pneumonic plague
Bubonic
1-6 days, dose dependent.
2-8 days.
High fever, chills, HA, malaise, myalgias.
Acute and fulminant onset of non-specific symptoms.
Increasing dyspnea, stridor, cyanosis, rapidly progressive respiratory failure, circulatory collapse.
Characteristic Bubo.
CliniCAl mAniFesTATions oF PlAGUe
Yersinia pestis bubonic plague x250
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Report the possibility of plague to the local healthdepartment.Othertestsneedtobe coordinated through the local health department.
TreATmenTAlthough early treatment is important, plague is not believed to be as contagious as once thought. Persons transmit the plague infection most at the end stage of the disease. Parenteral antibiotics,
given early, in the first 20-24 hours, clears the sputum of the plague bacillus. (CDC)
PosT-exPosUre ProPHYlAxisThose individuals with face-to-face contact (within 6 ft) to person or persons with pneumonic plague or exposed to the aerosol of a potential BW attack should receive antibiotic prophylaxis for 7 days. No vaccine is currently available for plague.
Research is ongoing to develop new and improved plague vaccines, particularly in light of the current bioterrorist threat and concerns about intentional dissemination of aerosolized plague organisms.
inFeCTion ConTrolDroplet precautions, a transmission based technique, in addition to Standard Precautions should be implemented until affected patients have been on the appropriate antibiotic of 48 hours.
A biohazard clean suit is an example of personal protective equipment
Select a strong, comfortable medical glove related to the procedure or task at hand
17
Droplet Precautions
•Placethepatientinaprivateroomorin a room with other patients who have the same infection. Special air handling capabilities is not required.
•Whenaprivateroomandlikeinfectionpatients are unavailable, spatial separation of a least three feet should be maintained.
•Healthcareworkersshouldwearastandard surgical mask when working within three feet of the patient. A mask is to be donned prior to entering the patient room.
Standard Precautions
1. Handwashing Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments.
2. Gloves Wear gloves when touching blood, bodily fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin.
Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.
Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient. Wash hands immediately to avoid transfer of microorganisms to other patients or environments.
3. Masks, Eye Protection, Face Shields Wear a standard surgical mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and activities that are likely to generate
splashes or sprays. In all forms of plague, avoid surgery, autopsy, or any other procedure that could cause aerosolization. If it is absolutely necessary to perform these procedures, wear an N-95 mask and perform the procedure in a negative pressure room.
PersonAL Protective eQuiPment (PPe)
DeFiniTionInformeduseofPPEisacriticalcomponent of a hospital’s infection prevention and bioterrorism response program. Where there is likelihood of contact with potentially infectious material, appropriatePPEincludesgloves,gowns,laboratory coats, face shields, masks, eye protection, and ventilation devices.
PPEreferstoavarietyofbarriersand/orrespirators to protect mucus membranes, airways, skin , and clothing from contact with infectious agents.
meDiCAl GloVes When selecting a medical glove, an important consideration should be the barrier requirement related to the procedure or task at hand. Be aware of the level of exposure risk that the patient-care activities will require. Procedures that involve exposure to blood, bodily fluids, and other potentially infectious material require a glove that provides appropriate barrier protection.
lATex meDiCAl GloVesNatural rubber latex (NRL), commonly referred to as “latex”, remains the gold standard for hand barrier protection due to its strength, proven barrier protection, elasticity, fit, feel, comfort, and relatively low cost. With the availability of low-protein, powder-free gloves, many clinicians are confidently continuing to wear gloves made of latex. Latex gloves
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are recommended as the first choice for barrier protection in the healthcare environment, except for wearers who are allergic to latex proteins. In the event of bioterrorist activity, clinical personnel can have confidence in the barrier properties of the latex glove to protect them. Double-gloving in a bioterrorist event is also recommended. Latex is available in both surgical and examination gloves.
lATex-Free meDiCAl GloVesFor healthcare workers allergic to latex, the preferred recommendation as an alternative for medical examination gloves would be a latex-free material of nitrile or neoprene, and a latex-free material of neoprene or polyisoprene for surgical gloves. In independent testing for barrier properties, studies showed that nitrile, neoprene, and latex gloves are comparable in barrier properties during in-use performance testing.
Nitrile Nitrile is a petroleum-based, cross-linked film. It is extremely strong with puncture resistance superior to all glove films. Nitrile’s elasticity is very good and the gloves tend to conform to the shape of the wearer’s hands, providing good comfort and fit. There are no latex proteins in nitrile; therefore, there is no chance of latex allergy with use. Nitrile exhibits excellent chemical resistance and is recommended as a preferred alternative to latex for a bioterrorist event. Nitrile is available in examination gloves.
Neoprene (Polychloroprene) Neoprene is a petroleum-based cross-linked film that provides a similar fit, feel, and barrier protection to latex. Neoprene contains no latex proteins, and is available without chemical accelerators, making it a great choice for those with Type IV chemical allergy. It is a strong material, with good resistance to many chemicals, and provides great comfort. Neoprene’s elasticity is close to that of latex with very high memory. The film is able to retain its
original shape and is somewhat puncture resistant. Neoprene is available in both surgical and examination gloves.
Polyisoprene Polyisoprene is a petroleum-based, cross-linked film. Polyisoprene provides high strength, elasticity, and comfort. It contains no latex proteins, but contains some curing agents that can cause allergic reactions. Polyisoprene is durable and is somewhat puncture resistant. Polyisoprene provides good barrier protection but is more permeable than latex, and is recommended as a preferred alternative to latex in a bioterrorist event if nitrile or neoprene are not available. Polyisoprene is available in surgical gloves.
Polyvinyl Chloride (PVC) Many hospitals provide a latex-free material called Polyvinyl chloride (PVC), commonly known as “vinyl”, as a choice for exam gloves. PVC is a petroleum-based film, but it is not molecularly cross-linked. Because it lacks cross-linking, the individual molecules of vinyl tend to separate when the film is stretched or flexed. This causes small holes and breaches to form during glove donning and normal use. Repeated studies have demonstrated that vinyl gloves have higher failure rates when tested in simulated and actual conditions. (CDC 2007) Vinyl is the weakest of the glove films, with poor elasticity, memory and fit. In 2007 the CDCreleasedtheGuidelineforIsolationPrecautions: Preventing Transmission of Infectious Agents in Healthcare Settings. This document also emphasized the poor barrier properties of vinyl gloves. It reads, “While there is little difference in the barrier properties of unused intact gloves, studies have shown repeatedly that vinyl gloves have higher failure rates than latex or nitrile gloves when tested under simulated and actual clinical conditions.” For this reason either latex or nitrile gloves are preferable for clinical procedures that
19
require manual dexterity and/or will involve more than brief patient contact. Because of these poor physical properties, vinyl would not be an acceptable choice to use when handling the diseases caused by biological agents. Polyvinyl chloride is only available in examination gloves.
seleCTinG A GloVe THAT is riGHT For YoU Gloveselectionisseriousbusiness.Thetwoprimary considerations should be barrier protection and allergen content. If a glove does not provide an intact barrier, it is not doing its job. To maximize barrier effectiveness, you may wish to choose a glove manufacturer that is reliable and experienced, to ensure that your gloves will be of consistent quality and regularly available.
ConClUsion
“Biological weapons are widely available,” statesformerFLGovernorandUSSenatorBobGraham,and“Thenumberofpeoplewhocan manipulate pathogens has increased.”
The healthcare community is on the forefront of access, preparedness and recognition. We need to keep our skills and knowledge current to be able to service our communities.
LocalLawEnforcementAuthorities* LocalorCountyHealthDepartment* StateHealthDepartment* CDCEmergencyResponseHotline: 770-488-7100CDC Bioterrorism Preparedness & Response Program: 404-639-0385CDCEmergencyPreparednessResources: http:www.bt.cdc.govStrategic National Stockpile: Access through State Health DeptFBI (general point of contact): 202-324-3000FBI (suspicious package info): http://www.fbi.gov/pressrel/pressrel01/mail3.pdfUSAMRIIDGeneralInformation: http://www.usamriid.army.mil USAMRICD Training Materials: http://ccc.apgea.army.milU.S. Army Medical NBC Defense Information: http://www.nbc-med.org Johns Hopkins Center for Civilian Biodefense: http://www.hopkins-biodefense.org Infectious Diseases Society of America: www.idsociety.org/bt/toc.htm
Table3.PointsofContactandTrainingResources.*Clinicians&ResponsePlannersareencouragedtopostthis list in a an accessible location. Specific local and state points of contact should be included.
ePiDemioloGiC ClUes oF A BW or TerrorisT ATTACK
The presence of a large epidemic with a•similar disease or syndrome, especially ina discrete population
Many cases of unexplained diseases or•deaths
More severe disease than is usually•expected for a specific pathogen or failureto respond to therapy
Unusual routes of exposure for a pathogen,•such as the inhalational route for diseasesthat normally occur through otherexposures
A disease that is unusual for a given•geographic area or transmission season
Disease normally transmitted by a vector•that is not present in the local area
Multiple simultaneous or serial epidemics•of different diseases in the samepopulation
A single case of disease be an uncommon•agent (smallpox, some viral hemorrhagicfevers, inhalational anthrax, pneumonicplague)
A disease that is unusual for an age group•
Unusual strains or variants of organisms or•antimicroboal resistance patterns differentfrom those known to be circulating
A similar or exact genetic type among•agents isolated from distinct sources atdifferent times or locations
Higher attack rates among those exposed•in certain areas, such as inside a buildingif released indoors, or lower rates in thoseinside a sealed building if released outside
Disease outbreaks of the same illness•occurring in noncontiguous areas
A disease outbreak with zoonotic impact•
Intelligence of a potential attack, claims•by a terrorist or aggressor of a release,and discovery of munitions, tampering,or other potential vehicle of spread (spraydevice, contaminated letter)(USAMRIID 2005)
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BiBLiogrAPHY
Davis D, Bor B. Biological Contamination and Bioterrorism Preparedness: Key Considerations for Infection Control Practitioners. inf Control Today. July 2002: 40-44.
SinclairR,BooneS,GreenbergD,KeimP,GerbaG. PersistenceofCategoryASelectAgentsintheEnvironment.App environ micro. 2008: pg 555-563.
Pattillo M. Bioterrorism. Advance for nurses. Oct2005:17-22.
Cosgrove S, Perl T, Song X, Sisson S. Ability of Physicians to Diagnose and Manage Illness Due to Category A Bioterrorism Agents. Arch int med. 2005;165: 2002-2006
Beasley A, Kenenally S, Mickel N, Korowicki K, McCann S, Arundell J, Simmons W, Williams H. Treating Patients withSmallposintheOperatignRoom.Aorn Journal. 2004;80: 681-689.
Chronological History of Bioterrorism- History of Bioterrorism. Biological Terrorism Response Manual. http://www.bio-terry.com/HistoryBioTerr.html. accessed 25 May 2010.
Phillips M. Bioterrorism: A Brief History. DCMS online. 2005: 32-35
www.dcmsonline accessed 25 May 2005.
Percentage of Hospitals with Staff Members Trained to Respond to Selected Terrorism-Related Diseases of Exposures.MMRW2007;56:401.
US Army Medical Research Institute of Infectious Diseases (USAMRIID). Medial Management of Biological CasualtiesHandbook.SixthEdition.Apr2005
Reidel S. Biological warefare and Bioterrism: a historical review. BUmC Proceedings. 2004;17:400-4006.
Weiss M, Weiss P, Weiss J. Antrax Vaccine and Public Health Policy. Am J Public Health. Nov 2007; 97: 1945-1951.
Inglesby T, et al. Anthrax as a Biological Weapon, 2002 Updated Recommendations for Management. JAmA. 2002; 287: 2236-2252.
MMRW. Human Plague-Four States, 2006, MMWR 2006; 55: 940-943.
McLendon M, Apicella M, Allen L. Francisella tularensis: Taxonomy,Genetics,andImmunopathogenesisofaPotential Agent of Bioterrorism, Annu Rev Microbiol. 2006;60:167-185.
Dennis d, etal. Tularemia as a Biological Weapon, Medical and Public Management. JAMA 2001;285: 2763-2773.
WHO-http://www.who.int/mediacentre/factsheets/smallpox/en/ Smallpox. accessed 13 June 2010.
Chickenpox and Smallpox, How to Recognize the Difference http://www.idph.state.il.us/Bioterrorism/smallpoxchickenpox15.htm accessed 13 June 2010
Travelers’ Health Yellow Book, http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-5/viral-hemorrhagic-fevers.aspx. Accessed 14 June 2010
CDC.GuidelinesforIsolationOrecautions:PreventingTransmission of Infectious Agents in the HealthcareSetting 2007. http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
CDC Summary of Annual US Botulism Cases. http://botulismtoolkit.com/?p=736
Weber DJ. Journal of the American Medical Association 2003;289:1274
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