BIOLOGICAL AGENTSBIOLOGICAL AGENTS

CDC has prioritized them in Lists A - CCDC has prioritized them in Lists A - C A List:A List:

Easily transmitted/disseminated Easily transmitted/disseminated High mortality rateHigh mortality rate Potential for public panicPotential for public panic Public Health impact requiring Public Health impact requiring

preparednesspreparedness

““A” LISTA” LIST Smallpox*Smallpox* Anthrax*Anthrax* PlaguePlague Botulism toxinBotulism toxin TularemiaTularemia Viral Hemorrhagic Fevers* Viral Hemorrhagic Fevers* *person to person transmission possible*person to person transmission possible

Primarily disease of animals Primarily disease of animals who ingest anthrax spores from who ingest anthrax spores from soil, (spores can last in soil for soil, (spores can last in soil for decades) decades)

Natural transmission to Natural transmission to humans by contact with humans by contact with infected animals or infected animals or contaminated animal products contaminated animal products

Cutaneous form most common Cutaneous form most common form of anthrax (usually form of anthrax (usually occupational); 224 cases in occupational); 224 cases in U.S. between 1944 – 1994U.S. between 1944 – 1994

Anthrax: OverviewAnthrax: Overview

CDC: Gram stain of B. anthracis

Anthrax: CutaneousAnthrax: CutaneousInoculation of spores Inoculation of spores underunder skin skin

through cut/abrasionthrough cut/abrasion Incubation: hours to 7 days Incubation: hours to 7 days

(average 5 days)(average 5 days) Small bump (3 – 5 days) Small bump (3 – 5 days) ulcer ulcer

surrounded by blisters 24-28h latersurrounded by blisters 24-28h later Toxin production leads to local Toxin production leads to local

edemaedema Painless black scab over ulcerPainless black scab over ulcer Painful , swollen lymph nodes Painful , swollen lymph nodes

possiblepossible Death 20% untreated; rare treated Death 20% untreated; rare treated

USAMRIID: Eschar with surroundingedema

Anthrax: InhalationalAnthrax: Inhalational Inhalation of spores, which then grow Inhalation of spores, which then grow

into bacteriainto bacteria Incubation: 1 to 43 days Incubation: 1 to 43 days Initial symptoms (2-5 d) Initial symptoms (2-5 d)

fever, cough, myalgia, malaisefever, cough, myalgia, malaise Terminal symptoms (1-2d )Terminal symptoms (1-2d )

high fever, shortness of breathhigh fever, shortness of breath Most of signs occur in lungs: swollen Most of signs occur in lungs: swollen

lymph nodes and fluid accumulationlymph nodes and fluid accumulation rapid progression to shock / death rapid progression to shock / death

because toxins released by the anthrax because toxins released by the anthrax bacteriabacteria

Mortality rate ~100% despite Mortality rate ~100% despite aggressive Rx aggressive Rx

CDC: CXR with widened mediastinum of inhalational anthrax

Anthrax: Anthrax: Post-exposure TreatmentPost-exposure Treatment

Ciprofloxacin or Doxycycline Ciprofloxacin or Doxycycline Antibiotics for 60 days without Antibiotics for 60 days without vaccine vaccine

Antibiotics for 30 days with 3 doses of Antibiotics for 30 days with 3 doses of vaccine (animal studies)vaccine (animal studies)

Antibiotic Adverse EffectsAntibiotic Adverse Effects Cipro: Nausea, vomiting, abdominal pain, Cipro: Nausea, vomiting, abdominal pain,

dizziness, headache, restlessness, confusiondizziness, headache, restlessness, confusion Doxy: GI disturbances, diarrhea, teeth staining Doxy: GI disturbances, diarrhea, teeth staining

in children < 6 y/oin children < 6 y/o Compliance?Compliance?

Between 25 – 75% of Washington D.C. postal Between 25 – 75% of Washington D.C. postal workers in 2001 did not complete course because workers in 2001 did not complete course because of side effects of antibioticsof side effects of antibiotics

Anthrax: VaccineAnthrax: Vaccine FDA approved for persons 18-65 years of ageFDA approved for persons 18-65 years of age Not entirely sure how fully it protects against Not entirely sure how fully it protects against

inhalational anthraxinhalational anthrax Six shots over 18 monthsSix shots over 18 months 3 shots (0, 2, and 4 weeks ) may be effective for 3 shots (0, 2, and 4 weeks ) may be effective for

post-exposure treatmentpost-exposure treatment

Plague: Overview Plague: Overview Bacterial disease found in certain Bacterial disease found in certain

animals:animals: rats, squirrels, chipmunks, rats, squirrels, chipmunks,

rabbits, and carnivoresrabbits, and carnivores Usual infection through contact Usual infection through contact

with rodents/fleas that have with rodents/fleas that have bitten animals carrying plaguebitten animals carrying plague

About 10-15 cases / year in U.S.About 10-15 cases / year in U.S. mainly SW statesmainly SW states bubonic most common formbubonic most common form

only 1-2 cases / yr. of only 1-2 cases / yr. of pneumonic formpneumonic form CDC: Wayson’s Stain of Y. pestis showing

bipolar staining

USAMRIID: Inguinal/femoral buboes

Plague: BubonicPlague: Bubonic

Incubation: 2-6 daysIncubation: 2-6 days Sudden onset headache, Sudden onset headache,

fatigue, muscle aches, fatigue, muscle aches, fever, tender lymph nodesfever, tender lymph nodes

Lymph nodes in area of Lymph nodes in area of flea bite will swell flea bite will swell (Buboes)(Buboes)

Not contagiousNot contagious

USAMRIID: Pneumonic infiltrateof pneumonic plague

Plague: PneumonicPlague: Pneumonic Incubation: 1-3 daysIncubation: 1-3 days Sudden onset headache, Sudden onset headache,

fatigue, fever, muscle fatigue, fever, muscle aches, cough aches, cough

Pneumonia progresses Pneumonia progresses rapidly to shortness of rapidly to shortness of breath, patient coughs up breath, patient coughs up bloodblood

Death from respiratory Death from respiratory collapse and spread of collapse and spread of infection to bloodinfection to blood

Can be contagiousCan be contagious

Plague: ProphylaxisPlague: Prophylaxis Bubonic contacts Bubonic contacts

Consider Doxycycline, Tetracycline, or sulfa drug for 7 Consider Doxycycline, Tetracycline, or sulfa drug for 7 daysdays

other close contacts, fever watch for 7 days (treat if other close contacts, fever watch for 7 days (treat if febrile)febrile)

Pneumonic contacts Pneumonic contacts consider Doxycycline, Tetracycline, orulfa drug for 7 consider Doxycycline, Tetracycline, orulfa drug for 7

daysdays

Vaccine no longer manufactured in U.S.Vaccine no longer manufactured in U.S. not protective against pneumonic plaguenot protective against pneumonic plague

Tularemia: OverviewTularemia: Overview

Acquired through contact with blood/tissue of Acquired through contact with blood/tissue of infected animals, or bites of infected deerflies, infected animals, or bites of infected deerflies, mosquitoes, or ticksmosquitoes, or ticks

About 200 cases/year in U.S.About 200 cases/year in U.S. most in rural South central and Western states most in rural South central and Western states majority of cases in summer (tick exposure)majority of cases in summer (tick exposure)

No person-to-person transmissionNo person-to-person transmission

Tularemia: Clinical Forms Tularemia: Clinical Forms Many different types of infections in lymph nodes, can Many different types of infections in lymph nodes, can

also occur in eyesalso occur in eyes

PneumoniaPneumonia Possible presentation for bioterrorist attackBTPossible presentation for bioterrorist attackBT

Tularemia: PneumonicTularemia: Pneumonic

Incubation: 3 to 5 days Incubation: 3 to 5 days (range 1-21 days)(range 1-21 days)

Abrupt onset fever, chills, Abrupt onset fever, chills, headaches, muscle aches, headaches, muscle aches, non-productive coughnon-productive cough

Patchy pneumonia on chest Patchy pneumonia on chest x-rayx-ray

Mortality 30% if untreated; Mortality 30% if untreated; < 10% if treated with < 10% if treated with antibioticsantibiotics

USAMRICD: Pneumonic infiltrates of pneumonic tularemia

Tularemia: Tularemia: Treatment/ProphylaxisTreatment/Prophylaxis

TreatmentTreatment Streptomycin or GentamicinStreptomycin or Gentamicin TetracyclinesTetracyclines

Post Exposure ProphylaxisPost Exposure Prophylaxis Fever watch for 7 days (preferable)Fever watch for 7 days (preferable) Doxycycline or Tetracycline for 14 days if febrile (Cipro also Doxycycline or Tetracycline for 14 days if febrile (Cipro also

possible)possible) Vaccine investigationalVaccine investigational

Not available for general useNot available for general use Role in treatment of disease or post-exposure prophylaxis Role in treatment of disease or post-exposure prophylaxis

unknownunknown