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In 1984, to alter the outcome of a local election, Rejneeshee Cult members sprayed salmonella on salad bars in Oregon, sickening more than 700 people. In 1995, the Aun Shinrikyo cult used Sarin gas to attack Tokuyo subway passengers. More recently, in 2001, letters laden with anthrax were mailed to media, news organizations and politicians. Biological weapons have distinct advantages over traditional weapons. First, you 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. Experts once estimated that fifteen hundred dollars in traditional nuclear weapon killing power is equal to about a penny’s worth of anthrax. 5 While nuclear weapons production requires specific facilities, anthrax can be germinated in a basement lab. An additional reason that the threat of using biological agents as weapons has increased, is that 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. It has been reported that some of these Soviet scientists went to work for terrorist organizations and rogue nations, taking their knowledge, equipment and even samples, including smallpox, with them. Biological agents can be delivered in several different ways, including orally in food, water or air. Today, most experts predict the most likely method of biological attack would be a large-scale attack of 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 CDC, and USMARIID 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, with Category A being the most likely agents to be used. Category A consists of 6 diseases: anthrax, smallpox, botulism, viral hemorrhagic fever, tularemia and plague. This study guide will go over the 6 Category A diseases, description, clinical manifestation, diagnosis, treatment, post-exposure prophylaxis and infection control including appropriate barrier protection.
Anthrax Anthrax is caused by the Bacillus anthracis, a grampositive spore-forming bacterium. This bacterium is found in soil worldwide. Humans contract the disease from close contact with animals or animal products infected with the bacteria. Of the three routes of exposure – inhalation, cutaneous, and gastrointestinal, inhalational anthrax is the one that is of greatest concern as a bioweapon. 6 Inhaled spores can germinate for up to 60 days 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: Skin (cutaneous) Most common natural form. Mortality 10% to 20% if untreated, less than 1% when treated. Lungs (inhalation) Most lethal form, with mortality of 45% to 87% following inhalation of spores. Most likely form of the disease to occur in a bioterrorism event Digestive (gastrointestinal) Rare, but highly fatal form that occurs after ingestion of spores. There is a potential use in a bioterrorism event, which might be seen in an aerosol release. 7 Clinical manifestation of the three forms of Anthrax 17 Anthrax Incubation Period Early Signs/ Symptoms Later Signs/ Symptoms Inhalational (primary involvement is the mediastinum) Cutaneous 1-7 days, possibly up to 12 days. Gastrointestinal 1-7 days, typically 2-5 days. Diagnosis 2-60 days. Flu-like symptoms including fever, malaise, headache, cough, fatigue and anorexia, prominent absence of rhinitis. There are no specific laboratory tests 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 facilities standard routine. If the culture grows gram + bacilli, it must be sent to the state laboratory to be analyzed further. 1 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. There are no available rapid specific tests for early anthrax disease. 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 give directions to obtain and send the cultures. 4 Fever and malaise, small papular or vesicular rash that may be pruritic. Fever, abdominal pain, vomiting and bloody diarrhea and headache. Treatment Fever, chest pain, severe respiratory distress, diaphoresis, shock and death. Painless ulceration with overlying eschar, localized edema, often on the head, forearms and hands. Shock and death. Treatment consists of hospitalization, IV antibiotics and intensive supportive care. Antibiotic treatment should be administered as soon as the diagnosis is suspected because early initiation can reduce the mortality, which approaches 100%, when treatment is delayed. Post-Exposure Prophylaxis Antibiotics should be administered to all persons that have been exposed or potentially exposed to the release of anthrax before symptoms have occurred. Patient contact, (family, friends and healthcare workers) who were not originally exposed to the release do not 7, 9 require prophylaxis. Vaccination A licensed cell-free, effective and safe vaccine exists, but is currently not available to the general public.
Page 1: Bioterrorism Agents and Barrier Pro
Page 5 and 6: Clinical Manifestation of Smallpox
Page 7 and 8: Clinical manifestations of Botulism
Page 9 and 10: Clinical manifestations of VHF 17 V
Page 11 and 12: Infection Control Person-to-person
Page 13 and 14: Personal Protective Equipment Perso
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