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Bioterrorism
PREPAREDNESS FOR HEALTHCARE PROFESSIONALS
© National Center of Continuing Education Bioterrorism Page 1
Copyright © 2012W.S. Keefer All rights reserved Published by the National Center of Continuing Education, Inc., Lakeway, Texas. Printed in the United States of America.
©
FEATUR
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A NATIONAL EPIDEMIC
WE ALL KNOW . . .. . . that U.S. Copyright Law grants to the copyright owner the exclusive right to duplicate copyrighted, printed and recorded materials. Piracy involves the illegal duplication of copyrighted materials. YOU MAY NOT KNOW . . . . . . that every time you use or make an illegal copy of any printed material in any form or by any method you may be liable for further litigation. ������WKDW�\RXU�LQVWLWXWLRQ·V�GXSOLFDWLRQ�RU�SURFHVVLQJ�HTXLSPHQW�PD\�DOVR�EH�FRQÀVFDWHG�DQG�GHVWUR\HG�LI�LQ-
volved in illegal duplication.
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. . . that civil or criminal litigation may be costly and embarrassing to any organization or individual. We request
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BIOTERRORISM: PREPAREDNESS FOR HEALTHCARE PROFESSIONALS
Course # 2028Contact Hours: 5 Hours
Author: Diana Harland, BS, CCRCEditor: Shelda L. K. Hudson, RN, BSN, PHN
Course Material valid through 07/2015
Page 2 Bioterrorism © National Center of Continuing Education
About the Author/Editor ....................................... 3Purpose and Goals ................................................. 3Instructional Objectives ......................................... 3Introduction ............................................................ 3History .................................................................... 4Biological Agents and Terror ................................. 4
General Characteristics .................................... 4The US Terrorism Advisory System ................. 4
The Health Alert Network ................................. 4 The Biowatch Program ..................................... 4
The Strategic National Stockpile ...................... 4 Figure 1 ......................................................... 4The Ideal Bioweapon ......................................... 5Methods of Delivery for Bioweapons ................ 5
Personal Protective Equipment and Decontamination ......................................... 5Table 1 .................................................................... 5 Biosafety Levels ................................................. 6Table 2 .................................................................... 6Recognizing a Bioweapon Attack .......................... 7Reporting Suspected Cases or Exposure to a Bioterrorist Agent .................................................. 7Tables 3 and 4 ........................................................ 7&ODVVLÀFDWLRQ�RI�$JHQWV�RI�%LRWHUURULVP ............... 8
Category "A" Agents of Bioterrorism ................ 8Category "B" Agents of Bioterrorism ................ 8Category "C" Agents of Bioterrorism ................ 8
The Category "A" Agents ....................................... 8 Anthrax .............................................................. 8 Figures 2-4 .................................................... 9
Smallpox ........................................................... 11 Figures 5-6 .................................................. 11
Plague ............................................................... 13 Figure 7 ....................................................... 13 Tularemia ......................................................... 14 Botulinum Toxin .............................................. 14Table 5 .................................................................. 15The Viral Hemorrhagic Fevers ............................ 16Chemical and Nuclear Terrorism ........................ 17
Chemical Terrorism ........................................ 17Table 6 .................................................................. 17
Nuclear Terrorism and Radiation ................... 18 Figure 8 ....................................................... 18
Conclusion ............................................................ 19Suggested Reading and References .................... 19
© We Want You To Learn!
Table of Contents
© National Center of Continuing Education Bioterrorism Page 3
About the Author/Editor
Diana Harland, BS, CCRC, re-
ceived her degree in Microbiology from the University of Texas at El Paso. She worked in pre-clinical research in retrovirology while in undergraduate school and again after graduation at Texas Biomedical Research Institute (formerly Southwest Foundation for Biomedical Research) in San Antonio, Texas. While at SWFBR, she worked in the department of Virology and Im-munology at biosafety level 3-4 (BSL-3/BSL-4). She has extensive training in NIH, OSHA, and CDC guidelines for sterility and asepsis in tissue culture and retrovirology. She holds a certificate in bioterrorism from Tulane University School of Public Health and Tropical Medicine and the University of Alabama at Birmingham School of Public Health. She is a member of the Austin Disaster Relief Network (infrastructure for the city of Austin, TX disaster response) and the Association for Clinical Research Professionals. (GLWLQJ� GRQH� E\� Shelda Hudson,
RN, BSN, PHN��'LUHFWRU� RI�+HDOWK-
FDUH� ,QIRUPDWLRQ��0V��+XGVRQ� LV� UH-
VSRQVLEOH� IRU� GLUHFWLQJ� WKH� DFWLYLWLHV�RI� WKLV�GHSDUWPHQW�� VHOHFWLQJ�TXDOLÀHG��FUHGHQWLDOHG� DXWKRUV� IRU� WKH� FRXUV-HV� RIIHUHG� E\� WKH� 1DWLRQDO� &HQWHU��DV�ZHOO� DV� DGYLVLQJ� VWDII� RI� UHTXLUHG�FRXUVH�GHVLJQ�DQG�FULWHULD��0V��+XGVRQ
KDV����\HDUV�RI�H[WHQVLYH�H[SHULHQFH�
Purpose and Goals�7KH�JRDO�RI� WKLV� FRXUVH� WR� UDLVH� WKH�
OHYHO�RI�SUHSDUHGQHVV�E\�HGXFDWLQJ�WKH�KHDOWKFDUH�SURIHVVLRQDO�LQ�WKH�DJHQWV�RI�ELRWHUURULVP��8QIRUWXQDWHO\��WHUURULVP�LV�QRW�OLPLWHG�WR�ELRORJLFDO�KD]DUGV��WKHUH�is also great concern regarding chemical
terrorism, as well as radiological, and
nuclear terrorism. This course will also
EULHÁ\�FRYHU�FKHPLFDO��UDGLRORJLFDO�DQG�nuclear terrorism so that, should a bio-
logical or other hazardous incident occur
(be it naturally occurring or intentionally
driven), the healthcare worker can be
instrumental in knowing how to handle,
UHSRUW�� DQG� HIIHFWLYHO\� GHDO�ZLWK� WKHVH�potentially deadly agents and situations.
16. ([SODLQ�WKH�PRVW�LPSRUWDQW�IDFWRUV�LQ� SURWHFWLRQ� IURP� UDGLDWLRQ� DQG�IDOORXW��UHFRJQL]H�WKH�EHVW�ORFDWLRQV�IRU�VKHOWHULQJ�LQ�SODFH��DQG�GHVFULEH�WKH� V\PSWRPV� RI� DFXWH� UDGLDWLRQ�syndrome.
IntroductionThere has been much public concern
RYHU�WKH�\HDUV�DERXW�WKH�WKUHDW�RI�ELRWHU-URULVP�� �%LRWHUURULVP� LV�GHÀQHG�DV� WKH�XVH�RI�D�ELRORJLF�DJHQW�WR�LQWHQWLRQDOO\�cause disease against civilian popula-
WLRQV�IRU�WKH�SXUSRVH�RI�FUHDWLQJ�WHUURU���$�biological agent is a living organism or
RWKHU�LQIHFWLRXV�DJHQW�WKDW�LV�FDSDEOH�RI�replicating in a host victim’s body. The
U.S. military currently recognizes more
WKDQ� ��� GLIIHUHQW� FRXQWULHV� �LQFOXGLQJ�5XVVLD�� ,UDQ�� 6\ULD�� ,VUDHO�� DQG�1RUWK�.RUHD��WKDW�DUH�VXVSHFWHG�RI�KDYLQJ�RI-IHQVLYH� ELRORJLFDO�ZHDSRQV� SURJUDPV�in place.
In past years, the United States also
SRVVHVVHG�LWV�RZQ�VWRFNSLOH�RI�ELRZHDS-
RQV��LQFOXGLQJ�DQWKUD[��XQWLO������ZKHQ�the Biological and Toxin Weapons &RQYHQWLRQ��%7:&� treaty was signed
E\�3UHVLGHQW�1L[RQ���8QGHU�WKLV�WUHDW\��QDWLRQV�DUH�SURKLELWHG�IURP�GHYHORSLQJ��producing, or retaining (stockpiling)
bioweapons or the equipment or means
RI�GHOLYHULQJ�WKHP���8QIRUWXQDWHO\��WKHUH�is no real way to monitor compliance,
DQG�HYLGHQFH�RI�ELRORJLFDO�ZHDSRQV�KDV�HYHQ�EHHQ�IRXQG�LQ�FHUWDLQ�FRXQWULHV�WKDW�have signed this treaty.
%HFDXVH� WKH� WKUHDW� RI� SXEOLF� KDUP�WKURXJK�WKH�XVH�RI�D�ELRORJLFDO�DJHQW�LV�D�very real possibility in today’s society, all
$PHULFDQV��HVSHFLDOO\�WKRVH�LQYROYHG�LQ�healthcare, must be particularly vigilant.
([SHUWV� RQ� ELRWHUURULVP� DQG� GLVDVWHU�preparedness now agree that there is
QR�ORQJHU�D�TXHVWLRQ�RI�´LIµ�DQ�LQFLGHQW�ZLOO�RFFXU�EXW�D�TXHVWLRQ�RI�´ZKHQµ�WKH�QH[W� LQFLGHQW�ZLOO� RFFXU�� �+HDOWKFDUH�workers may be required to take on the
UROH�RI�ÀUVW�UHVSRQGHUV�ZKR�VHH�SDWLHQWV�ZLWK�XQXVXDO� V\PSWRPV��RU�DFW�DV�ÀUVW�UHVSRQGHUV�LQ�WKH�FDVH�RI�D�PDVV�FDVXDOW\�incident. They will play increasingly
important roles in saving lives.
Instructional Objectives8SRQ�FRPSOHWLRQ�RI� WKLV� FRXUVH�� WKH�
learner will be able to:
1. 'HÀQH�ELRWHUURULVP�DQG�WKH�UHDVRQV�ZK\� WKH� WKUHDW� RI� ELRWHUURULVP� LV�a very real possibility in today’s
society.
2. /LVW� WKH� JHQHUDO� FKDUDFWHULVWLFV� RI�biological agents that make them
HIIHFWLYH�LQ�FDXVLQJ�WHUURU�3. Relate how the CDC implements the
+HDOWK�$OHUW�1HWZRUN�LQ�WKH�8�6��4. 6WDWH�ZK\� WKH�+D]DUG�9XOQHUDELOLW\�$QDO\VLV�DQG�(PHUJHQF\�0DQDJHPHQW�3ODQ�DUH�YLWDO�LQ�KHDOWKFDUH�IDFLOLWLHV�
5. /LVW�33(�UHTXLUHG�E\�ÀUVW� UHFHLYHUV�DQG� VWDWH� WKH� FRUUHFW� SURFHGXUH� IRU�GHFRQWDPLQDWLRQ� RI� YLFWLPV�ZKHQ�YLFWLPV� RI�PDVV� FDVXDOW\� LQFLGHQWV�are brought to the hospital and the
substance released is an unknown
substance.
6. ,GHQWLI\� DQRPDOLHV� WKDW�PD\� VLJQDO�WKH�RFFXUUHQFH�RI�D�ELRZHDSRQ�DWWDFN�
7. 2XWOLQH�WKH�UHDVRQV�ZK\�FDWHJRU\�́ $µ�DJHQWV�RI�ELRWHUURULVP�DUH�JLYHQ�WKH�highest priority by the CDC.
8. ([SODLQ� ZK\�B. anthracis is so
KLJKO\� LQIHFWLRXV�� DQG� GHILQH� WKH�WKUHH�W\SHV�RI�DQWKUD[��LQFOXGLQJ�WKHLU�clinical presentation, diagnosis, and
treatment.
9. 'HVFULEH� FULWHULD� IRU� SUH�H[SRVXUH�YDFFLQH�IRU�SUHYHQWLRQ��SRVW�H[SRVXUH�WUHDWPHQW� DQG� GHFRQWDPLQDWLRQ� IRU�$QWKUD[�
10. Describe the variola virus and the
FOLQLFDO� SUHVHQWDWLRQ� RI� VPDOOSR[�as well as vaccination against the
disease.
11. Compare and contrast the symptoms
DQG�WUHDWPHQW�RI�SODJXH�DQG�WXODUHPLD�12. 5HFRJQL]H� WKH� W\SHV� RI� ERWXOLVP�DQG� WKHLU� FDXVHV�� DQG� H[SODLQ� KRZ�botulism is treated.
13. Outline the viral hemorrhagic
IHYHUV�� WKHLU� HSLGHPLRORJ\�� DQG� WKH�LVRODWLRQ� SUHFDXWLRQV� QHFHVVDU\� IRU�healthcare workers.
14. Recognize the symptoms associated
ZLWK � FKHPLFDO � H[SRVXUH � DQG�GHVFULEH� WKH� SURFHVV� RI� FKHPLFDO�GHFRQWDPLQDWLRQ� IRU� YLFWLPV� RI�chemical emergencies.
15. Compare chemical versus nuclear
H[SORVLRQV�
Page 4 Bioterrorism © National Center of Continuing Education
History 7KH�XVH�RI�ELRZHDSRQV�KDV�RFFXUUHG�
throughout history. Prior to 500 BC, the
$VV\ULDQV�SRLVRQHG�HQHP\�ZDWHU�ZHOOV�ZLWK�U\H�HUJRW��D�IXQJXV�WKDW�LQIHFWV�U\H�and other grains), causing many symp-
WRPV�RI�LOOQHVV�LQFOXGLQJ�KDOOXFLQDWLRQV��psychosis, and mania in those who drank
the water. In 1346, the Tartars cata-
SXOWHG�FRUSVHV�RI�SHUVRQV�ZKR�KDG�GLHG�RI� SODJXH�RYHU� WKH� FLW\�ZDOOV� RI�&DIID��WKH� FLW\� RI� )HRGRVL\D� LQ� WKH� SUHVHQW�day Ukraine), contributing to the Black
'HDWK�WKDW�WRRN�WKH�OLYHV�RI�PLOOLRQV�LQ�(XURSH�DQG�NLOOHG�DQ�HVWLPDWHG����WR����SHUFHQW�RI�WKH�SRSXODWLRQ��7KH�ÀUVW�XVH�RI�ELRZHDSRQV�LQ�$PHULFD�FDPH�GXULQJ�WKH�)UHQFK�DQG�,QGLDQ�:DU�ZKHQ�/RUG�-HIIUH\�$PKHUVW�JDYH�EODQNHWV�LQIHFWHG�ZLWK�VPDOOSR[�WR�WKH�,QGLDQ�DOOLHV�RI�WKH�)UHQFK�� FDXVLQJ� GHDGO\� VPDOOSR[� HSL-GHPLFV�LQ�WKH�QDWLYH�SRSXODWLRQ���0RUH�UHFHQWO\� LQ� ������ DQWKUD[�ZDV� VHQW� LQ�envelopes through the mail to two U.S.
6HQDWRUV�DQG� WR� VHYHUDO�GLIIHUHQW�QHZV�PHGLD�� LQIHFWLQJ����SHRSOH�DQG�NLOOLQJ�ÀYH�RWKHUV�
Biological Agents and Terror
General Characteristics7KH�XVH�RI�ELRORJLFDO�DJHQWV�LV�HVSH-
cially good at causing terror in a popula-
tion primarily because they are invisible
to the human eye. These agents are also
generally odorless, tasteless, and unde-
WHFWDEOH�ZLWKRXW�WKH�PHDQV�RI�ODERUDWRU\�aids. They can be spread through air,
IRRG� VRXUFHV��ZDWHU�� VXUIDFHV�� fomites
(inanimate objects such as pens, toys,
or doorknobs that are contaminated with
DQ� LQIHFWLRXV� RUJDQLVP� DQG� FDQ� VHUYH�in their transmission), or direct contact
ZLWK�DQ�LQIHFWHG�LQGLYLGXDO���,W�PD\�WDNH�GD\V�IRU�DQ�LQIHFWHG�LQGLYLGXDO�WR�VKRZ�V\PSWRPV�RI�GLVHDVH���6RPH�DJHQWV��VXFK�DV� WKH�EDFWHULD� UHVSRQVLEOH� IRU� DQWKUD[�RU�WKH�EDFWHULD�UHVSRQVLEOH�IRU�ERWXOLVP�SRLVRQLQJ��FDQ�H[LVW�LQ�D�GRUPDQW�HQGR-
VSRUH�IRUP�WKDW�LV�UHVLVWDQW�WR�KHDW��FROG��UDGLDWLRQ��GU\LQJ��DQG�HYHQ�GLVLQIHFWDQWV�IRU�PDQ\�\HDUV�EHIRUH�FDXVLQJ�LQIHFWLRQ���)XUWKHUPRUH��ELRZHDSRQV�DUH�HDVLHU� WR�obtain and to use than nuclear weapons.
$OO� WKHVH� FKDUDFWHULVWLFV� FDXVH� D� JUHDW�
IHDU�RI�WKH�XQNQRZQ��OHDYLQJ�WKH�SXEOLF�IHHOLQJ� WKDW� WKH\� DUH� YXOQHUDEOH� DQG�RXW�RI�FRQWURO�� �3XEOLF�SDQLF� LV� IXUWKHU�IXHOHG�E\�PLVLQIRUPDWLRQ��UXPRUV��DQG�WKH�EHOLHI�WKDW�UHVRXUFHV�DUH�OLPLWHG�DQG�DYDLODEOH� WR� RQO\� D� VHOHFW� IHZ� RI� WKH�population.
7KH�8�6��7HUURULVP�$GYLVRU\�6\VWHP
In January 2011, the United States
'HSDUWPHQW� RI�+RPHODQG� 6HFXULW\��'+6��announced a new terrorism advi-
sory scale called the National Terrorism $GYLVRU\�6\VWHP��17$6�. Under this
new system, the public is to be alerted
ZLWK�ZKDWHYHU� LQIRUPDWLRQ�+RPHODQG�Security is able to give so that the pub-
OLF� FDQ� SURWHFW� LWVHOI� DW� WKH� LQGLYLGXDO��IDPLO\�� DQG� FRPPXQLW\� OHYHOV�� �$OHUWV�DUH�WR�EH�LVVXHG�XQGHU�WKH�FDWHJRULHV�RI�either HOHYDWHG (credible terrorist threat
against the United States) or imminent �FUHGLEOH��VSHFLÀF��DQG�LPSHQGLQJ�WKUHDW�DJDLQVW�WKH�8QLWHG�6WDWHV���,QIRUPDWLRQ�on threat assessment and steps to take
in response to threats are to be given
WKURXJK�WKH�XVH�RI�QHZV�PHGLD�DQG�VRFLDO�PHGLD�QHWZRUNV���$�VXQVHW�SURYLVLRQ is
also included, which means individual
WKUHDW�DOHUWV�ZLOO�EH�LVVXHG�IRU�D�VSHFLÀF�WLPH�SHULRG�DQG�WKHQ�ZLOO�H[SLUH�XQOHVV�WKH� WKUHDW� HYROYHV� RU� QHZ� LQIRUPDWLRQ�becomes available.
The Health Alert 1HWZRUN
The +HDOWK�$OHUW�1HWZRUN� �+$1���sponsored by the Centers for Disease &RQWURO��&'&�, is a program that pro-
YLGHV� YLWDO� KHDOWK� LQIRUPDWLRQ� DQG� WKH�LQIUDVWUXFWXUH�WR�VXSSRUW�WKH�GLVVHPLQD-WLRQ�RI�WKDW�LQIRUPDWLRQ�DW�VWDWH�DQG�ORFDO�levels and beyond. Currently, all 50
VWDWHV���� WHUULWRULHV�� WKH�'LVWULFW�RI�&R-
lumbia, and several large city and county
health departments are all connected to
WKH�+$1���$FFRUGLQJ�WR�WKH�&'&��D�YDVW�PDMRULW\�RI�VWDWH�EDVHG�+$1�SURJUDPV�KDYH�RYHU�����RI�WKHLU�SRSXODWLRQ�FRY-
HUHG�XQGHU�WKH�XPEUHOOD�RI�+$1�7KH�+$1�DOVR�HQVXUHV�WKDW�HDFK�FRP-
munity has:
�� rapid and timely access to emergent
KHDOWK�LQIRUPDWLRQ�� D�JURXS�RI�KLJKO\�WUDLQHG�SURIHVVLRQDO�
personnel
�� evidence-based practices and
SURFHGXUHV�IRU�HIIHFWLYH�SXEOLF�KHDOWK�preparedness, response, and service
on a 24/7 basis
7KH�+$1�0HVVDJLQJ�6\VWHP�GLUHFWO\�DQG�LQGLUHFWO\�WUDQVPLWV�YDULRXV�W\SHV�RI�PHVVDJHV�YLD�HPDLO�RU�566�IHHG�WR�RYHU�RQH�PLOOLRQ� UHFLSLHQWV�� �0HVVDJHV� DUH�FDWHJRUL]HG�EDVHG�RQ�OHYHO�RI�LPSRUWDQFH�DV�IROORZV�1. Health Alerts:� � +LJKHVW� OHYHO� RI�
importance that warrants immediate
attention.
2. +HDOWK�$GYLVRULHV� Important
LQIRUPDWLRQ� IRU� D� VSHFLÀF� LQFLGHQW�or situation that may not require
immediate action.
3. Health Updates:� � ,QIRUPDWLRQ�regarding an incident or situation
that is unlikely to require immediate
action.
4. ,QIR� 6HUYLFH�0HVVDJHV� General
LQIRUPDWLRQ� WKDW� LV� QRW� QHFHVVDULO\�FRQVLGHUHG� WR� EH� RI� DQ� HPHUJHQW�nature.
+HDOWKFDUH�SURIHVVLRQDOV�FDQ�EH�DGGHG�WR�WKH�+$1�E\�XVLQJ�WKH�OLQN�KWWS���ZZZ�EW�FGF�JRY�+$1�XSGDWHV�DVS� DYDLODEOH�DW� WKH�&'&�ZHEVLWH�DQG� IROORZLQJ� WKH�directions to enter a recipient’s email
DGGUHVV��LQIRUPDWLRQ�SUHIHUHQFHV��VWDWH��and zip code.
7KH�%LRZDWFK�3URJUDP7KH�%LRZDWFK�SURJUDP�EHJDQ�DIWHU�WKH�
8�6��DQWKUD[�DWWDFNV�LQ��������,W�FRQVLVWV�RI�D�V\VWHP�RI�ÀOWHUV�SODFHG�ZLWKLQ�H[LVW-ing (QYLURQPHQWDO�3URWHFWLRQ�$JHQF\��(3$�� ÀOWHUV� WKDW�PRQLWRU� DLU� TXDOLW\���7KHVH�ÀOWHUV��ORFDWHG�LQ�PDMRU�PHWURSROL-tan cities, can detect pathogens released
LQWR�WKH�DLU�DQG�WKXV�SURYLGH�ZDUQLQJ�RI�D�SRWHQWLDO�ELRWHUURULVP�HYHQW���$QDO\VLV�RI�ÀOWHU�FRQWHQWV�LV�GRQH�DW�VWDWH�DQG�ORFDO�levels and is coordinated by the CDC.
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© National Center of Continuing Education Bioterrorism Page 5
Source: OSHA Best Practices for Hospital-based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances
The 6WUDWHJLF�1DWLRQDO�6WRFNSLOH��616� is managed by both the Department of +HDOWK� DQG�+XPDQ�6HUYLFHV� �++6� and the Department of Homeland Se-FXULW\��'+6����,Q�WKH�HYHQW�RI�DQ�HPHU-JHQF\��WKH�8�6��KROGV�D�UHVHUYH�VXSSO\�RI�vaccines, antibiotics, chemical antidotes,
OLIH� VXSSRUW�PHGLFDWLRQV�� DQG�PHGLFDO�surgical supplies that are warehoused
in armed, guarded, unmarked, and clas-
VLÀHG�JHRJUDSKLF� ORFDWLRQV� WKURXJKRXW�the country. Should a bioweapon attack
occur, needed supplies can be deployed
wherever necessary. In the early hours
RI�DQ�HYHQW��Push Packages FRQVLVWLQJ�RI�pharmaceuticals, medical supplies, and
antidotes can be delivered where neces-
VDU\�ZLWKLQ����KRXUV�RI�IHGHUDO�UHTXHVW�(see Figure 1����,I�PRUH�SKDUPDFHXWLFDOV�or supplies are needed, Vendor Man-DJHG�,QYHQWRU\��90,� is structured to
have additional supplies arrive within
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able, and when used they carry a high
OHYHO� RI� XQFHUWDLQW\� DV� WR� WKH�RXWFRPH�RI�D�EDWWOH���7KHUH�LV�DOVR�KLJK�FROODWHUDO�damage associated with their use. To be
DQ�LGHDO�ELRZHDSRQ��WKH�DJHQW�RI�FKRLFH�
ZRXOG�QHHG�WR�EH�ERWK�KLJKO\�LQIHFWLYH�and highly virulent, with no available
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LQKDODWLRQ�RI�WKH�DJHQW�ZRXOG�FDXVH�LW�WR�go into the lung alveoli. Once there, it
could be quickly ingested by phagocy-
WRVLV�RI�DOYHRODU�PDFURSKDJHV��PDNLQJ�LW�GLIÀFXOW�IRU� WKH�ERG\�WR�HOLPLQDWH�LW���$JHQWV�WKDW�KDYH�D�SDUWLFOH�VL]H�RI�����RU�PRUH�DUH�WDNHQ�XS�E\�PXFRXV�ÁRZ�DQG�transported to the digestive tract where
elimination by the body is much easier.
Methods of Delivery for %LRZHDSRQV�
7KH�JRDO�RU�FKDOOHQJH�RI�ELRZHDSRQ�GHOLYHU\�LV�WR�GHOLYHU�WKH�DJHQW�LQ�D�VZLIW�manner and with the greatest strategic
HIIHFW�� �%LRZHDSRQV� FDQ� EH� GHOLYHUHG�through aerosolization, through animals,
WKURXJK�IRRG�DQG�ZDWHU�FRQWDPLQDWLRQ��through the postal system (as in the 2001
DQWKUD[�VSRUHV�PDLOHG�WKURXJK�WKH�8�6��postal system), and through person to
SHUVRQ� FRQWDFW�� �7KH�PRVW� IDYRUHG� RI�these methods is aerosolization.
Personal Protective (TXLSPHQW�DQG�'HFRQWDPLQDWLRQ
(DFK�KHDOWKFDUH�IDFLOLW\�VKRXOG�KDYH�LQ�place a +D]DUG�9XOQHUDELOLW\�$QDO\VLV��+9$��[required by the Joint Commis-sions on Accreditations of Healthcare 2UJDQL]DWLRQV� �-&$+2�� IRU� DFFUHGL-WDWLRQ� RI� KHDOWKFDUH� IDFLOLWLHV@�� DQG� DQ�(PHUJHQF\�0DQDJHPHQW�3ODQ��(03����These must both be conducted/devel-
oped and updated within the last year
DQG�WDLORUHG�WR�HDFK�LQGLYLGXDO�IDFLOLW\��%HFDXVH�KHDOWKFDUH�IDFLOLWLHV�PD\�KDYH�OLPLWHG� LQIRUPDWLRQ� RQ� DQ� DJHQW� WKDW�KDV�EHHQ�UHOHDVHG��WKHVH�IDFLOLWLHV�PXVW�conduct research on hazard assessments
IRU�WKH�EDVLV�RI�SURSHU�Personal Protec-WLYH�(TXLSPHQW��33(��VHOHFWLRQ���33(�VHOHFWLRQ�PXVW� EH� IRU� D�ZLGH� UDQJH�RI�substances since no material will protect
against all possible hazards.
Table 1�VKRZV�WKH�PLQLPXP�33(�UHF-RPPHQGHG�E\�26+$�IRU�ÀUVW�UHFHLYHUV�when the area covered is not the release
VLWH�RI�WKH�DJHQW��WKH�KD]DUGRXV�VXEVWDQFH�is unknown, and other eligibility condi-
WLRQV�KDYH�EHHQ�PHW��IRU�FRQGLWLRQV�VHH�WKH�26+$�ZHEVLWH�DW�KWWS���ZZZ�RVKD�gov/dts/osta/bestpractices/html/hospi-
WDOBÀUVWUHFHLYHUV�KWPO�W���� �+RVSLWDOV�
ZONE MINIMUM PPE
Hospital Decontamination Zone
1. All employees in this zone
(Includes, but not limited to, any of the following employees: decontamination team members, clinicians, set-up crew, cleanup crew, security staff, and patient
tracking clerks.)
1. Powered air-purifying respirator (PAPR) that provides a protection factor of 1,000. The respirator must be NIOSH-approved.
2. Combination 99.97% high-efficiency particulate air (HEPA)/organic vapor/acid gas respirator cartridges (also NIOSH-approved).
3. Double layer protective gloves. 4. Chemical resistant suit. 5. Head covering and eye/face protection (if not
part of the respirator). 6. Chemical-protective boots. 7. Suit openings sealed with tape.
Hospital Post-decontamination Zone
1. All employees in this zone
1. Normal work clothes and PPE, as necessary, for infection control purposes (e.g., gloves, gown, and appropriate respirator).
��� �
Table 1: Minimum Personal Protective Equipment Required for Hospital-based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Unknown Hazardous Substances
Page 6 Bioterrorism © National Center of Continuing Education
must use National Institute of Occu-SDWLRQDO�6DIHW\�DQG�+HDOWK (a division
RI�WKH�&'&��NIOSH-approved CBRN
(chemical, biological, radiological,
DQG�QXFOHDU��UHVSLUDWRUV�ZKHQ�WKH�+9$�UHYHDOV�D�SRWHQWLDO�ZHDSRQ�RI�PDVV�GH-VWUXFWLRQ� WKUHDW��1R�KHDOWKFDUH�ZRUNHU�VKRXOG�ZHDU�RU�XVH�VSHFLDOL]HG�33(�RU�respiratory protective equipment without
SURSHU�WUDLQLQJ�DQG�ÀW�WHVWLQJ��The 2FFXSDWLRQDO�6DIHW\�DQG�+HDOWK�
$GPLQLVWUDWLRQ� �26+$� has identi-
ÀHG�KHDOWKFDUH�ZRUNHUV�DW�D�KRVSLWDO�RU�KHDOWKFDUH�IDFLOLW\�ZKR�UHFHLYH�YLFWLPV�contaminated during a mass casualty
LQFLGHQW� IRU� WUHDWPHQW� DV�ÀUVW� UHFHLY-ers��7KLV�GLVWLQJXLVKHV�WKHP�IURP�ÀUVW�responders WKDW�LQFOXGH�ÀUHÀJKWHUV��ODZ�HQIRUFHPHQW�� DQG� HPHUJHQF\�PHGLFDO�SHUVRQQHO�� �26+$�KDV� SXEOLVKHG� EHVW�practice guidelines that help healthcare
IDFLOLWLHV�VHOHFW� WKH�PLQLPXP�33(�WKDW�26+$� DQWLFLSDWHV� JHQHUDOO\� ZLOO� EH�QHHGHG� WR� SURWHFW� ÀUVW� UHFHLYHUV� IDFHG�ZLWK�D�ZLGH�UDQJH�RI�XQNQRZQ�KD]DUGV����7KH� JXLGHOLQHV� FRYHU� SURWHFWLRQ� IRU�ÀUVW� UHFHLYHUV� GXULQJ�RYHUW� UHOHDVHV� RI�biological agents, as well as releases
RI�FKHPLFDOV�DQG�UDGLRORJLFDO�SDUWLFOHV�that may produce victims who may need
decontamination prior to administra-
WLRQ�RI�PHGLFDO�FDUH��7KH�JXLGHOLQHV�DUH�LQWHQGHG�IRU�PDVV�FDVXDOW\�LQFLGHQWV�DV�WKH\� DIIHFW� ÀUVW� UHFHLYHUV� DW� KRVSLWDOV��but concepts can also apply to mobile
FDVXDOW\� FDUH� IDFLOLWLHV� DQG� WHPSRUDU\�
shelters should a catastrophic incident
RFFXU�WKDW�LQYROYHV�WKRXVDQGV�RI�YLFWLPV���$VVXPSWLRQV�DUH�PDGH�E\�26+$�WKDW�WKH�KRVSLWDO�RU�KHDOWKFDUH�IDFLOLW\�LV�QRW�WKH�SULPDU\�LQFLGHQW�VLWH�DQG�WKDW�H[SRVXUH�FRPHV�IURP�YLFWLPV��WKHLU�FORWKLQJ��DQG�their personal belongings, rather than the
location where the hazardous substance
was released.
2QH�RI�WKH�PRVW�LPSRUWDQW�IDFWRUV�LQ�FRQVLGHUDWLRQ�RI�33(�IRU�WKH�KHDOWKFDUH�ZRUNHU� LV� WR� OLPLW� WKH� DPRXQW�RI� WR[LF�DJHQW�WR�ZKLFK�KH�VKH�LV�H[SRVHG���:KHQ�YLFWLPV�KDYH�EHHQ�H[SRVHG�WR�D�KD]DUG-
RXV�VXEVWDQFH��26+$�UHFRPPHQGV�WKH�ÀUVW�VWHS�LQ�WKH�GHFRQWDPLQDWLRQ�SURFHVV�WR�EH�UHPRYDO�RI�WKH�YLFWLP·V�FORWKLQJ�E\�cutting it away with blunt-nose shears to
DYRLG�DQ\�IXUWKHU�XQQHFHVVDU\�H[SRVXUH�to the victim or the worker. Clothing
removal is estimated to remove 75-
����RI�WKH�FRQWDPLQDQW�RQ�WKH�YLFWLP��Contaminated clothing and possessions
should then be placed in an approved
hazardous waste container that is isolated
outdoors. The second step is shower-
LQJ�RI� WKH�YLFWLP�ZLWK� WHSLG�ZDWHU�DQG�D� OLTXLG� VRDS� WKDW� KDV� JRRG� VXUIDFWDQW�properties but is not harsh on skin (good
H[DPSOHV�DUH�KDQG�RU�GLVKZDVKLQJ�VRDSV�such as Joy, Dawn, Ivory, and various
VKDPSRRV��IRU�D�minimum of 5 minutes
under running water. Scrubbing should
SURFHHG�GRZQZDUG�IURP�KHDG�WR�WRHV�WR�UHPRYH� WKH� FRQWDPLQDQW� IURP� WKH�KDLU�and skin. This step is also promoted by
WKH�8�6��$UP\�IRU�UHPRYDO�RI�ELRORJLFDO�agents as well as chemical agents and
UDGLRORJLFDO�SDUWLFOHV���/DVWO\��WR�IXUWKHU�PLQLPL]H�H[SRVXUH��ÀUVW�UHFHLYHUV�VKRXOG�UHPRYH�DOO�33(��see Table 2) and shower
WKHPVHOYHV���33(�DQG�VKRZHUV�PXVW�DOVR�be decontaminated.
Table 2 shows the recommended
SURFHGXUH�IRU�UHPRYDO�RI�33(�DQG�GH-contamination as outlined by the U.S.
'HSDUWPHQW�RI�+HDOWK�DQG�+XPDQ�6HU-vices $JHQF\�IRU�7R[LF�6XEVWDQFHV�DQG�'LVHDVH�5HJLVWU\��$67'5�.'HWDLOHG� RXWOLQHV� RI� SURFHGXUHV� IRU�
PRQLWRULQJ�RI�PHGLFDO�VWDII��GRQQLQJ�RI�33(��SDWLHQW�GHFRQWDPLQDWLRQ�� DQG�GH-FRQWDPLQDWLRQ�RI�ZRUNHUV�DQG�WKHLU�33(�DUH�DYDLODEOH�LQ�WKH�26+$�%HVW�3UDFWLFHV�IRU�+RVSLWDO�%DVHG�)LUVW�5HFHLYHUV� RI�9LFWLPV�)URP�0DVV�&DVXDOW\�,QFLGHQWV�,QYROYLQJ� WKH� 5HOHDVH� RI�+D]DUGRXV�6XEVWDQFHV�� DYDLODEOH� RQ� WKH� 26+$�website at http://www.osha.gov/dts/
RVWD�EHVWSUDFWLFHV�KWPO�KRVSLWDOBÀUVWUH-FHLYHUV�KWPO�W���
Biosafety LevelsThe CDC and the National Institute
RI�+HDOWK��1,+��KDYH�VSHFLÀHG�FHUWDLQ�biocontainment or lab ELRVDIHW\�OHYHOV��OHYHOV�RI�SUHFDXWLRQ�WKDW�SUHYHQW�ZRUN-
HUV�IURP�LQIHFWLRQ��QHFHVVDU\�WR�LGHQWLI\�and research various pathogenic agents.
$�VXPPDU\�RI�WKH�ELRVDIHW\�OHYHOV�BSL-1 through BSL-4 is shown in Table 3.
7DEOH�����7HFKQLFDO�'HFRQWDPLQDWLRQ�3URFHVV�IRU�(06�3HUVRQQHO
3HUVRQQHO�VKRXOG�UHPRYH�SURWHFWLYH�FORWKLQJ�LQ�WKH�IROORZLQJ�VHTXHQFH�1. 5HPRYH�WDSH��LI�XVHG��VHFXULQJ�JORYHV�DQG�ERRWV�WR�VXLW�2. Remove outer gloves, turning them inside out as they are removed.
3. 5HPRYH�VXLW��WXUQLQJ�LW�LQVLGH�RXW�DQG�IROGLQJ�LW�GRZQZDUG��$YRLG�VKDNLQJ�4. 5HPRYH�ERRW�VKRH�FRYHU�IURP�RQH�IRRW�DQG�VWHS�RYHU�WKH�FOHDQ�OLQH��5HPRYH�RWKHU�ERRW�VKRH�FRYHU�DQG�SXW�WKDW�IRRW�RYHU�
the clean line.
5. 5HPRYH�PDVN��7KH�ODVW�SHUVRQ�UHPRYLQJ�KLV�KHU�PDVN�PD\�ZDQW�WR�ZDVK�DOO�PDVNV�ZLWK�VRDS\�ZDWHU�EHIRUH�UHPRYLQJ�KLV�KHU�VXLW�DQG�JORYHV��3ODFH�WKH�PDVNV�LQ�D�SODVWLF�EDJ�DQG�KDQG�WKH�EDJ�RYHU�WKH�FOHDQ�OLQH�IRU�SODFHPHQW�LQ�D�VHFRQG�EDJ�KHOG�E\�DQRWKHU�VWDII�PHPEHU��6HQG�EDJ�IRU�GHFRQWDPLQDWLRQ�
6. Remove inner gloves and discard them in a drum inside the dirty area.
7. 6HFXUH�WKH�GLUW\�DUHD�XQWLO�WKH�OHYHO�RI�FRQWDPLQDWLRQ�LV�HVWDEOLVKHG�DQG�WKH�DUHD�LV�SURSHUO\�FOHDQHG�8. Personnel should then move to a shower area, remove undergarments and place them in a plastic bag.
9. Double-bag all clothing and label bags appropriately.
10. 3HUVRQQHO�VKRXOG�VKRZHU�DQG�UHGUHVV�LQ�QRUPDO�ZRUNLQJ�DWWLUH�DQG�WKHQ�UHSRUW�IRU�PHGLFDO�VXUYHLOODQFH�
7DEOH�WDNHQ�IURP�$JHQF\�IRU�7R[LF�6XEVWDQFHV�DQG�'LVHDVH�5HJLVWU\�0DQDJLQJ�+D]DUGRXV�0DWHULDOV�,QFLGHQWV�9RO�,,�²�+RVSLWDO�(PHUJHQF\�'HSDUWPHQWV���$�3ODQQLQJ�*XLGH�IRU�WKH�0DQDJHPHQW�RI�&RQWDPLQDWHG�3DWLHQWV��$YDLO�DW���KWWS���ZZZ�DWVGU�FGF�JRY�0+0,�PKPL�Y����SGI
© National Center of Continuing Education Bioterrorism Page 7
Recognizing a %LRZHDSRQ�$WWDFN�:LWK�WKH�H[FHSWLRQ�RI�VPDOOSR[��DOO�RI�
WKH�SRWHQWLDO�FDWHJRU\�$�DJHQWV��VHH�WKH�VHFWLRQ�HQWLWOHG�&DWHJRU\�´$µ�$JHQWV�RI�%LRWHUURULVP��DUH�RULJLQDOO\�GLVHDVHV�RI�animals. Should a bioweapon attack oc-
cur, it is very likely that animal popula-
WLRQV�ZLOO�EHFRPH�LOO�HLWKHU�EHIRUH�LOOQHVV�is seen in humans or simultaneously as
KXPDQV� EHFRPH� LOO�� �$�ELRZHDSRQ� DW-tack may have unusual circumstances
or characteristics that are not normally
seen with a particular disease. Because
RI�SRWHQWLDOO\� ORQJ� LQFXEDWLRQ�SHULRGV��persons who become ill may not seek
FDUH� IRU� GD\V� RU�ZHHNV�� � +HDOWKFDUH�ZRUNHUV�PD\�EH�RQH�RI�WKH�ÀUVW�JURXSV�to observe such anomalies and should be
DZDUH�RI�DQ\WKLQJ�XQXVXDO���Table 4 lists
anomalies that may signal the occurrence
RI�D�ELRZHDSRQ�DWWDFN�
5HSRUWLQJ�6XVSHFWHG�Cases or Exposure to a Bioterrorist Agent(DFK�IDFLOLW\�VKRXOG�KDYH�LQ�SODFH�SUR-
FHGXUHV�IRU� UHSRUWLQJ�RI�DQ\�VXVSHFWHG�RU�FRQÀUPHG�FDVHV�RU�DQ\�H[SRVXUH�RI�SDWLHQWV�RU�VWDII�WR�D�ELRWHUURULVW�DJHQW���,PPHGLDWH�QRWLÀFDWLRQ�WR�ORFDO�DQG�VWDWH�SXEOLF�KHDOWK�DJHQFLHV�LV�UHTXLUHG���$�OLVW�
7DEOH�����$QRPDOLHV�7KDW�0D\�6LJQDO�WKH�2FFXUUHQFH�RI�D�%LRZHDSRQ�$WWDFN
1. 'HDG�DQLPDOV��HVSHFLDOO\�LI�WKHUH�DUH�PXOWLSOH�DQLPDO�VSHFLHV�LQYROYHG�2. $�GLVHDVH�ZLWK�QR�QDWXUDO�YHFWRU�SUHVHQW��IRU�H[DPSOH��SODJXH�LQ�WKH�DEVHQFH�RI�UDWV�RU�ÁHDV�
3. Unusual illnesses in certain populations or certain age groups.
4. *URXSV�RI�SHRSOH�ZLWK�WKH�VDPH�GLVHDVH�LQ�JHRJUDSKLFDO�DUHDV�WKDW�DUH�QRW�DGMDFHQW�or near to each other.
5. *URXSV�RI�SHRSOH�ZKR�ZHUH�LQGRRUV�DQG�DUH�LOO�RU�VKRZ�KLJKHU�PRUELGLW\�WKDQ�WKRVH�SHRSOH�ZKR�ZHUH�RXWGRRUV��LQGLFDWLQJ�DQ�LQGRRU�DWWDFN���&RQYHUVHO\��JURXSV�RI�SHRSOH�who were outdoors who are ill or show higher morbidity than those people who were
indoors, indicating an outdoor attack.
6. $�GLVHDVH�WKDW�RFFXUV�LQ�DQ�XQXVXDO�JHRJUDSKLF�DUHD�7. $�ODUJH�QXPEHU�RI�SHUVRQV�ZLWK�WKH�VDPH�GLVHDVH�8. $�GLVHDVH� LQ�D�SRSXODWLRQ�DW�DQ�XQXVXDO� WLPH�RI� WKH�\HDU�� IRU�H[DPSOH��ÁX� LQ� WKH�
summer months.
9. $�GLVHDVH�ZLWK�D�VKRUWHU�LQFXEDWLRQ�WKDQ�LV�QRUPDOO\�H[SHFWHG��LQGLFDWLQJ�WKDW�SHUVRQV�KDYH�EHHQ�H[SRVHG�WR�KLJKHU�DPRXQWV�RI�DQ�DJHQW�WKDQ�LQ�D�QDWXUDO�RFFXUUHQFH��
10. $�GLVHDVH� WKDW� LV� QRW� QRUPDOO\� DQWLELRWLF� UHVLVWDQW� DQG� QRZ� VKRZV� DQWLELRWLF�resistance.
11. $�GLVHDVH�WKDW�VKRZV�IDLOXUH�WR�UHVSRQG�WR�XVXDO�WKHUDS\�12. $�GLVHDVH�FDXVHG�E\�DQ�XQXVXDO�RU�GLIIHUHQW�VWUDLQ�RI�DQ�RUJDQLVP�WKDQ�ZKDW� LV�
normally seen.
13. $�GLVHDVH�FDXVHG�E\�DQ�XQNQRZQ�RUJDQLVP�14. $�GLVHDVH�WKDW�KDV�EHHQ�WUDQVPLWWHG�LQ�DQ�XQXVXDO�ZD\��HVSHFLDOO\�LI�WKH�WUDQVPLVVLRQ�URXWH�LQYROYHV�IRRG�RU�ZDWHU�
15. $�GLVHDVH�WKDW�LV�FRPPRQ�EXW�QRZ�VKRZV�D�KLJKHU�PRUELGLW\�WKDQ�XVXDO�RU�PRUWDOLW\�ZKHUH�LW�LV�QRW�H[SHFWHG�
16. $�KLJK�LQFLGHQFH�RI�D�FHUWDLQ�GLVHDVH�17. $�VLQJOH�FDVH�RI�DQ�XQFRPPRQ�GLVHDVH�VXFK�DV�VPDOOSR[�RU�LQKDODWLRQDO�DQWKUD[�18. $Q\�XQH[SODLQHG�GLVHDVHV�RU�GHDWKV�
Table 3: Summary of Recommended Biosafety Levels for Infectious Agents
7DEOH�WDNHQ�IURP�8�6��'HSDUWPHQW�RI�+HDOWK�DQG�+XPDQ�6HUYLFHV��&'&�DQG�1,+�%LRVDIHW\�LQ�0LFURELRORJLFDO�DQG�%LRPHGLFDO�/DERUDWRULHV��WK�HG��
Page 8 Bioterrorism © National Center of Continuing Education
RI�VWDWH�KHDOWK�GHSDUWPHQWV�FDQ�EH�IRXQG�through the CDC website at http://www.
cdc.gov/mmwr/international/relres.html.
The CDC 'LYLVLRQ� RI� %LRWHUURULVP�Preparedness and Response can be
reached at 404-639-0385.The CDC also maintains a 24/7 Emer-
JHQF\�2SHUDWLRQV�&HQWHU� telephone
number 770-488-7100,� IRU� KHDOWKFDUH�SURIHVVLRQDOV�DQG�JRYHUQPHQW�RIÀFLDOV��ORFDO��VWDWH��DQG�IHGHUDO�DJHQFLHV��WR�DV-sist with questions on emergency patient
FDUH���,W�LV�QRW�IRU�WKH�JHQHUDO�SXEOLF��ZKR�are instead advised to call 911 in the
HYHQW�RI�DQ�HPHUJHQF\�
&ODVVLÀFDWLRQ�of Agents of %LRWHUURULVP
Category “A” Agents of %LRWHUURULVP
7KHUH� DUH� OLWHUDOO\� WKRXVDQGV� RI�PL-crobes that could potentially be used in
DQ�DWWDFN�RI�ELRWHUURULVP���2I�SDUWLFXODU�concern, as established by the CDC, are
WKH�DJHQWV�FODVVLÀHG�DV�&DWHJRU\�´$µ�agents of bioterrorism. These microbes
are given the highest priority because:
1. 7KH\� DUH� HDVLO\� WUDQVPLWWHG� IURP�person to person or are easily
dispersed.
2. They result in high morbidity and
high mortality rates.
3. They have the potential to cause
widespread panic and socia l
GLVUXSWLRQ�RI�WKH�SXEOLF�4. They require special preparedness to
deal with should an outbreak occur.
&DWHJRU\�$� DJHQWV� RI�%LRWHUURULVP�include:
1. %DFLOOXV�DQWKUDFLV���$QWKUD[2. 9DULROD� PDMRU�� 9DULROD� PLQRU���6PDOOSR[
3. Yersinia pestis---Plague
4. )UDQFLVHOOD�WXODUHQVLV���WXODUHPLD�5. Clostridium botulinum---Botulism
6. 7KH�9LUDO�+HPRUUKDJLF�)HYHUV�a. ) L O R Y L U X V H V � � � ( E R O D�KHPRUUKDJLF� IHYHU��0DUEXUJ�IHYHU
b. $UHQDYLUXVHV���/DVVD� IHYHU��$UJHQWLQH� KHPRUUKDJLF� IHYHU��%ROLYLDQ� KHPRUUKDJLF� IHYHU��9HQH]XHODQ�KHPRUUKDJLF�IHYHU��%UD]LOLDQ� KHPRUUKDJLF� IHYHU��etc.
Because the CDC considers these
PLFUREHV� WR� EH� RI� WKH� KLJKHVW� SULRULW\��WKLV�FRXUVH�ZLOO� IRFXV�RQ� WKH�&DWHJRU\�´$µ�DJHQWV��ZLWK�SDUWLFXODU�DWWHQWLRQ�WR�DQWKUD[�DQG�VPDOOSR[�
Category “B” Agents of %LRWHUURULVP
$JHQWV�ZLWK�D�FDWHJRUL]DWLRQ�RI�VHFRQG�KLJKHVW�SULRULW\�DUH�FODVVLÀHG�DV�Catego-U\�´%µ�DJHQWV�RI�ELRWHUURULVP� These
agents are moderately easy to disperse,
WKHLU� LQIHFWLRQ� UHVXOWV� LQ� D�PRGHUDWH�GHJUHH�RI�PRUELGLW\�ZLWK�ORZ�PRUWDOLW\��and their outbreak will cause the CDC to
enhance its diagnostic capacity and dis-
ease surveillance. These agents include:
1. Brucellosis spp.—Brucellosis
2. Clostridium perfringens³(SVLORQ�WR[LQ
3. Salmonella� VSS�� (VFKHULFKLD� FROL��Shigella� VSS�³)RRGERUQH� LOOQHVV�VDIHW\�WKUHDWV
4. Burkholderi mallei—Glanders
5. Burkho lde r i p seudomal l e i—
0HOLRGRVLV6. Chlamydia psittaci—Psittacosis
7. Coxiella burnetti³4�IHYHU8. Ricinus communis³5LFLQ�WR[LQ9. Staphylococcal enterotoxin B—
produces a multi-symptom disease
UHVHPEOLQJ�VHSVLV��H�J���7R[LF�VKRFN�syndrome)
10. Rickettsia prowazekii—Typhus
IHYHU11. $OSKDYLUXVHV³9LUDO�HQFHSKDOLWLV12. Vibrio cholera; Cryptosporidium
parvum³:DWHUERUQH� LOOQHVV� VDIHW\�threats
Category “C” Agents of %LRWHUURULVP
The third highest priority agents are
FODVVLILHG� DV�&DWHJRU\� ´&µ� DJHQWV� RI�bioterrorism. These microbes have
WKH�SRWHQWLDO�WR�EH�HQJLQHHUHG�IRU�ODUJH�scale use because they are readily avail-
able and can be easily produced and
GLVVHPLQDWHG�� �$Q� DWWDFN�ZLWK� DJHQWV�IURP�WKLV�FDWHJRU\�ZRXOG�SURGXFH�KLJK�PRUELGLW\�DQG�PRUWDOLW\���$JHQWV�LQFOXGH�HPHUJLQJ�PLFUREHV�VXFK�DV�1LSDK�YLUXV�DQG�+DQWDYLUXV�
The Category “A” Agents
Anthrax
(WLRORJ\$QWKUD[�LV�D�]RRQRWLF�GLVHDVH�SULPDU-
LO\� IRXQG� LQ� FDWWOH�� VKHHS�� KRUVHV�� DQG�JRDWV���7KH�QDPH�DQWKUD[�PHDQV�´FRDOµ�LQ�*UHHN� DQG�ZDV� QDPHG� IRU� WKH� FRDO�EODFN��FRORUHG�OHVLRQV�WKDW�DUH�FODVVLF�RI�WKH�FXWDQHRXV�IRUP�RI�WKH�GLVHDVH���$Q-
WKUD[�LV�FDXVHG�E\�WKH�EDFWHULXP�Bacillus
anthracis, a Gram-positive, non-motile,
VSRUH�IRUPLQJ�URG�WKDW�LV�W\SLFDOO\�VHHQ�LQ�ER[FDU�IRUPDWLRQ���$QWKUD[�LV�D�WR[LQ�PHGLDWHG�GLVHDVH��PHDQLQJ�LW�LV�WKH�WR[LQ�produced by the bacteria, not the bacteria
LWVHOI�� WKDW� FDXVHV� LQMXU\�� B. anthracis
produces a capsule that prevents leu-
NRF\WHV�IURP�EHLQJ�DEOH�WR�SKDJRF\WL]H�or lyse it, and it also produces three
proteins known as SURWHFWLYH� DQWLJHQ��3$��� OHWKDO� IDFWRU� �/)��� DQG� HGHPD�IDFWRU��()��� �$ORQH��WKH�WKUHH�SURWHLQV�DUH�QRW�WR[LF��EXW�LQ�FRPELQDWLRQ�LQ�WKH�ERG\� WKH\� DUH� UHVSRQVLEOH� IRU�PDVVLYH�bleeding, edema, tissue destruction, and
XOWLPDWH� GHDWK� RI� WKH� LQIHFWHG� SHUVRQ���$OO�WKHVH�FKDUDFWHULVWLFV�WRJHWKHU�H[SODLQ�why these bacteria can produce such a
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(SLGHPLRORJ\$QWKUD[�LV�VSUHDG�E\�VSRUHV��LW�LV�QRW�
known to be spread by human- to- human
FRQWDFW�� �+XPDQV�FDQ�FRQWUDFW�DQWKUD[�WKURXJK�WKH�KDQGOLQJ�RI�SURGXFWV�IURP�LQIHFWHG� DQLPDOV� �VXFK� DV� ZRRO� DQG�hides) when spores invade the skin via
VFUDWFKHV�DQG�ZRXQGV���$QWKUD[�FDQ�DOVR�be contracted through the consumption
RI�WKH�LQVXIÀFLHQWO\�FRRNHG�PHDW�RI�DQ�LQIHFWHG�DQLPDO�� WKURXJK�GLUHFW� LQKDOD-WLRQ�RI�WKH�VSRUHV��DQG�WKURXJK�WKH�ELWHV�RI�ÁLHV���7KH�HQGRVSRUHV�RI�B. anthracis
FDQ�OLYH�LQ�WKH�VRLO�IRU�GHFDGHV�DQG�VWLOO�return to their vegetative (active and
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DQWKUD[�ZRUOGZLGH�SHU�\HDU�� RFFXUULQJ�primarily in the developing countries.
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Clinical Presentation, Diagnosis, and TreatmentA. Cutaneous Anthrax 7KLV� IRUP�RI� LQIHFWLRQ� DFFRXQWV� IRU�
����RI�FDVHV���,WFKLQJ�RI�WKH�DIIHFWHG�DUHD�RFFXUV�D�IHZ�KRXUV�DIWHU�LQLWLDO�LQRFXOD-WLRQ��$�SDLQOHVV�KHPRUUKDJLF�SDSXOH�WKHQ�GHYHORSV�DIWHU������GD\V��DYHUDJH�RI���GD\V���IROORZHG�E\�DQ�XOFHU���$V�WKH�XOFHU�GULHV��D�EODFN�VFDU�RU�HVFKDU�IRUPV��DQG�WKLV�ZLOO�IDOO�RII�LQ�����ZHHNV�DQG�KHDO�with possible scarring (see Figures 2-4).
Diagnosis is made in part based on
WKH�SUHVHQFH�RI�D�SDLQOHVV�XOFHU���6SLGHU�ELWHV�FDQ�EH�GLIIHUHQWLDWHG�EHFDXVH�WKHVH�OHVLRQV�DUH�W\SLFDOO\�SDLQIXO��*UDP�VWDLQV�DQG�EDFWHULDO�FXOWXUHV�RI�WKH�OHVLRQ�PD\�EH�REWDLQHG���$�EORRG�FXOWXUH�VKRXOG�EH�collected in all patients.
7UHDWPHQW� RI� ELRWHUURULVP�UHODWHG�FXWDQHRXV�DQWKUD[�FRQVLVWV�RI�D����GD\�FRXUVH�RI�ÀUVW�OLQH�WKHUDS\�RUDO�DQWLELRW-LFV�FLSURÁR[DFLQ�RU�GR[\F\FOLQH�� � ,W� LV�important that lesions be kept clean and
covered and that all contaminated dress-
ings are properly handled and disposed.
Isolation precautions are standard with
DGGHG� FRQWDFW� SUHFDXWLRQV� LI� ZRXQG�GUDLQDJH�LV�H[FHVVLYH���,I�WKHUH�DUH�VLJQV�RI� V\VWHPLF� LQYROYHPHQW�� H[WHQVLYH�HGHPD��RU� LI� OHVLRQV�DUH�SUHVHQW�RQ�WKH�head or neck, treatment is intravenous
therapy with a multidrug regimen that
LQFOXGHV�FLSURÁR[DFLQ��IROORZHG�E\�RUDO�WKHUDS\�� �1DWXUDOO\�DFTXLUHG�FXWDQHRXV�DQWKUD[�FDQ�EH�WUHDWHG�ZLWK�RUDO�FLSUR-
ÁR[DFLQ�RU�GR[\F\FOLQH�IRU������GD\V�LQ�uncomplicated cases. There is less than
1% mortality in treated cases.
B. Gastrointestinal Anthrax7KLV� IRUP� RI� DQWKUD[� LV� UDUH�� DF-
FRXQWLQJ�IRU�OHVV�WKDQ����RI�DOO�DQWKUD[�FDVHV��DQG�UHVXOWV�IURP�FRQVXPSWLRQ�RI�WKH�PHDW�RI�LQIHFWHG�DQLPDOV���,QIHFWLRQ�may involve the intestines (intestinal anthrax) or the mouth or throat (oro-
SKDU\QJHDO�DQWKUD[). The incubation
period is 1 to 6 days.
6\PSWRPV�RI�LQWHVWLQDO�DQWKUD[�EHJLQ�with nausea, vomiting, abdominal pain,
DQG� IHYHU�� �$V� WLPH� SURJUHVVHV�� WKHUH�LV�DQ� LQFUHDVH�RI�ZDWHU\�GLDUUKHD�� WKHQ�PDVVLYH�DPRXQWV�RI�EORRG\�GLDUUKHD��DQG�H[WUHPH�H[KDXVWLRQ���(GHPD�LV�SUHVHQW�LQ�WKH�ORZHU�WUXQN���7KLV�W\SH�RI�DQWKUD[�LV�YHU\�GLIÀFXOW�WR�GLDJQRVH���&DVHV�FDQ�VWLOO�EH�WUHDWHG�DW�WKH�SRLQW�RI�EORRG\�GLDUUKHD�LI�WKH�WUHDWPHQW�LV�H[WUHPHO\�DJJUHVVLYH���Without treatment, there is cyanosis and
death. The mortality rate is 20-60%.
6\PSWRPV�RI�RURSKDU\QJHDO�DQWKUD[�LQFOXGH� H[WUHPH� WKURDW� SDLQ�� HQODUJHG�FHUYLFDO� O\PSK� QRGHV�� DQG� GLIILFXOW\�swallowing. Ulcers may be seen in the
WKURDW� RU�PRXWK�� �$Q� DLUZD\�PXVW� EH�placed in the patient at the point where
WKHUH�LV�GLIÀFXOW\�LQ�VZDOORZLQJ�EHFDXVH��DV�WKH�LQIHFWLRQ�SURJUHVVHV��WKHUH�LV�JUHDW�HGHPD�RI� WKH�QHFN�DQG� VXEPDQGLEXODU�areas.
7UHDWPHQW� RI�*,� DQWKUD[� LV� QRW�ZHOO�GRFXPHQWHG� EXW� VKRXOG� FRQVLVW� RI� DQ�aggressive intravenous multi-drug an-
WLELRWLF� WKHUDS\�ZLWK� FLSURÁR[DFLQ� DV�the primary antibiotic, and one to two
DGGLWLRQDO�DQWLPLFURELDOV�IROORZHG�E\�DW�OHDVW����GD\V�RI�RUDO�WKHUDS\���,VRODWLRQ�precautions are standard.
C. Inhalation Anthrax,QKDODWLRQ� DQWKUD[� KDV� WZR� SKDVHV���
Phase one�EHJLQV�ZLWK�D�ÁX�OLNH�XSSHU�respiratory illness. Symptoms include
PLOG� IHYHU�� IDWLJXH�� D� QRQ�SURGXFWLYH�cough, and malaise. Substernal chest
GLVFRPIRUW�DQG�VKRUWQHVV�RI�EUHDWK��G\V-SQHD��PD\�EH�SUHVHQW���$IWHU�D�IHZ�GD\V��there is slight improvement. Phase two progresses rapidly and results in death
within 24 hours. Symptoms include nau-
sea, vomiting, severe respiratory distress,
F\DQRVLV��HGHPD�RI�WKH�FKHVW�DQG�QHFN��and cardiovascular collapse. The lungs
and alveoli are destroyed. Death results
IURP�VXIIRFDWLRQ�DQG�HIIHFWV�RI�WKH�WR[LQ�
'LDJQRVLV�DW�WKH�RQVHW�RI�GLVHDVH�LV�GLI-ÀFXOW�EHFDXVH�RI�LWV�QRQ�VSHFLÀF�ÁX�OLNH�SUHVHQWDWLRQ���$�WKRURXJK�SDWLHQW�KLVWRU\�LV�HVVHQWLDO�WR�GHWHUPLQH�LI�H[SRVXUH�WR�VSRUHV�PD\�KDYH�RFFXUUHG���$�NH\�V\PS-
WRP�RI�SKDVH�RQH�LV�G\VSQHD (shortness
RI�EUHDWK���ZKLFK�LV�SUHVHQW�LQ�RQO\����RI�LQÁXHQ]D�FDVHV���,QKDODWLRQ�DQWKUD[�IURP�the 2001 U.S. postal cases showed an
����LQFLGHQFH�RI�G\VSQHD���6XEVWHUQDO�FKHVW�GLVFRPIRUW�LV�DOVR�PRUH�FRPPRQ�LQ� LQKDODWLRQ� DQWKUD[� WKDQ� LQ� FDVHV� RI�LQÁXHQ]D���7KH�FODVVLF�FKHVW�UDGLRJUDSK�will show mediastinal widening that is
due to hemorrhage and massive edema.
7KLV�UHVXOWV�IURP�WKH�H[RWR[LQ�UHOHDVHG�E\�LQFUHDVLQJ�FRQFHQWUDWLRQV�RI�DQWKUD[�bacilli in the regional lymph nodes that
drain pulmonary alveoli. This is an im-
SRUWDQW�LQGLFDWLRQ�RI�LQKDODWLRQ�DQWKUD[���,I�D�&7�VFDQ�LV�GRQH��LW�ZLOO�VKRZ�KHPRU-UKDJLF�PHGLDVWLQLWLV��LQÁDPPDWLRQ�RI�WKH�WLVVXHV�RI�WKH�PHGLDVWLQXP���DQG�WKLV�LV�GLDJQRVWLF�RI�LQKDODWLRQ�DQWKUD[���$�EORRG�culture should always be taken because
B. anthracis is present in blood cultures
HYHQ�LQ�WKH�HDUO\�VWDJH�RI�WKH�GLVHDVH�7UHDWPHQW� RI� LQKDODWLRQ� DQWKUD[� LV�
also an intravenous multidrug therapy
ZLWK�FLSURÁR[DFLQ��UHFRPPHQGHG�RYHU�GR[\F\FOLQH��DV�WKH�SULPDU\�DQWLELRWLF��and one to two additional antimicrobials
ZLWK�JRRG�&16�SHQHWUDWLRQ��IROORZHG�E\�DW�OHDVW����GD\V�RI�RUDO�WKHUDS\���,VRODWLRQ�precautions are standard. Without treat-
ment, mortality is nearly 100%, and with
treatment mortality is 75%.
D. Complications of Anthrax InfectionSepticemic anthrax is due to inva-
VLRQ� RI� WKH� DQWKUD[� EDFLOOL� LQWR� WKH�bloodstream and may be secondary to
LQIHFWLRQ�RI� DQ\�RI� WKH� DERYH� W\SHV�RI�DQWKUD[� EXW�PRUH� IUHTXHQWO\� IROORZV�LQKDODWLRQ� RU� JDVWURLQWHVWLQDO� DQWKUD[���8QWUHDWHG� FDVHV� RI� FXWDQHRXV� DQWKUD[�ZLOO� SURJUHVV� WR� VHSWLFHPLF� DQWKUD[� LQ���LQ���RU�����RI�FDVHV���6\PSWRPV�LQ-
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Figure 3- Day 6 postinfection Figure 4- Day 10 postinfectionFigure 2- Eschar formation
Photos taken from the CDC
Page 10 Bioterrorism © National Center of Continuing Education
DQG� YLVLRQ�� � ,QIHFWLRQ� LV� VSUHDG� DORQJ�O\PSKDWLF�FKDQQHOV���7KH�WUHDWPHQW�IRU�VHSWLFHPLF�DQWKUD[�LV�D�YHU\�DJJUHVVLYH�FRXUVH�RI�LQWUDYHQRXV�DQWLELRWLF�WKHUDS\�with a multidrug regimen that includes
FLSURÁR[DFLQ� �XQOHVV� FRQWUDLQGLFDWHG���IROORZHG�E\�RUDO�WKHUDS\��
Anthrax meningitis may also result
IURP� DQ\� IRUP� RI� DQWKUD[� DV� EDFLOOL�spread to the central nervous system.
&16� WLVVXHV� EHFRPH�KHPRUUKDJLF� DQG�ÀOOHG�ZLWK� HGHPD�� 6\PSWRPV� LQFOXGH�IHYHU��GHWHULRUDWLQJ�PHQWDO�IXQFWLRQ��DQG�VHL]XUHV���'HDWK�FDQ�UHVXOW�LQ�DV�IHZ�DV�����GD\V���0RUWDOLW\�LV�DERXW������E. Important Notes about Anthrax
MedicationsOriginally, penicillin was considered
WR�EH�D�ÀUVW�OLQH�DQWLELRWLF�IRU�WUHDWPHQW�RI�DQWKUD[���$IWHU�WKH������SRVWDO�DQWKUD[�DWWDFNV��KRZHYHU��WKLV�KDV�FKDQJHG���1DW-XUDOO\�RFFXUULQJ�LVRODWHV�RI�B. anthracis
KDYH�EHHQ�VKRZQ�WR�SURGXFH�WKH�FODVV�RI�enzymes known as beta-lactamases that
inactivate penicillins, cephlasporins, and
VLPLODU�DQWLPLFURELDO�GUXJV���,VRODWHV�RI�B. anthracis have also been shown to
FRQWDLQ�WKH�SUHVHQFH�RI�FHSKODVSRULQDVH�DQG�SHQLFLOOLQDVH���7KHUHIRUH��HVSHFLDOO\�LQ� WKH� FDVH� RI� ELRWHUURULVP�� SHQLFLOOLQ�DORQH� LV� QRW� UHFRPPHQGHG�EHFDXVH� RI�WKH� SRWHQWLDO� IRU� JHQHWLFDOO\� DOWHUHG�B. anthracis. The CDC recommends
FLSURÁR[DFLQ� DQG� GR[\F\FOLQH� DV� ÀUVW�OLQH� DQWLELRWLFV�� ZLWK� SUHIHUHQFH� IRU�FLSURÁR[DFLQ� LQ� DQ\� VHYHUH� FDVHV�� � ,Q�FDVHV� RI�PHQLQJLWLV� RU�&16� LQYROYH-
PHQW�� GR[\F\FOLQH� VKRXOG� QRW� EH� XVHG�EHFDXVH� LW� KDV� SRRU� SHQHWUDWLRQ� RI� WKH�&16�� � &RQVXOWDWLRQ� ZLWK� LQIHFWLRXV�disease specialists at the CDC is highly
UHFRPPHQGHG�IRU�WUHDWPHQW�RI�DQ\�FDVHV�LQYROYLQJ�DQWKUD[���F. 3UH�H[SRVXUH�3URSK\OD[LV�$Q�)'$�OLFHQVHG�DQWKUD[� YDFFLQH��
$QWKUD[�9DFFLQH�$GVRUEHG��$9$�, is
DYDLODEOH� LQ� WKH�8�6�� IRU� SUH�H[SRVXUH�human use in individuals between 18
DQG���� \HDUV� RI� DJH� DQG� LV� NQRZQ�E\�the trade name BioThrax. It is not li-
FHQVHG�IRU�SRVWH[SRVXUH�XVH���7KH�8�6��'HSDUWPHQW�RI�'HIHQVH�UHFRPPHQGV�DOO�military personnel be vaccinated against
DQWKUD[�� � 7KH�$GYLVRU\�&RPPLWWHH�IRU� ,PPXQL]DWLRQ�3UDFWLFHV� �$&,3�, D�SDQHO�RI�H[SHUWV�VHOHFWHG�E\�WKH�6HF-UHWDU\�RI�WKH�++6�WR�SURYLGH�DGYLFH�WR�the CDC, also recommends the vaccine
IRU� DQ\RQH� LQ� WKH�ZRUNSODFH�ZKR� KDV�
FRQWDFW�ZLWK�LPSRUWHG�DQLPDO�KLGHV��IXUV��wool, bone meal, bristles, and animal
hair (especially goat hair), as well as
all persons who engage in diagnostic
or investigational activities involving
DQWKUD[�VSRUHV���3UHJQDQW�ZRPHQ�VKRXOG�QRW�EH�YDFFLQDWHG�EHFDXVH�HIIHFWV�RQ�WKH�IHWXV�DUH�QRW�NQRZQ���7KH�YDFFLQH�FRXUVH�FRQVLVWV�RI�WZR�LQWUDPXVFXODU�LQMHFWLRQV��given at 0 and 4 weeks, then three ad-
ditional injections given at 6, 12, and 18
months. To maintain immunity, annual
booster injections are also needed.
Currently, the U.S. holds a reserve
RI�%LR7KUD[� YDFFLQH� LQ� WKH� 6WUDWHJLF�1DWLRQDO�6WRFNSLOH���7KHUH�DUH�QR�FRP-
PHUFLDOO\� DYDLODEOH� GRVHV� RI� DQWKUD[�YDFFLQH�� DOO� DQWKUD[� YDFFLQH� LV� RZQHG�DQG�PDQDJHG�E\�WKH�86�'HSDUWPHQW�RI�'HIHQVH���7KH�VKHOI�OLIH�IRU�%LR7KUD[�LV�three years.
$W�WKH�SUHVHQW�WLPH��QR�DQWLELRWLFV�DUH�DSSURYHG�IRU�SUH�H[SRVXUH�SURSK\OD[LV�WR�DQWKUD[�VSRUHV�$QWLWR[LQ�NQRZQ�DV�Anthrax Immune
*ORELQ��$,*���PDGH�IURP�SODVPD�WKDW�LV�WDNHQ�IURP�LQGLYLGXDOV�ZKR�ZHUH�SUHYL-RXVO\�LPPXQL]HG�ZLWK�DQWKUD[�YDFFLQH��LV�DYDLODEOH�LQ�WKH�616���,W�FDQ�EH�XVHG�in addition to antibiotic therapy to treat
SHUVRQV�VKRZLQJ�DQWKUD[�V\PSWRPV���$�PRQRFORQDO�DQWLERG\�FDOOHG�5D[LEDFXP-
ab (under the trade name $%WKUD[� that
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animal studies.
G. 3RVWH[SRVXUH�3URSK\OD[LV)RU�SRVWH[SRVXUH�SURSK\OD[LV��3(3��
RI� SRWHQWLDO� LQKDODWLRQDO� H[SRVXUH�� WKH�CDC recommends decontamination
LI� QHFHVVDU\�� IROORZHG� E\� YDFFLQDWLRQ�(although the vaccine is not licensed
IRU�3(3��DQG�DQWLELRWLF�WUHDWPHQW���9DF-FLQDWLRQ��ZKLFK�LQ�FDVHV�RI�ELRWHUURULVP�would be available under an ,QYHVWL-JDWLRQDO�1HZ�'UXJ� �,1'� protocol,
FRQVLVWV� RI� WKUHH� GRVHV� RI� %LR7KUD[�given at week 0, week 2, and week 4.
In asymptomatic individuals, a 60 day
FRXUVH�RI�FLSURÁR[DFLQ�ZLWK�GR[\F\FOLQH�(or other tetracycline) or penicillin is
UHFRPPHQGHG���7KH����GD\V�RI�WKHUDS\�has been considered critical and should
QHYHU�EH�UHGXFHG�EHFDXVH�RI�WKH�SRWHQWLDO�VSRUH�IRUPDWLRQ�RI�B. anthracis.��$QWKUD[�LV� NQRZQ� WR� UHFXU� XS� WR� ���GD\V� DIWHU�LQLWLDO�LQIHFWLRQ�LQ�VLPLODU�VWXGLHV�
Research by the 8�6��$UP\�0HGLFDO�Research Institute of Infectious Dis-HDVHV� �86$05,,'� and the National ,QVWLWXWH� RI�$OOHUJ\� DQG� ,QIHFWLRXV�'LVHDVHV� �1,$,'�� has shown that
ZKHQ� DQWKUD[� YDFFLQH� LV� DGPLQLVWHUHG�with a short-term 14 day combination
RI� DQWLELRWLFV� EHJLQQLQJ� RQH� WR� WZR�KRXUV� SRVWH[SRVXUH�� QRQ�KXPDQ� SUL-PDWHV�ZHUH�FRPSOHWHO\�SURWHFWHG�IURP�LQKDODWLRQ� DQWKUD[�� �0RUH� LQIRUPDWLRQ�FDQ� EH� IRXQG� DW� KWWS���ZZZ�SQDV�RUJ�FRQWHQW�������������IXOO�� �5HJDUGOHVV�RI�WKH�FRXUVH�GXUDWLRQ�RI�DQWLELRWLFV��LP-
PHGLDWH�SURSK\OD[LV�RI�FDVHV�RI�SRWHQWLDO�H[SRVXUH�ZLOO�EH�RI�XWPRVW�LPSRUWDQFH�H. Decontamination of Anthrax+DQGZDVKLQJ�ZLWK� VRDS� DQG�ZDWHU��
IROORZHG�E\� VKRZHULQJ�ZLWK� VRDS� DQG�ZDWHU��LV�WKH�UHFRPPHQGHG�PHWKRG�IRU�GHFRQWDPLQDWLRQ� RI� DQ\� SHUVRQV�ZKR�KDYH�FRPH�LQWR�FRQWDFW�ZLWK�VRXUFHV�RI�potential B. anthracis spores. The use
RI� EOHDFK� KDV� QRW� VKRZQ� DQ\� DGYDQ-
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should be triple bagged in plastic bags
EHIRUH�WUDQVSRUWLQJ��WKHQ�LQFLQHUDWHG�RU�autoclaved.
The CDC recommends a 1:10 bleach solution (one part household bleach
containing 5.25% sodium hypochlorite
WR�QLQH�SDUWV�ZDWHU��DV�DQ�HIIHFWLYH�VSR-
ricidal solution to decontaminate any
ZRUN�VXUIDFHV��RU�VXUIDFHV�FRQÀUPHG�WR�have contamination. Other approved
sporicidal agents may also be used.
1RQ�VWHULOL]DEOH� HTXLSPHQW� VKRXOG� EH�routinely cleaned with a sporicidal agent.
,WHPV�WKDW�FDQ�EH�DXWRFODYHG�VKRXOG�ÀUVW�be soaked in a sporicidal solution, then
autoclaved.
,I�WKHUH�LV�DQ�DFFLGHQWDO�FRQWDPLQDWLRQ�IURP� IUHVK� FOLQLFDO� VDPSOHV�� WKH� DUHD�VKRXOG�EH�ÁRRGHG�ZLWK�VSRULFLGDO�VROX-
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plates), areas with accidents that involve
organic matter, or areas with contamina-
tion where there is a temperature, lower
than room temperature should be gently
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ricidal solution should then be liberally
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claved. It should be noted that boiling
at 100ºC does NOT�NLOO�HQGRVSRUHV��WKH\�DUH�NQRZQ�WR�VXUYLYH�IRU�KRXUV�DW�ERLOLQJ�temperatures.
I. Reporting of Anthrax Cases3XEOLF� KHDOWK� DQG� ODZ� HQIRUFHPHQW�
RIÀFLDOV�VKRXOG�EH�QRWLÀHG�LPPHGLDWHO\�LI�D�FDVH�RI�DQWKUD[�LV�GLDJQRVHG�RU�VXV-pected. It is essential that any lab that
ZLOO�EH�KDQGOLQJ�VSHFLPHQV�VXVSHFWHG�RI�FRQWDLQLQJ�DQWKUD[�EH�QRWLÀHG�EHFDXVH�clinical specimens must be handled at
ELRVDIHW\�OHYHO����%6/����RU�DW�ELRVDIH-W\�OHYHO����%6/����LI�KLJKHU�FRQFHQWUD-WLRQV�DUH�KDQGOHG�RU�LI�VFUHHQLQJ�LQYROYHV�environmental samples (especially
SRZGHUV�� IURP� DQWKUD[� FRQWDPLQDWHG�locations. It is also important to alert
the diagnostic lab so that the suspect
DJHQW�FDQ�EH�SURSHUO\�LGHQWLÀHG�EHFDXVH�Bacillus is generally considered to be a
contaminant and is normally not tested.
6PDOOSR[
(WLRORJ\�6PDOOSR[� LV� FDXVHG� E\� HLWKHU� RI� WKH�
GRXEOH� VWUDQGHG�'1$�� EULFN�VKDSHG�viruses Variola major or Variola minor,
PHPEHUV� RI� WKH� RUWKRSR[YLUXV� IDPLO\���Variola major causes a more severe
IRUP�RI�WKH�GLVHDVH�ZLWK�D�PRUH�VHYHUH�UDVK��KLJKHU�IHYHU��DQG�XS�WR�����PRU-tality. V. major�DFFRXQWV�IRU�IRXU�W\SHV�RI�LQIHFWLRQ�
1. 2UGLQDU\�� �PRVW� IUHTXHQW�� DFFRXQWV�IRU�����RI�FDVHV
2. 0RGLILHG�� �PLOG� DQG� RFFXUULQJ� LQ�previously vaccinated persons
3. )ODW�� OHVLRQV� GR� QRW� SURMHFW� DERYH�
WKH� VNLQ� VXUIDFH�� UDUH�� VHYHUH�� DQG�XVXDOO\�IDWDO
4. +HPRUUKDJLF�� � KHPRUUKDJHV� RFFXU�LQ�WKH�VNLQ�DQG�PXFRXV�PHPEUDQHV��UDUH��VHYHUH��DQG�XVXDOO\�IDWDO
Variola minor causes a less severe
IRUP�RI� WKH�GLVHDVH�ZLWK� OHVV� WKDQ����PRUWDOLW\�� �6PDOOSR[�YLUXV�LQIHFWV�RQO\�humans and has no animal reservoir.
(SLGHPLRORJ\&DVHV� RI� VPDOOSR[� KDYH� EHHQ� GRFX-
mented throughout history, and this
GLVHDVH� LV� RQH�RI� WKH�PRVW� GHYDVWDWLQJ�diseases known to mankind. It is be-
OLHYHG� WKDW� WKH�PXPPLÀHG� UHPDLQV� RI�5DPVHV�9�RI�(J\SW��UHLJQHG�IURP�����������%&��VKRZ�WKDW�KH�GLHG�RI�VPDOOSR[�LQIHFWLRQ��PDNLQJ�WKLV�SKDUDRK�WKH�ROGHVW�known victim with actual visible signs
RI�WKH�SR[�SXVWXOHV��6PDOOSR[�KDV�VKRZQ�great morbidity and mortality throughout
the ages and has even destroyed entire
FLYLOL]DWLRQV�LQFOXGLQJ�WKH�,QFDV��WKH�$]-WHFV��DQG�PDQ\�1DWLYH�$PHULFDQ�WULEHV���In survivors, blindness, osteomyelitis,
DUWKULWLV��DQG�GLVÀJXULQJ�VFDUV�ZHUH�FRP-
PRQ���%HFDXVH�WKHUH�LV�QR�WUHDWPHQW�IRU�VPDOOSR[�� YDFFLQDWLRQ� LV� WKH� RQO\�ZD\�WR� SUHYHQW� WKH� GLVHDVH��$IWHU� JUHDW� HI-IRUWV�WKURXJK�YDFFLQDWLRQ�SURJUDPV��WKH�:RUOG�+HDOWK�2UJDQL]DWLRQ� �:+2��GHFODUHG� VPDOOSR[� WR� EH� HUDGLFDWHG� LQ�1979. There is now no variola virus
LQ�WKH�ZRUOG�H[FHSW�IRU�WKH�YLUXV�VWRUHG�in laboratory stockpiles. The only two
:+2�DXWKRUL]HG�UHIHUHQFH�VLWHV�DUH�WKH�&'&�LQ�$WODQWD��*$��DQG�WKH�9(&725�LQVWLWXWH�LQ�.ROWVRYR��5XVVLD�6PDOOSR[�LV�VSUHDG�WKURXJK�ÁXLGV�DQG�
VFDEV�IURP�WKH�SXVWXOHV�FKDUDFWHULVWLF�RI�the disease (see Figure 5), and requires
SURORQJHG�IDFH��WR��IDFH�FRQWDFW���6LQFH�SXVWXOHV�ÀUVW�IRUP�LQ�WKH�PRXWK��VDOLYD�that is spread through coughing, sneez-
ing, speaking, or breathing can transmit
WKH� YLUXV� WR� RWKHUV�� �$OWKRXJK� LQGLUHFW�FRQWDFW� LV� OHVV� HIILFLHQW� IRU� WKH� YLUXV�WR�VSUHDG��IRPLWHV�PD\�DOVR�VSUHDG�WKH�YLUXV���,W�LV�XQFHUWDLQ�LI�JHQHWLFDOO\�HQJL-QHHUHG�VPDOOSR[�YLUXV�ZRXOG�EH�VSUHDG�in the same manner as the naturally oc-
curring virus. The incubation period is
��WR����GD\V��ZLWK�DQ�DYHUDJH�RI����WR����GD\V�SRVWH[SRVXUH�IRU�V\PSWRPV�WR�begin. During this incubation, people
are not contagious. The greatest problem
IDFHG�E\�HSLGHPLRORJLVWV��KRZHYHU��LV�WKH�IDFW�WKDW�LGHQWLÀFDWLRQ�RI�WKH�index case
�WKH�ÀUVW�SHUVRQ�IRXQG�WR�KDYH�WKH�GLVHDVH�OHDGLQJ�WR�WKH�GLDJQRVLV�RI�RWKHUV�ZLWK�the same disease in a population) occurs
ZHHNV�SRVWH[SRVXUH��DQG�E\�WKH�WLPH�D�diagnosis is made, there may have been
PDQ\�SHUVRQV�H[SRVHG���,W�LV�PRVW�OLNHO\�that variola would be released by air-
ERUQH�GLVSHUVLRQ�LI�XVHG�DV�D�ELRZHDSRQ��
Clinical Presentation, Diagnosis, and Treatment6PDOOSR[�EHJLQV�ZLWK�DQ�DFXWH�ÁX�OLNH�
Prodrome phase which can last up to 4
GD\V���6\PSWRPV�FDQ�LQFOXGH�KLJK�IHYHU����������)��� FKLOOV�� EDFN� SDLQ�� ERG\�aches, headache, vomiting, abdominal
pain, malaise, and rigors. Patients are
SRVVLEO\�FRQWDJLRXV���7KH�QH[W�SKDVH�LV�(DUO\�5DVK�when small red spots appear
on the mouth and tongue. Persons are
KLJKO\�FRQWDJLRXV�DW�WKLV�WLPH���$V�PRXWK�sores break down, rash appears on the
skin and can spread to all body parts in
���KRXUV���)HYHU�PD\�IDOO�DQG�WKH�SDWLHQW�IHHOV�EHWWHU���,W�VKRXOG�EH�QRWHG�KHUH�WKDW�patients are contagious in all phases
LQYROYLQJ� UDVK�� �$IWHU� WKH��UG�GD\�� WKH�rash becomes raised bumps. On the 4th
GD\��WKH�EXPSV�EHFRPH�ÀOOHG�ZLWK�WKLFN��RSDTXH�ÁXLG� DQG�KDYH� D� FKDUDFWHULVWLF�GHSUHVVLRQ� LQ� WKH� FHQWHU� �OLNH� D� ´EHOO\�EXWWRQµ��WKDW�LV�GLDJQRVWLF�RI�VPDOOSR[���)HYHU�ZLOO�XVXDOO\�ULVH�DJDLQ�DQG�UHPDLQ�XQWLO� VFDEV� IRUP�� �$�Pustular Rash
SKDVH��ODVWLQJ�DERXW���GD\V��IROORZV�DV�bumps become sharply raised pustules
WKDW�DUH�URXQG�DQG�ÀUP���7KH�OHVLRQV�DUH�LQ�WKH�GHHS�OD\HUV�RI�VNLQ�DQG�IHHO�KDUG�DV�LI�DQ�REMHFW�LV�HPEHGGHG�WKHUH��1H[W�is the Pustules and Scabs phase, lasting
Figure 5:� 6PDOOSR[� SXVWXOHV� RQ�WKH�IDFH�RI�D�\RXQJ�ER\���3KRWR�WDNHQ�IURP�&'&�3XEOLF�+HDOWK�,PDJH�/L-EUDU\� �3+,/� ����� DYDLO� DW�� � KWWS���HPHUJHQF\�FGF�JRY�DJHQW�VPDOOSR[�VPDOOSR[�LPDJHV�VPDOOSR[��KWP
Figure 6: Distribution of rash in smallpox and chickenpox.Image taken from CDC
Page 12 Bioterrorism © National Center of Continuing Education
DQRWKHU���GD\V��ZKHQ�SXVWXOHV� IRUP�D�FUXVW� DQG� WKHQ� D� VFDE�� �0RVW� SXVWXOHV�ZLOO�KDYH�VFDEV�E\�WKH�HQG�RI�WKH�VHFRQG�ZHHN�RI�UDVK���$�5HVROYLQJ�6FDEV phase
IROORZV��ODVWLQJ�DERXW���GD\V���$V�VFDEV�IDOO�RII��WKH�DUHD�RQ�WKH�VNLQ�ZLOO�HYHQWX-
ally become a pitted scar. The person is
considered no longer contagious when
the last scab is gone. The total disease
duration is about 4 weeks.
6PDOOSR[�FDQ�EH�GLIIHUHQWLDWHG�IURP�FKLFNHQ�SR[�E\� WKH�SDWWHUQ�RI� UDVK�RQ�the body (see Figure 6��� �6PDOOSR[�LV�GLVWULEXWHG�LQ�FHQWULIXJDO�IDVKLRQ��ZLWK�OHVLRQV� DSSHDULQJ�RQ� WKH� SHULSKHU\� RI�the body. The rash is common on the
SDOPV� DQG� VROHV�� �&KLFNHQSR[� UDVK� LV�GLVWULEXWHG�LQ�FHQWULSHWDO�IDVKLRQ��ZLWK�more rash appearing on the trunk, and
IHZ�RU�QR�OHVLRQV�RQ�WKH�SDOPV�DQG�VROHV���&KLFNHQSR[�FDQ�DOVR�EH�GLVWLQJXLVKHG�IURP�VPDOOSR[�EHFDXVH�WKH�IHYHU�EHJLQV�at the same time as the rash (as opposed
WR�VPDOOSR[�ZLWK�D�����GD\�IHYHU�3UR-
dromal stage and no lesions), and the
OHVLRQV�ZLOO� EH� LQ� GLIIHUHQW� VWDJHV� �DV�RSSRVHG�WR�VPDOOSR[�ZLWK�OHVLRQV�DOO�LQ�the same stage).
Diagnosis is made by patient history
RI�D�SURGURPDO�VWDJH�SULRU�WR�UDVK��ZLWK�IHYHU�JUHDWHU�WKDQ�����)��DQG�DW�OHDVW�RQH�symptom including headache, backache,
vomiting, chills, or abdominal pain.
2EVHUYDWLRQ�RI�WKH�OHVLRQV�FKDUDFWHULVWLF�RI�VPDOOSR[�ZLWK�OHVLRQV�DOO�LQ�WKH�VDPH�VWDJH�RI�GHYHORSPHQW�DUH�DOVR�GLDJQRV-WLF�� �$Q\� VDPSOHV� VHQW� IRU� ODERUDWRU\�LGHQWLÀFDWLRQ�PXVW� EH� FROOHFWHG� E\� D�previously vaccinated individual and
H[DPLQHG�RQO\�DW�D�GHVLJQDWHG�ELRVDIHW\�OHYHO����%6/����ODERUDWRU\���$Q\�FDVHV�RI�VXVSHFWHG�VPDOOSR[�PXVW�EH�LPPHGL-DWHO\�UHSRUWHG�WR�SXEOLF�KHDOWK�RIÀFLDOV���,QIHFWLRXV�GLVHDVH�VSHFLDOLVWV�DW�WKH�&'&�should be consulted.
7KHUH� LV� QR� WUHDWPHQW� IRU� VPDOOSR[���Patients can be managed with support-
ive care and should be isolated until
all scabs have separated. It is debat-
able whether YDFFLQLD�LPPXQRJORELQ��9,*��LV�KHOSIXO�LQ�VHYHUH�FDVHV��
Vaccination5RXWLQH� YDFFLQDWLRQ� RI�$PHULFDQV�
ZDV�HQGHG�LQ�������$W�SUHVHQW��WKHUH�LV�uncertainty as to whether or not there
is any residual immunity in persons
YDFFLQDWHG� SULRU� WR� ������ WKHUHIRUH��the CDC considers these persons to be
VXVFHSWLEOH���,Q�WKH�HYHQW�RI�DQ�DWWDFN�RI�ELRWHUURULVP�XVLQJ� VPDOOSR[�� YDFFLQD-WLRQ�RI�DQ\�SHUVRQV�H[SRVHG�WR�WKH�YLUXV�is highly recommended. The CDC has
VWDWHG�WKDW�YDFFLQDWLRQ�ZLWKLQ���GD\V�RI�H[SRVXUH�ZLOO� SUHYHQW� RU� VLJQLÀFDQWO\�OHVVHQ� WKH� VHYHULW\� RI� VPDOOSR[� V\PS-
WRPV�LQ�WKH�YDVW�PDMRULW\�RI�SHRSOH��DQG�YDFFLQDWLRQ�����GD\V�SRVWH[SRVXUH�OLNHO\�RIIHUV�VRPH�SURWHFWLRQ�IURP�WKH�GLVHDVH�RU�PD\�PRGLI\�WKH�VHYHULW\�RI�GLVHDVH���$Q�RXWEUHDN�RI�VPDOOSR[�FDQ�EH�KDOWHG�E\�YDFFLQDWLQJ�D�́ ULQJµ�RI�SHRSOH�DURXQG�HDFK�FDVH�DQG�WKHLU�FRQWDFWV��0DVV�YDF-FLQDWLRQ�RI�WKH�SXEOLF�LV�RQO\�D�ODVW�UHVRUW�
The avai lable vaccine (ei ther
$&$0�����RU�'U\YD[�� LV�PDGH�ZLWK�live attenuated (decreased pathogenicity)
vaccinia virus, not variola�YLUXV���9DF-cination is done on the deltoid (recom-
PHQGHG�E\�WKH�&'&��ZLWK�D�ELIXUFDWHG�QHHGOH�� �$� YDFFLQDWLRQ� LV� FRQVLGHUHG�VXFFHVVIXO�LI�WKHUH�LV�D�́ WDNHµ�RU�VXIÀFLHQW�UHDFWLRQ�LQGXFHG���7KH�WDNH�FRQVLVWV�RI�SDSXOH�DQG�YHVLFOH�IRUPDWLRQ��IROORZHG�E\�D�ZHOO�IRUPHG�SXVWXOH�� WKHQ�D�VFDE��DQG�ÀQDOO\�VFDE�GHWDFKPHQW�DQG�D�UHVXOW-ing scar. In addition to the localized
UHDFWLRQ�DQG�VFDU�IRUPDWLRQ��KHDGDFKH��and body aches, the vaccine has other
LPSRUWDQW�SRWHQWLDO�VLGH�HIIHFWV�1. ,QDGYHUWHQW� LQRFXODWLRQ� The
vaccination site must be kept well
covered to prevent inadvertent
LQRFXODWLRQ��WUDQVIHU��WR�RWKHU�VLWHV�RQ�the body. This is the most common
adverse reaction. Rate = 529 per
million persons vaccinated.
2. *HQHUDOL]HG�YDFFLQLD� Occurs when
the virus spreads throughout the body
via the bloodstream. Rate = 250 per
million persons vaccinated.
3. (U\WKHPD� PXOWLIRUPH�� $� UDVK�characterized by symmetric red
patchy areas. Rate = 165 per million
persons vaccinated.
4. 3RVWYDFFLQDO� HQFHSKDOLWLV��$� OLIH�threatening, demyelinating acute
LQÁDPPDWLRQ�RI�WKH�EUDLQ��5DWH� ������per million vaccinated
5. (F]HPD� YDFFLQDWXP� � � $� OLIH�threatening reaction that occurs
in persons with eczema or atopic
dermatitis when the vaccinia virus
spreads to these areas. This can also
RFFXU�LI�WKH�HF]HPD�RU�GHUPDWLWLV�LV�LQDFWLYH� DW� WKH� WLPH�RI� YDFFLQDWLRQ��RU�LI�D�SHUVRQ�KDV�HYHQ�RQO\�RQFH�KDG�eczema or other skin conditions. Rate
= 38.5 per million vaccinated.
6. 3URJUHVVLYH� YDFFLQLD�� � $� OLIH�threatening reaction that occurs when
lesions go through muscle down to
the bone. Rate = 1.5 per million
persons vaccinated.
7. 0RUWDOLW\� UDWH�� The mortality
UDWH� IURP�YDFFLQDWLRQ� LV� �� WR� �� SHU�million persons vaccinated, equal to
WKH�PRUWDOLW\�UDWH�UHVXOWLQJ�IURP�ÁX�vaccination.
The vaccine is contraindicated in vari-
ous persons, including children under
���PRQWKV�� SUHJQDQW� RU� EUHDVWIHHGLQJ�mothers, persons with heart conditions,
LPPXQRGHÀFLHQW� LQGLYLGXDOV�� SHUVRQV�undergoing immunosuppressive therapy,
persons with active eye disease, and
WKRVH�ZKR�DUH�VHYHUHO\�LOO���$�FRPSOHWH�OLVW�RI�FRQWUDLQGLFDWLRQV�DQG�PRUH�LQIRU-PDWLRQ�RQ�WKH�YDFFLQH�FDQ�EH�IRXQG�DW�KWWS���ZZZ�EW�FGF�JRY�DJHQW�VPDOOSR[���
PPE, Infection Control, and Decontamination
Isolation precautions are combined
standard, contact, and airborne until all
scabs have separated. The CDC recom-
PHQGV�WKDW�ÀW�WHVWHG�1���PDVNV�EH�XVHG�E\�DQ\RQH�FDULQJ�IRU�VPDOOSR[�SDWLHQWV�LQ�D�FRQWUROOHG�KHDOWKFDUH�VHWWLQJ���$IWHU�FRQÀUPDWLRQ�RI�YDFFLQH�WDNH��KHDOWKFDUH�workers are no longer required to wear
1���PDVNV��)RU�FRQWDPLQDWHG�SDWLHQW�DU-HDV��33(�PXVW�LQFOXGH�GLVSRVDEOH�JRZQV�DQG�JORYHV�WKDW�DUH�GLVSRVHG�RI�SULRU�WR�leaving those areas. Laundry and linens
must be bagged and laundered on the
premises by only vaccinated workers,
RU�ÀUVW�DXWRFODYHG�LI�ODXQGHUHG�E\�QRQ�vaccinated persons. Laundry should be
washed in hottest water and hot air dried.
Disposable items should be used when-
HYHU�SRVVLEOH���)RRG�VKRXOG�EH�SUHSDUHG�on the premises or brought in using dis-
SRVDEOH�VHUYLQJ�ZDUH���0RUH�LQIRUPDWLRQ�is available on the CDC website at http://
HPHUJHQF\�FGF�JRY�DJHQW�VPDOOSR[�UHVSRQVH�SODQ�ÀOHV�JXLGH�F�SDUW���SGI��1R�SURGXFWV�DUH�UHJLVWHUHG�E\�WKH�En-
YLURQPHQWDO�3URWHFWLRQ�$JHQF\��(3$��DV�VSHFLÀF�IRU�variola virus inactivation
RQ�VXUIDFHV���6LQFH�variola is physically
and biochemically similar to Vaccinia,
which is inactivated by low or interme-
GLDWH� OHYHO� GLVLQIHFWLQJ� SURGXFWV�� LW� LV�presumed that these products would be
HIIHFWLYH�DJDLQVW�Variola�DV�ZHOO���0RVW�KHDOWKFDUH� IDFLOLWLHV� XVH� KLJKHU� OHYHO�GLVLQIHFWDQWV�WKDQ�WKRVH�ZKLFK�LQDFWLYDWH�
© National Center of Continuing Education Bioterrorism Page 13
Vaccinia��VR�LW�LV�H[SHFWHG�WKDW�WKHVH�GLV-LQIHFWDQWV�ZLOO�DOVR�LQDFWLYDWH�Variola in
SDWLHQW�FDUH�DUHDV���)RU�PRUH�LQIRUPDWLRQ��see the CDC website at http://emergency.
FGF�JRY�DJHQW�VPDOOSR[�UHVSRQVH�SODQ�ÀOHV�JXLGH�I�SGI��
Plague
(WLRORJ\Plague is caused by the bacterium
Yersinia pestis,� D�PHPEHU� RI� WKH�En-
terobacteriaceae� IDPLO\��Y. pestis is a
gram-negative coccobacillus that shows
D�FKDUDFWHULVWLF�´VDIHW\�SLQµ�DSSHDUDQFH�with staining. These bacteria are easily
destroyed by sunlight and drying but
may survive up to 1 hour when released
into the air. Y. pestis causes three main
W\SHV� RI� SODJXH� LQ� KXPDQV�� � EXERQLF��septicemic, and pneumonic. Pharyngeal
plague, meningeal plague, and ocular
SODJXH�DUH�OHVV�FRPPRQ�IRUPV�
(SLGHPLRORJ\
Plague has long been recorded in
KLVWRU\���7KH�SDQGHPLF�3ODJXH�RI�-XVWLQ-
LDQ����������$'���ZDV�GXH�WR�EXERQLF�plague likely originating in China. It was
VSUHDG� WKURXJK� WKH� LPSRUWLQJ� RI� HQRU-PRXV� DPRXQWV�RI� JUDLQ� IURP�(J\SW� WR�&RQVWDQWLQRSOH�DV�UDWV�DQG�ÁHDV�RQ�JUDLQ�VKLSV�LQIHVWHG�WKH�JUDLQ��7KH�%ODFN�'HDWK�pandemic (1347-1351) that occurred in
&KLQD��$VLD��(XURSH��DQG�$IULFD�IROORZHG�later, killing an estimated 75-100 mil-
OLRQ�SHRSOH���7KH�´EODFN�GHDWKµ�UHIHUUHG�to the characteristic black color due to
F\DQRVLV�DQG�JDQJUHQH�RI�WKH�ÀQJHUV�DQG�WRHV�DV�WKH�GLVHDVH�SURJUHVVHG���$�WKLUG�pandemic that began in China in 1855
killed more than 12 million in China and
India alone and involved both bubonic
DQG�SQHXPRQLF�IRUPV���5HPQDQWV�RI�WKLV�SDQGHPLF�DUH�WKH�OLNHO\�VRXUFH�IRU�WKH�Y.
pestis currently present in the U.S.
Plague is transmitted to humans by
ÁHDV�WKDW�KDYH�ELWWHQ�DQ�LQIHFWHG�DQLPDO�and then bite a human. Plague can also
EH�WUDQVPLWWHG�E\�KDQGOLQJ�DQ�LQIHFWHG�animal or by close person- to- person
FRQWDFW� LQ�FDVHV�RI�SQHXPRQLF�SODJXH��7KH�:+2�UHSRUWV�������WR�������FDVHV�RI�ZRUOGZLGH�SODJXH�HDFK�\HDU���3ODJXH�naturally occurs in animals throughout
WKH�ZHVWHUQ�8QLWHG�6WDWHV��$FFRUGLQJ�WR�the CDC, human cases in the U.S. occur
LQ�WZR�PDLQ�UHJLRQV������QRUWKHUQ�1HZ�0H[LFR��QRUWKHUQ�$UL]RQD��DQG�VRXWKHUQ�&RORUDGR��SULPDULO\�IURP�URFN�VTXLUUHOV�DQG�WKHLU�ÁHDV��DQG����&DOLIRUQLD��VRXWK-
HUQ�2UHJRQ�� DQG� IDU�ZHVWHUQ�1HYDGD��SULPDULO\� IURP� JURXQG� VTXLUUHOV� DQG�WKHLU�ÁHDV��'RPHVWLF�FDWV�DUH�DOVR�HDVLO\�LQIHFWHG�DQG�FDQ�EULQJ�LQIHFWHG�ÁHDV�RU�rodents into the home. Dogs are some-
WLPHV�LQIHFWHG��7KHUH�DUH��������FDVHV�RI�plague in the U.S. each year, primarily
in rural areas.
It is most likely that Y. pestis would be
DHURVROL]HG�LQ�DQ�DWWDFN�RI�ELRWHUURULVP��FDXVLQJ�WKH�FRQWDJLRXV�SQHXPRQLF�IRUP�RI�SODJXH�
Clinical Presentation, Diagnosis, and Treatment
Bubonic plague has an incubation
SHULRG�RI���WR���GD\V��,QLWLDO�V\PSWRPV�LQFOXGH�IHYHU��KHDGDFKH��H[KDXVWLRQ��DQG�JHQHUDO�PDODLVH�� IROORZHG� E\� SDLQIXO�swollen lymph nodes. The diagnostic
VLJQ�RI� SODJXH� LV� WKH�SUHVHQFH�RI� YHU\�ODUJH�� VZROOHQ��SDLQIXO�� DQG�KRW� O\PSK�nodes (especially in the groin area)
called buboes (see Figure 7). The dis-
ease progresses rapidly and can lead to
septicemic plague as bacteria invade
WKH� EORRGVWUHDP�� � ,I� DQWLELRWLF� WKHUDS\�is not started, pneumonic plague may
IROORZ�� �3ULPDU\�SQHXPRQLF� SODJXH KDV�DQ�LQFXEDWLRQ�SHULRG�RI���WR���GD\V���3DWLHQWV�SUHVHQW�ZLWK�KLJK�IHYHU��FKLOOV��FRXJK��DQG�EORRG\�VSXWXP���'LDJQRVLV�RI�plague is made by patient history, symp-
toms, and blood and lymph node speci-
PHQ�FXOWXUHV�� �/DE� LGHQWLÀFDWLRQ�PXVW�EH�KDQGOHG�DW�D�PLQLPXP�RI�ELRVDIHW\�OHYHO����%6/��� or at ELRVDIHW\�OHYHO����%6/���� LI� FXOWXUHV� KDYH� SRWHQWLDO� IRU�antibiotic resistance or there is aerosol
production.
3DWLHQWV� VXVSHFWHG� RI� KDYLQJ� SODJXH�should be isolated and promptly treated
with streptomycin or gentamicin as
SUHIHUUHG� DQWLELRWLFV�� �'R[\F\FOLQH� LV�DOVR� HIIHFWLYH� DV� DQ� DOWHUQDWLYH� GUXJ���7HWUDF\FOLQH� LV� XVXDOO\� VXEVWLWXWHG� IRU�VWUHSWRP\FLQ�WR�PLQLPL]H�WR[LFLW\�DIWHU�VHYHUDO�GD\V�RI�WKHUDS\���7UHDWPHQW�PD\�DOVR� LQFOXGH� LQFLVLRQ� DQG� GUDLQDJH� RI�buboes. Without antibiotic treatment,
bubonic plague has a 13.5% mortality
rate, septicemic plague has a near 100%
mortality rate, and pneumonic plague has
a 57% mortality rate.
Prophylactic antibiotic treatment with
FLSURÁR[DFLQ�RU�GR[\F\FOLQH�IRU����GD\V�LV� UHFRPPHQGHG� IRU� DQ\� FRQWDFWV� RI�SHUVRQV�RU�SHWV�ZLWK�FRQÀUPHG�RU�VXV-pected pneumonic plague. Prophylactic
WUHDWPHQW�LV�QRW�QHFHVVDU\�IRU�FRQWDFWV�RI�EXERQLF�RU�VHSWLFHPLF�SODJXH���$QWLELRWLF�WKHUDS\� LV� DOVR� UHFRPPHQGHG� IRU� DQ\�SHUVRQV�H[SRVHG�WR�ÁHD�ELWHV�RI�ZLOG�UR-
GHQWV�RU�WLVVXHV�DQG�ÁXLGV�RI�DQ�LQIHFWHG�DQLPDO�GXULQJ�DQ�RXWEUHDN�RI�SODJXH�
In 1999, plague vaccine production
was stopped because it was unlikely to
SURWHFW�IURP�SULPDU\�SQHXPRQLF�SODJXH���There is now no commercially available
vaccine in the U.S., but new vaccines
being developed against primary pneu-
monic plague are in clinical trials.
,W�LV�WKH�ODZ�WKDW�DOO�FDVHV�RI�VXVSHFWHG�plague be immediately reported to lo-
cal and state public health departments
DQG�WKDW�D�GLDJQRVLV�LV�FRQÀUPHG�E\�WKH�CDC. The CDC must then report all
FDVHV�RI�SODJXH�WR�WKH�:+2��
PPE, Infection Control, and Decontamination
Isolation precautions are standard
IRU� SHUVRQV�ZLWK�EXERQLF� SODJXH��ZLWK�GURSOHW� SUHFDXWLRQV� DGGHG� IRU� DQ\RQH�ZLWK�SQHXPRQLF�SODJXH�XQWLO����KRXUV�RI�antibiotic therapy have elapsed. Droplet
SUHFDXWLRQV� DUH� DOVR� UHFRPPHQGHG� IRU�all patients until pneumonia has been
UXOHG�RXW�DQG�WUHDWPHQW�KDV�EHJXQ���$Q\�laboratory spills should be covered in
DEVRUEHQW�PDWHULDO� DQG�ÁRRGHG�ZLWK� D������EOHDFK�VROXWLRQ�WKDW�LV�OHIW�RQ�IRU����PLQXWHV�DQG�WKHQ�FOHDQHG���([SRVHG�VNLQ�should be cleaned with a nonabrasive
VRDS�DQG�ZDWHU��$Q\�FRQWDPLQDWHG�PDWH-ULDO�VKRXOG�EH�GLVSRVHG�RI�LQ�ELRKD]DUG�waste bags and autoclaved. Workers
H[SRVHG�LQ�WKH�ÀHOG�PXVW�ZHDU�SURWHFWLYH�clothing, gloves, booties, and positive
Figure 7: Patient with plague showing a swollen and ruptured inguinal lymph node known as a bubo. Photo taken from CDC Public Health Image Library
Page 14 Bioterrorism © National Center of Continuing Education
SUHVVXUH�+(3$�ÀOWHUHG�UHVSLUDWRUV���33(�PXVW�EH�GHFRQWDPLQDWHG�RU�GLVSRVHG�RI�as biohazardous waste.
7XODUHPLD
(WLRORJ\7XODUHPLD��DOVR�NQRZQ�DV�UDEELW�IHYHU�
RU�GHHU�Á\�IHYHU��LV�D�KLJKO\�LQIHFWLRXV�zoonotic disease that is endemic in many
SDUWV�RI�WKH�ZRUOG�DQG�LQ�1RUWK�$PHULFD���It is caused by the gram-negative,
nonmotile coccobacillus Francisella
tularensis. F. tularensis is an intracel-
lular bacterium that lives and multiplies
within the host’s macrophage cells.
(SLGHPLRORJ\7XODUHPLD�LV�VSUHDG�E\�WKH�ELWH�RI�WLFNV��
GHHU�ÁLHV��RU�RWKHU�DUWKURSRGV�� FRQWDFW�ZLWK�DQ�LQIHFWHG�DQLPDO��PRVW�FRPPRQO\�UDEELWV��LQJHVWLRQ�RI�XQGHUFRRNHG�PHDW�RI� LQIHFWHG� DQLPDOV�� LQJHVWLRQ� RI� FRQ-
WDPLQDWHG�ZDWHU�� RU� LQKDODWLRQ�RI� FRQ-
taminated dusts or aerosols. There are
DERXW�����FDVHV�RI�QDWXUDOO\�RFFXUULQJ�tularemia per year in the U.S., and it has
EHHQ�UHSRUWHG�LQ�HYHU\�VWDWH�H[FHSW�+D-waii. Domestic cats are very susceptible
and can transmit the disease to humans.
F. tularensis in natural conditions can
VXUYLYH�H[WHQGHG�SHULRGV�LQ�FROG��PRLVW�environments.
It is most likely that F. tularensis
ZRXOG� EH� DHURVROL]HG� LQ� DQ� DWWDFN� RI�bioterrorism, causing primarily the
SQHXPRQLF�IRUP�RI�WKH�GLVHDVH�
Clinical Presentation, Diagnosis, and Treatment
Patients with tularemia present with
GLIIHUHQW�V\PSWRPV�GHSHQGLQJ�RQ�KRZ�the bacteria enters the body. Onset may
EH�DEUXSW��ZLWK�IHYHU��FKLOOV��KHDGDFKH��ERG\� DFKHV�� DQG� VRUH� WKURDW�� �1DXVHD��vomiting, and diarrhea may also be pres-
HQW���8S�WR�����RI�SDWLHQWV�PD\�VKRZ�D�blotchy rash that may become pustular.
2WKHU� V\PSWRPV�PD\� YDU\� E\� VLWH� RI�bacterial entry:
1. Ulceroglandular: �0RVW� FRPPRQ�IRUP��IURP�HLWKHU�WKH�ELWH�RI�D�WLFN�RU�GHHUÁ\�RU�IURP�KDQGOLQJ�DQ�LQIHFWHG�DQLPDO���$�VNLQ�XOFHU�IRUPV�DW�WKH�VLWH��DQG�VZHOOLQJ�RI�O\PSK�JODQGV�LQ�WKH�armpit or groin is common.
2. Glandular: Likely occurs when
bacteria enter through an unseen
DEUDVLRQ��VLPLODU� WR�XOFHURJODQGXODU�but without an ulcer.
3. Oculoglandular: Occurs when a
SHUVRQ�WRXFKHV�WKH�H\H�DQG�WUDQVIHUV�the bacteria there. Symptoms include
SXUXOHQW� FRQMXQFWLYLWLV� RI� WKH� H\H��SHULRUELWDO� HGHPD�� DQG� VZHOOLQJ� RI�O\PSK�JODQGV�LQ�IURQW�RI�WKH�HDU�
4. 2URSKDU\QJHDO�� � 2FFXUV� IURP�consuming contaminated meat
(usually rabbit) or water. Symptoms
LQFOXGH� VRUH� WKURDW�� H[XGDWLYH�tonsillitis, mouth ulcers, and swollen
lymph glands in the neck.
5. Pneumonic: 0RVW� VHULRXV� IRUP��FRQWUDFWHG� DIWHU� EUHDWKLQJ� GXVW� RU�aerosols containing the bacteria or
ZKHQ� RWKHU� IRUPV� RI� WXODUHPLD� DUH�OHIW�XQWUHDWHG�DQG�GLVHDVH�SURJUHVVHV�to the lungs via the bloodstream.
Symptoms include dry cough,
VXEVWHUQDO�FKHVW�SDLQ��DQG�GLIÀFXOW\�breathing.
6. 7\SKRLGDO��VHSWLFHPLF��� Symptoms
LQFOXGH�IHYHU��FKLOOV��ZHLJKW�ORVV��DQG�malaise, and possibly pneumonia.
'LIÀFXOW� WR� GLDJQRVH� EHFDXVH� WKHUH�LV�XVXDOO\�DQ�DEVHQFH�RI�XOFHUV� DQG�lymphadenopathy.
'LDJQRVLV�RI�WXODUHPLD�LV�GLIÀFXOW�EH-cause the disease is rare and symptoms
UHVHPEOH�WKRVH�RI�RWKHU�LOOQHVVHV���5RX-
WLQH�ODE�ZRUN�LV�QRW�GLDJQRVWLF���$�WKRU-RXJK�SDWLHQW�KLVWRU\�VKRZLQJ�H[SRVXUH�to animals or insect bites is important.
Diagnosis is generally made with sero-
logical testing. Blood and tissue cultures
VKRZLQJ�JURZWK�RI�F. tularensis are also
GLDJQRVWLF�� � /DEV� VKRXOG� EH� DOHUWHG� LI�tularemia is suspected because special
FXOWXUH�PHGLD� LV� UHTXLUHG� IRU� EDFWHULDO�SURSDJDWLRQ���$GGLWLRQDOO\��ODE�LGHQWLÀFD-tion must be handled at ELRVDIHW\�OHYHO����%6/��� or at ELRVDIHW\�OHYHO����%6/����LI�SURFHGXUHV�DUH�PRUH�FRPSOLFDWHG�RU�might produce aerosols.
The CDC recommends intravenous
antibiotic treatment with streptomycin as
WKH�GUXJ�RI�FKRLFH�DQG�JHQWDP\FLQ�DV�DQ�DFFHSWDEOH�DOWHUQDWLYH���$�����GD\�FRXUVH�is recommended. Tetracyclines and
FKORUDPSKHQLFRO� �XVHG�IRU�D�PLQLPXP�RI����GD\V��VKRXOG�EH�XVHG�ZLWK�FDXWLRQ�due to relapses and primary treatment
IDLOXUH�� �$OWKRXJK� FLSURIOR[DFLQ� DQG�ÁXRURTXLQRORQHV� DUH� QRW� DSSURYHG� IRU�WUHDWPHQW��WKHUH�KDV�EHHQ�JRRG�HIÀFDF\�in both animals and humans. F. tularensis
LV� UHVLVWDQW� WR�SHQLFLOOLQV�DQG�ÀUVW�JHQ-
eration cephlasporins. Patients should
respond quickly with correct antibiotic
treatment, and dramatic changes should
be observed within 24-48 hours.
Currently, there is a live attenuated
vaccine that has been used to protect
ODE�ZRUNHUV� WKDW� LV�XQGHU�)'$�UHYLHZ���There is no immune globulin available
IRU� WUHDWPHQW�� DQG� QR� DQWLELRWLFV� DUH�OLFHQVHG� IRU� SUH�H[SRVXUH� SURSK\OD[LV��3RVWH[SRVXUH� SURSK\OD[LV� ODVWLQJ� ���GD\V�VKRXOG�EHJLQ�ZLWKLQ����KRXUV�DIWHU�H[SRVXUH�ZLWK�HLWKHU�GR[\F\FOLQH�RU�FLS-
URÁR[DFLQ�DV�WKH�GUXJV�RI�FKRLFH��
PPE, Infection Control, and Decontamination
Isolation precautions are standard and
SDWLHQW�LVRODWLRQ�LV�QRW�UHFRPPHQGHG�IRU�tularemia because person- to- person
transmission is rare. Standard hospital
GHFRQWDPLQDWLRQ�SURFHGXUHV�IRU�VXUIDFHV�DQG�ODXQGU\�DUH�VXIÀFLHQW���
%RWXOLQXP�7R[LQ
(WLRORJ\%RWXOLQXP�WR[LQV�DUH�SURGXFHG�E\�WKH�
DQDHURELF�JUDP�SRVLWLYH�VSRUH�IRUPLQJ�bacillus Clostridium botulinum and two
other Clostridium species. There are
VHYHQ� QHXURWR[LQV�� NQRZQ� DV� W\SHV�$�through G, which are produced when the
bacterial spores return to the vegetative
state under anaerobic conditions. The
$��%��DQG�(�W\SHV�FDXVH�KXPDQ�GLVHDVH���Types C and D cause animal disease.
%RWXOLQXP� WR[LQV� DUH� WKH�PRVW� WR[LF�compounds per weight known to man.
They can be absorbed through the respi-
ratory tract, eyes, skin breaks, and mu-
FRXV�PHPEUDQHV��7KH�WR[LQV�FDQ�ELQG�WR�WKH�SUHV\QDSWLF�MXQFWLRQ�RI�HLWKHU�QHXUR-
muscular or autonomic nerve junctions.
Once bound, the damage is irreversible.
7KH�WR[LQV�ZRUN�WR�EORFN�QHXURPXVFXODU�WUDQVPLVVLRQ�E\�SUHYHQWLQJ�WKH�UHOHDVH�RI�acetylcholine across the nerve synapse.
5HFRYHU\�FDQ�RFFXU�RQO\�LI�WKH�QHXURQ�GHYHORSV�D�QHZ�D[RQ��D�SURFHVV�WKDW�PD\�take several months. Without treatment,
GHDWK�RFFXUV�GXH�WR�SDUDO\VLV�RI�UHVSLUD-WRU\�PXVFOHV�� �%RWXOLQXP�WR[LQ� LV�DOVR�XVHG� IRU�PHGLFDO� SXUSRVHV�� LQFOXGLQJ�WUHDWPHQW� RI� VWUDELVPXV��PXVFOH� SDLQ�GLVRUGHUV��H[FHVVLYH�XQGHUDUP�VZHDWLQJ��and chronic migraines. It is also used in
FRVPHWLF�SURFHGXUHV��%RWR[��
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© National Center of Continuing Education Bioterrorism Page 15
Family Virus & mortality rate
Disease Natural Reservoir
Regions Found
Filoviridae
These viruses are transmitted through
exposure to natural reservoir, and person to
person transmission.
Marburg (mortality up to 25%)
Marburg Fever Likely to be
Fruit bats
Marburg W. Germany, Yugoslavia, Africa
Ebola (mortality as high
as 90% with certain strains of Ebola)
Ebola HF Tropical Regions of
Africa
Arenaviridae Lassa (<10% of cases are severe but mortality
can reach 25% in these)
Lassa Fever Old world
rats and mice
Rural W. Africa
These viruses are
transmitted through inhalation of aerosols
from rodent urine or excrement, ingestion of
rodent-contaminated food, or direct contact
of broken skin with rodent excreta. Also
person to person transmission.
Lujo Unnamed HF LUsaka, Zambia, and
JOhannesburg, S. Africa
Junin (mortality 15-30%)
Argentine HF New World
rats
and mice.
Argentina
Machupo (mortality 15-
30%)
Bolivian HF Bolivia
Guanarito (mortality
15-30%)
Venezuelan HF Venezuela
Sabia Brazilian HF Brazil
Chapare Unnamed HF Bolivia
Whitewater Arroyo Whitewater Arroyo HF W. United States
��� �throughout literature. Clostridia spp.
FDQ�EH� IRXQG� WKURXJKRXW� WKH�ZRUOG� LQ�VDPSOHV� WDNHQ� IURP� VRLO��PDULQH� VHGL-PHQWV��KRXVHKROG�GXVW��DQG�WKH�VXUIDFHV�RI�IRRG�7KHUH�DUH�6L[�W\SHV�RI�ERWXOLVP�
1. Foodborne botulism IURP� HDWLQJ�IRRGV�WKDW�ZHUH�LPSURSHUO\�FDQQHG�RU�preserved and are contaminated with
SUHIRUPHG�WR[LQ���2FFXUV�SULPDULO\�LQ�KRPH��FDQQHG�IRRGV�
2. Wound botulism � I URP� WR[LQ�SURGXFHG� LQ� DQ� LQIHFWHG� ZRXQG���0D\�EH�IRXQG�LQ�FDVHV�VHFRQGDU\�WR�
VXUJHU\�RU�WUDXPD��LQ�FDVHV�RI�VLQXVLWLV�IURP� LQWUDQDVDO� FRFDLQH� DEXVH�� RU�LQ� FDVHV� RI� VXEFXWDQHRXV� KHURLQ�injection (especially black tar heroin
XVH�LQ�&DOLIRUQLD��3. Infant botulism� RFFXUV� LQ� LQIDQWV�XQGHU���\HDU�ROG�IURP�FRQVXPSWLRQ�RI�VSRUHV�LQ�IRRG��KRQH\��WKDW�JHUPLQDWH�and colonize the intestines.
4. Adult intestinal toxemia botulism RFFXUV� DIWHU� SHUVRQV� ZLWK� ERZHO�conditions that disrupt normal
LQWHVWLQDO� IORUD� FRQVXPH� VSRUH�FRQWDLQLQJ�IRRG�
5. Iatrogenic botulism� RFFXUV� IURP�DFFLGHQWDO�RYHUGRVH�RI�SKDUPDFHXWLFDO�ERWXOLQXP� WR[LQ�� � &DVHV� DUH� UDUH�EHFDXVH�WKH�)'$�UHTXLUHV�GRVHV�WR�EH�EHORZ�KXPDQ�WR[LFLW\�OHYHO��
6. Inhalational botulism is rare and
only recently seen in lab workers who
DFFLGHQWDOO\�LQKDOHG�WR[LQ�7KHUH�DUH�DERXW�����UHSRUWHG�FDVHV�RI�
ERWXOLVP�LQ�WKH�8�6��SHU�\HDU��,Q�D�FDVH�RI�ELRWHUURULVP��ERWXOLQXP�WR[LQ�FRXOG�EH�spread through aerosolization or through
Table 5: Characteristics of Filoviruses and Arenaviruses 6RXUFH���1&&(�*UDSKLFV
Page 16 Bioterrorism © National Center of Continuing Education
IRRG�DQG�ZDWHU�FRQWDPLQDWLRQ�
Clinical Presentation, Diagnosis, and Treatment:LWKLQ� ��� KRXUV� RI� H[SRVXUH� WR� WKH�
WR[LQ�� SDWLHQWV� SUHVHQW� ZLWK� FODVVLF�symptoms, including dry mouth, double
vision, blurred vision, ptosis, slurred
speech, dysphagia, and muscle weak-
QHVV���)HYHU�LV�DEVHQW��DQG�SDWLHQWV�DUH�IXOO\� DOHUW�ZLWK� IXOO\� LQWDFW� VHQVDWLRQ���Overall, a descending motor paralysis
can be seen as respiratory muscles, arms
�DQG�OHJV�EHFRPH�DIIHFWHG��,QIDQWV�DUH�OH-thargic and have a weak cry, poor muscle
WRQH��SRRU�IHHGLQJ��DQG�FRQVWLSDWLRQ����Diagnosis is based on patient his-
WRU\�DQG�SK\VLFDO�DQG�QHXURORJLF�H[DPV�DQG�LV�FRQÀUPHG�E\�ODE�DQDO\VLV�� �/DE�LGHQWLÀFDWLRQ�PXVW� EH� KDQGOHG� DW�bio-VDIHW\� OHYHO����%6/��� or at ELRVDIHW\�OHYHO����%6/����LI�SURFHGXUHV�DUH�PRUH�complicated or might produce aerosols.
Suspected cases must be immediately
reported to state health departments that
ZLOO�WKHQ�QRWLI\�WKH�&'&�����7UHDWPHQW�FRQVLVWV�RI�SURPSW�GRVLQJ�
RI� DQWLWR[LQ� DQG� LQWHQVLYH� VXSSRUWLYH�WKHUDS\���,I�ERWXOLVP�LV�VXVSHFWHG��DQWL-WR[LQ�VKRXOG�EH�JLYHQ�DV�VRRQ�DV�SRVVLEOH��SULRU� WR� ODE� FRQÀUPDWLRQ�� EHFDXVH� LW�can minimize subsequent nerve damage
and speed recovery. It will not reverse
DQ\� H[LVWLQJ� SDUDO\VLV��7KH�KHSWDYD-OHQW� ERWXOLVP� DQWLWR[LQ� �+%$7�� RI�equine origin is available through a
&'&�VSRQVRUHG� )'$� ,QYHVWLJDWLRQDO�1HZ�'UXJ��,1'��SURWRFRO�IRU�QRQLQIDQW��naturally occurring botulism. It is now
WKH�RQO\�DQWLWR[LQ�DYDLODEOH�IRU�QRQLQIDQW�ERWXOLVP�� � ,QIDQW�botulism immune JORELQ� �%DE\�%,*�� LV� DYDLODEOH� IURP�WKH�&DOLIRUQLD�6WDWH�+HDOWK�'HSDUWPHQW���6NLQ�WHVWLQJ�IRU�VHQVLWLYLW\�WR�VHUXP�RU�DQWLWR[LQ�PXVW� EH� SHUIRUPHG� SULRU� WR�DGPLQLVWUDWLRQ� RI� DQWLWR[LQ�� � 3DWLHQWV�placed on mechanical ventilation usually
UHTXLUH���WR����ZHHNV�RI�WKHUDS\�EXW�PD\�require up to seven months. There is no
FXUUHQW�YDFFLQH�IRU�ERWXOLVP�
PPE, Infection Control, and Decontamination3HUVRQ�� WR�� SHUVRQ� WUDQVPLVVLRQ� RI�
botulism does not occur, and isolation
precautions are standard. In a bioweapon
VLWXDWLRQ��WKH�SULPDU\�ULVN�RI�DHURVROL]HG�WR[LQ�IURP�D�SDWLHQW·V�ZRXQG�RU�VNLQ�LV�
ORZ���$Q\RQH�GHFRQWDPLQDWLQJ�D�SDWLHQW�H[SRVHG� WR�C. botulinum� WR[LQ� VKRXOG�ZHDU�VSODVK��SURRI�DQG�ZDWHUSURRI�RXWHU�garments, chemical resistant gloves, eye
SURWHFWLRQ��DQG�D�1,26+�DSSURYHG�1���ÀW�WHVWHG�UHVSLUDWRU��C. botulinum is in-
DFWLYDWHG�E\�D������GLOXWLRQ�RI�KRXVHKROG�bleach with a 30 minute contact time.
%RWXOLVP�WR[LQ�LQ�IRRG�LV�GHVWUR\HG�E\�KHDWLQJ�IRRG�WR�DQ�LQWHUQDO�WHPSHUDWXUH�RI����&�IRU�DW�OHDVW���PLQXWHV�
7KH�9LUDO�+HPRUUKDJLF�Fevers
(WLRORJ\�DQG�(SLGHPLRORJ\The YLUDO�KHPRUUKDJLF�IHYHUV��9+)�
DUH�D�JURXS�RI�GLVHDVHV�FDXVHG�E\�VHY-
HUDO�IDPLOLHV�RI�YLUXVHV���7KHVH�YLUXVHV�damage the body’s vascular system and
DIIHFW�PXOWLSOH� RUJDQ� V\VWHPV�� � 7KH�YLUXVHV� DUH� JURXSHG� LQWR� IRXU� JURXSV���ÀORYLUXVHV��DUHQDYLUXVHV��EXQ\DYLUXVHV��DQG�ÁDYLYLUXVHV�� �$OO�DUH�51$�YLUXVHV�DQG�WKH\�DUH�IRXQG�LQ�DUHDV�ZKHUH�WKHLU�QDWXUDO�UHVHUYRLUV�OLYH��KXPDQV�DUH�QRW�their natural reservoirs. This course will
IRFXV�RQ�WKH�ÀORYLUXVHV�DQG�DUHQDYLUXVHV�because they are in the CDC category
$�OLVW�� Table 5�VKRZV�FKDUDFWHULVWLFV�RI�ÀORYLUXVHV�DQG�DUHQDYLUXVHV�)LORYLUXVHV� EHORQJ� WR� WKH�ÀORYLULGDH
IDPLO\���7KH�WZR�PHPEHUV�RI�WKLV�IDPLO\�WKDW� KDYH� EHHQ� LGHQWLÀHG� DUH�0DUEXUJ�YLUXV�DQG�(EROD�YLUXV���7KH�QDWXUDO�UHV-ervoir is still unknown but is suspected
WR� EH� IUXLW� EDWV�� �7UDQVPLVVLRQ� RFFXUV�IURP�H[SRVXUH�WR� WKH�QDWXUDO�UHVHUYRLU���Once the virus is in a human, transmis-
sion is by close personal contact with an
LQIHFWHG�SHUVRQ��LQIHFWHG�EORRG��LQIHFWHG�ERG\�ÁXLGV��RU�FDGDYHUV���7KH\�DUH�DOVR�known to spread in laboratories through
VPDOO�SDUWLFOH�DHURVROV���$HURVRO�VSUHDG�among humans is unclear.
$UHQDYLUXVHV�EHORQJ�WR�WKH�arenaviri-
dae�IDPLO\��0HPEHUV�RI�WKLV�IDPLO\�DUH�/DVVD� YLUXV� �/DVVD� IHYHU��� -XQLQ� YLUXV��$UJHQWLQH�KHPRUUKDJLF�IHYHU���0DFKX-
SR�YLUXV��%ROLYLDQ�KHPRUUKDJLF�IHYHU���*XDQDULWR� YLUXV� �9HQH]XHODQ� KHPRU-UKDJLF� IHYHU��� 6DELD� YLUXV� �%UD]LOLDQ�KHPRUUKDJLF�IHYHU���:KLWHZDWHU�$UUR\R�virus (whitewater arroyo hemorrhagic
IHYHU���DQG�PRVW�UHFHQWO\�WKH�/XMR�YLUXV�discovered in 2009. These viruses are
VSUHDG�WKURXJK�H[SRVXUH�WR�URGHQWV�DQG�human- to- human contact.
,Q�D�FDVH�RI�ELRWHUURULVP��YLUXVHV�FDXV-
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Clinical Presentation, Diagnosis, and Treatment,QFXEDWLRQ�IRU�9+)V�LV���WR����GD\V���
$OWKRXJK�WKHUH�DUH�GLIIHUHQFHV�LQ�V\PS-
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EOHHGLQJ�PDQLIHVWDWLRQV�WKDW�UDQJH�IURP�HFFK\PRVLV�WR�RYHUW�EOHHGLQJ���1DXVHD��vomiting, bloody diarrhea, abdominal
pain, maculopapular rash, sore throat,
chest pain, and jaundice are also com-
mon symptoms. Tremor, seizures, coma,
DQG�GHDWK�PD\�IROORZ�Diagnosis is made by a thorough pa-
WLHQW�KLVWRU\�DQG�GHÀQLWLYH�ODE�DQDO\VLV���$Q\� VXVSHFWHG� FDVHV� RI�9+)�PXVW� EH�LPPHGLDWHO\�UHSRUWHG�WR�WKH�&'&·V�9LUDO�6SHFLDO�3DWKRJHQV�%UDQFK���$OO�ODE�ZRUN�must be done at�ELRVDIHW\�OHYHOV���DQG����%6/���DQG�%6/��� due to the ability
RI�WKH�YLUXVHV�WR�LQIHFW�YLD�DHURVROV�DQG�WKHLU�DELOLW\�WR�FDXVH�UDSLG�RQVHW�RI�OLIH�threatening disease.
7KHUH�LV�QR�FXUH�IRU�WKH�9+)V���7UHDW-PHQW� FRQVLVWV� SULPDULO\� RI� VXSSRUWLYH�WKHUDS\�� LQFOXGLQJ� PDLQWHQDQFH� RI�electrolytes, mechanical ventilation,
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viruses. Ribavirin is teratogenic.
$Q\� SHUVRQV� H[SRVHG� WR� D�9+)� RU�ZKR� DUH� FRQWDFWV� RI� D� SDWLHQW�ZLWK� D�9+)� VKRXOG� EH� FORVHO\� PRQLWRUHG���Prophylactic antiviral therapy is NOT
UHFRPPHQGHG���,I�WHPSHUDWXUH�LV�����)�RU�JUHDWHU��RU�LI�RWKHU�V\PSWRPV�RI�9+)�are present, and the suspected virus is not
(EROD��0DUEXUJ��RU�D�ÁDYLYLUXV��ULEDYLULQ�should be initiated.
PPE, Infection Control, and Decontamination
Isolation precautions are strict contact
precautions with airborne precautions
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rally acquired, droplet precautions can
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H[SRVXUH� LQFOXGH� FKHPLFDO� EXUQV�� VNLQ�EOLVWHULQJ� DQG� UHGQHVV�� H[WUHPH� SDLQ��coughing, choking, dyspnea, lung and
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agents can penetrate clothing and are
quickly absorbed through the skin,
decontamination must be done as soon
DV�SRVVLEOH�WR�EH�PRVW�HIIHFWLYH��SUHIHU-DEO\�ZLWKLQ��� WR���PLQXWHV�DIWHU�H[SR-
sure. Contaminated clothing should be
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clothing that must be pulled over the
KHDG�WR�UHPRYH�VKRXOG�EH�FXW�RII�LQVWHDG�WR�SUHYHQW�IXUWKHU�H[SRVXUH�RI�H\HV�DQG�PXFRXV�PHPEUDQHV�� � ,I� SRVVLEOH�� DQ\�H[SRVHG�DUHDV�RI�VNLQ�VKRXOG�EH�ZDVKHG�ZLWK� ODUJH�DPRXQWV�RI�VRDS�DQG�ZDWHU���(\HV�VKRXOG�EH�LUULJDWHG�ZLWK�ZDWHU�RU�saline. Contact lenses should be removed
and discarded with contaminated cloth-
LQJ�� �$OO� FRQWDPLQDWHG�PDWHULDO� DQG�clothing should be double- bagged in
plastic bags and tightly sealed. Persons
who have undergone decontamination
should avoid contact with others who
have not been decontaminated and
should avoid areas where the chemical
release occurred.
7UHDWPHQW� IRU� FKHPLFDO� H[SRVXUH�ZLOO�YDU\�EDVHG�RQ�WKH�W\SH�RI�FKHPLFDO�DQG� V\PSWRPV�� �0HGLFDO�PDQDJHPHQW�JXLGHOLQHV� IRU� DFXWH� FKHPLFDO� H[SR-
sure as compiled by the $JHQF\� IRU�7R[LF�6XEVWDQFHV�DQG�'LVHDVH�5HJLVWU\�
Chemical Explosion Nuclear Explosion
Amount of heat produced Several thousand degrees Millions of degrees where matter becomes plasma
Size of gaseous fireball Several meters in diameter (1meter=3.28ft)
1,450ft (~442 meters) for a 10KT nuclear device (�mile=1320ft)
Energy Released Derived from reactions between molecules
Derived from splitting (fission) of the ~atomic nuclei of uranium or plutonium
Amount of energy released when compared pound for pound
1X energy ~10 million X energy
Equivalents ~1000 tons of TNT‡
~10,000 tons of TNT
Low yield nuclear device= 1KT
Low yield nuclear device=10KT*
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Table 6: A Comparison of Chemical vs. Nuclear Explosions
Table adapted from the federal interagency document Planning Guidance for Response to a Nuclear Detonation. Available at http://www.hps.org/hsc/documents/Planning_Guidance_for_Response_to_a_Nuclear_Detonation-2nd_Edition_FINAL.pdf‡For comparison, the blast in the Oklahoma City, OK, bombing of the Murrah Federal Building in 1995 was equivalent to 2 tons of TNT.*Department of Homeland Security bases its planning factors on a low-yield nuclear device of 10KT (kilotons) detonated at ground level in an urban area.
Page 18 Bioterrorism © National Center of Continuing Education
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Radiation emergencies could be
caused by dirty bombs, nuclear blasts,
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ZLOO�EH�YLVLEOH�DV�ÀQH�SDUWLFOHV�WKH�VL]H�RI� VDQG�� �7KH� ODFN� RI� DSSDUHQW� IDOORXW�does not mean there is no radiation. The
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SRUWXQLW\���7KH�PRVW�LPSRUWDQW�IDFWRUV�LQ�SURWHFWLRQ�IURP�UDGLDWLRQ�DQG�IDOORXW�DUH��1. Distance. The greater the distance
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WKH� GLIIHUHQW� DPRXQWV� RI� VKLHOGLQJ�SURWHFWLRQ�RIIHUHG�GHSHQGLQJ�RQ�WKH�ORFDWLRQ�RI�SHUVRQV�ZLWKLQ�D�EXLOGLQJ���7KHVH� IDFWRUV� DSSO\� RQO\� WR� IDOORXW�
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UDGLDWLRQ�IDOORXW�SDUWLFOHV��WKH�JUHDWHU�the protection. The more earth, rock,
FRQFUHWH�� DQG� VR� IRUWK�� EHWZHHQ� D�SHUVRQ� DQG� IDOORXW� SDUWLFOHV�� WKH�better.
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SURSRUWLRQDO�WR�WKH�WLPH�RI�H[SRVXUH���The�HOHFWURPDJQHWLF�SXOVH��(03�� or
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Figure 8: Protection/Shielding Offered by Various Locations within a Building*
*Figure used with permission: Brooke Buddemeier, Lawrence Livermore National Laboratory. Protection factors ap-ply only to fallout from a nuclear detonation and are not appropriate for use after reactor incidents, dirty bombs, or chemical/biological events.
© National Center of Continuing Education Bioterrorism Page 19
phones and communication systems,
electrical appliances, and ignition sys-
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ZLWKLQ�D�GLVWDQFH�RI�������PLOHV�FRXOG�EH�GDPDJHG���$Q�(03�PD\�DOVR�KDUP�SDFH-makers and other electronic implants.
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LV�QRW�ZDVKHG�RII�RU�EUXVKHG�DZD\�FDQ�FDXVH�EHWD�EXUQV� WR� WKH�VNLQ�� WKHUHIRUH�,any action (such as brushing/dusting
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