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NPS Office of Public Health National Park Service
U.S. Department of the Interior
Visitor and Resource Protection Directorate
Public Health Update
Saturday, March 05, 2005
from every state except Hawaii; however,
Tularemia Other symptoms of tularemia depend on
most cases occur in south- central and
how a person was exposed to the tularemia
western states (especially Missouri,
Note: The following material is excerpted bacteria. These symptoms can include
Arkansas, Oklahoma, South Dakota, and
and edited from materials provided by CDC. ulcers on the skin or mouth, swollen and
Montana). In Eurasia, the disease is also
painful lymph glands, swollen and painful
widely endemic, although the greatest
There were at least two cases of Tularemia eyes, and a sore throat.
numbers of human cases are reported from
within the NPS system last year. northern and central Europe, especially
Scandinavian countries and those of the
Tularemia is a potentially serious illness former Soviet Union. Tularemia is almost
that occurs naturally in the United States. It entirely a rural disease, although urban and
is caused by the bacterium Francisella suburban exposures occasionally do occur.
tularensis found in animals (especially
rodents, rabbits, and hares). Throughout its range, F tularensis is found
in widely diverse animal hosts and habitats
and can be recovered from contaminated
water, soil, and vegetation. A variety of
small mammals, including voles, mice,
water rats, squirrels, rabbits, and hares, are
natural reservoirs of infection. They
acquire infection through bites by ticks,
How Does Tularemia Spread? flies, and mosquitoes, and by contact with
contaminated environments. Although
People can get tularemia many different
enzootic cycles of F tularensis typically
ways:
occur without notice, epizootics with
sometimes extensive die- offs of animal
• being bitten by an infected tick, hosts may herald outbreaks of tularemia in
deerfly or other insect humans.
The causative agent of tularemia is one of
the most infectious pathogenic bacteria
• handling infected animal Incidence
known, requiring inoculation or inhalation
carcasses
of as few as 10 organisms to cause disease.
The worldwide incidence of tularemia is
Symptoms of tularemia could include: • eating or drinking contaminated not known, and the disease is probably
food or water greatly underrecognized and
underreported. In the United States,
• sudden fever reported cases have dropped sharply from
• breathing in the bacteria, F.
several thousand per year prior to 1950 to
tularensis
• chills less than 200 per year in the 1990s. Between
1985 and 1992, 1409 cases and 20 deaths
Tularemia is not known to be spread from
were reported in the United States, for a
• headaches person to person. People who have
mean of 171 cases per year.
tularemia do not need to be isolated.
• diarrhea People who have been exposed to the
tularemia bacteria should be treated as
• muscle aches soon as possible. The disease can be fatal if
it is not treated with the right antibiotics.
• joint pain How Soon Do Infected People Get Sick?
• dry cough Symptoms usually appear 3 to 5 days after
exposure to the bacteria, but can take as
long as 14 days.
• progressive weakness
Geographic Distribution and Human
People can also catch pneumonia and Exposures
develop chest pain, bloody sputum and can
have trouble breathing and even sometimes Tularemia occurs throughout much of
stop breathing. North America and Eurasia. In the United
States, human cases have been reported
Public Health Update - 3/5/2005
Persons in all age groups were affected, but or livestock, and consult a veterinarian if Direct or indirect contact of domestic
most were children younger than 10 years they develop unusual symptoms. flocks with wild migratory waterfowl has
and adults aged 50 years or older. been implicated as a frequent cause of
epidemics. Live bird markets have also
Most cases occur in June through Avian Influenza played an important role in the spread of
September, when arthropod- borne epidemics.
transmission is most common. Cases in Note: The following information is excerpted
winter usually occur among hunters and and edited from material provided by the World The quarantining of infected farms and
trappers who handle infected animal Health Organization destruction of infected or potentially
carcasses. In the United States, cases are exposed flocks are standard control
mostly sporadic or occur in small clusters; measures aimed at preventing spread to
in Eurasia, waterborne, arthropod- borne, other farms and eventual establishment of
and airborne outbreaks involving hundreds the virus in a country’s poultry population.
of persons have been reported. Apart from being highly contagious, avian
influenza viruses are readily transmitted
Prior to the advent of antibiotics, the from farm to farm by mechanical means,
overall mortality from infections with the such as by contaminated equipment,
more severe type A strains was in the range vehicles, feed, cages, or clothing. Highly
of 5% to 15%, and fatality rates as high as pathogenic viruses can survive for long
30% to 60% were reported for untreated periods in the environment, especially
pneumonic and severe systemic forms of when temperatures are low. Stringent
72, 78
disease. Currently, the overall case- sanitary measures on farms can, however,
fatality rate of reported cases in the United confer some degree of protection.
34, 49
States is less than 2%. Type B infections
are rarely fatal.
In ulceroglandular tularemia, the form that
The disease in birds: impact and control
typically arises from handling a
measures
contaminated carcass or following an
infective arthropod bite, a local cutaneous
papule appears at the inoculation site at Avian influenza is an infectious disease of
about the time of onset of generalized birds caused by type A strains of the
symptoms, becomes pustular, and ulcerates influenza virus. The disease, which was first
within a few days of its first appearance. identified in Italy more than 100 years ago,
The ulcer is tender, generally has an occurs worldwide.
indolent character, and may be covered by
an eschar. Typically, one or more regional All birds are thought to be susceptible to
afferent lymph nodes may become infection with avian influenza, though
enlarged and tender within several days of some species are more resistant to infection
the appearance of the papule. Even with than others. Infection causes a wide
antibiotic treatment, the affected nodes spectrum of symptoms in birds, ranging
may become fluctuant and rupture. In from mild illness to a highly contagious and
oculoglandular tularemia, which follows rapidly fatal disease resulting in severe
direct contamination of the eye, ulceration epidemics. The latter is known as “highly
occurs on the conjunctiva, accompanied by pathogenic avian influenza”. This form is
pronounced chemosis, vasculitis, and characterized by sudden onset, severe
regional lymphadenitis. Glandular illness, and rapid death, with a mortality A constantly mutating virus: two
tularemia is characterized by that can approach 100%. consequences
lymphadenopathy without an ulcer.
Fifteen subtypes of influenza virus are Influenza viruses lack mechanisms for the
What Can I Do To Prevent Becoming known to infect birds, thus providing an “proofreading” and repair of errors that
Infected with Tularemia? extensive reservoir of influenza viruses occur during replication. As a result of
potentially circulating in bird populations. these uncorrected errors, the genetic
Tularemia occurs naturally in many parts of To date, all outbreaks of the highly composition of the viruses changes as they
the United States. Use insect repellent pathogenic form have been caused by replicate in humans and animals, and the
containing DEET on your skin, or treat influenza A viruses of subtypes H5 and H7. existing strain is replaced with a new
clothing with repellent containing antigenic variant. These constant,
permethrin, to prevent insect bites. Wash Migratory waterfowl – most notably wild permanent and usually small changes in the
your hands often, using soap and warm ducks – are the natural reservoir of avian antigenic composition of influenza A
water, especially after handling animal influenza viruses, and these birds are also viruses are known as antigenic “drift”.
carcasses. Be sure to cook your food the most resistant to infection. Domestic
thoroughly and that your water is from a poultry, including chickens and turkeys, The tendency of influenza viruses to
safe source. are particularly susceptible to epidemics of undergo frequent and permanent antigenic
rapidly fatal influenza. changes necessitates constant monitoring
Note any change in the behavior of your of the global influenza situation and annual
pets (especially rodents, rabbits, and hares)
Public Health Update - 3/5/2005
adjustments in the composition of reduced opportunities for further direct further spread at live poultry markets and
influenza vaccines. transmission to humans, and may have by migratory birds.
averted a pandemic.
Influenza viruses have a second The epidemic of highly pathogenic avian
characteristic of great public health That event alarmed public health influenza caused by H5N1, which began in
concern: influenza A viruses, including authorities, as it marked the first time that mid- December 2003 in the Republic of
subtypes from different species, can swap an avian influenza virus was transmitted Korea and is now being seen in other Asian
or “reassort” genetic materials and merge. directly to humans and caused severe countries, is therefore of particular public
This reassortment process, known as illness with high mortality. Alarm mounted health concern. H5N1 variants
antigenic “shift”, results in a novel subtype again in February 2003, when an outbreak demonstrated a capacity to directly infect
different from both parent viruses. As of H5N1 avian influenza in Hong Kong humans in 1997, and have done so again in
populations will have no immunity to the caused 2 cases and 1 death in members of a Viet Nam in January 2004. The spread of
new subtype, and as no existing vaccines family who had recently travelled to infection in birds increases the
can confer protection, antigenic shift has southern China. Another child in the family opportunities for direct infection of
historically resulted in highly lethal died during that visit, but the cause of death humans. If more humans become infected
pandemics. For this to happen, the novel is not known. over time, the likelihood also increases that
subtype needs to have genes from human humans, if concurrently infected with
influenza viruses that make it readily Two other avian influenza viruses have human and avian influenza strains, could
transmissible from person to person for a recently caused illness in humans. An serve as the “mixing vessel” for the
sustainable period. outbreak of highly pathogenic H7N7 avian emergence of a novel subtype with
influenza, which began in the Netherlands sufficient human genes to be easily
Conditions favourable for the emergence in February 2003, caused the death of one transmitted from person to person. Such an
of antigenic shift have long been thought to veterinarian two months later, and mild event would mark the start of an influenza
involve humans living in close proximity to illness in 83 other humans. Mild cases of pandemic.
domestic poultry and pigs. Because pigs are avian influenza H9N2 in children occurred
susceptible to infection with both avian and in Hong Kong in 1999 (two cases) and in
mammalian viruses, including human mid- December 2003 (one case). H9N2 is
strains, they can serve as a “mixing vessel” not highly pathogenic in birds. Influenza pandemics: can they be
for the scrambling of genetic material from averted?
human and avian viruses, resulting in the The most recent cause for alarm occurred
emergence of a novel subtype. Recent in January 2004, when laboratory tests Based on historical patterns, influenza
events, however, have identified a second confirmed the presence of H5N1 avian pandemics can be expected to occur, on
possible mechanism. Evidence is mounting influenza virus in human cases of severe average, three to four times each century
that, for at least some of the 15 avian respiratory disease in the northern part of when new virus subtypes emerge and are
influenza virus subtypes circulating in bird Viet Nam. readily transmitted from person to person.
populations, humans themselves can serve However, the occurrence of influenza
as the “mixing vessel”. Why H5N1 is of particular concern pandemics is unpredictable. In the 20th
century, the great influenza pandemic of
Human infection with avian influenza 1918–1919, which caused an estimated 40 to
viruses: a timeline 50 million deaths worldwide, was followed
by pandemics in 1957–1958 and 1968–1969.
Avian influenza viruses do not normally
infect species other than birds and pigs. Experts agree that another influenza
The first documented infection of humans pandemic is inevitable and possibly
with an avian influenza virus occurred in imminent.
Hong Kong in 1997, when the H5N1 strain
caused severe respiratory disease in 18 Most influenza experts also agree that the
humans, of whom 6 died. The infection of prompt culling of Hong Kong’s entire
humans coincided with an epidemic of poultry population in 1997 probably
highly pathogenic avian influenza, caused averted a pandemic.
by the same strain, in Hong Kong’s poultry
population. Several measures can help minimize the
Of the 15 avian influenza virus subtypes,
global public health risks that could arise
H5N1 is of particular concern for several
Extensive investigation of that outbreak from large outbreaks of highly pathogenic
reasons. H5N1 mutates rapidly and has a
determined that close contact with live H5N1 avian influenza in birds. An
documented propensity to acquire genes
infected poultry was the source of human immediate priority is to halt further spread
from viruses infecting other animal species.
infection. Studies at the genetic level of epidemics in poultry populations. This
Its ability to cause severe disease in humans
further determined that the virus had strategy works to reduce opportunities for
has now been documented on two
jumped directly from birds to humans. human exposure to the virus. Vaccination
occasions. In addition, laboratory studies
Limited transmission to health care of persons at high risk of exposure to
have demonstrated that isolates from this
workers occurred, but did not cause severe infected poultry, using existing vaccines
virus have a high pathogenicity and can
disease. effective against currently circulating
cause severe disease in humans. Birds that
human influenza strains, can reduce the
survive infection excrete virus for at least 10
Rapid destruction – within three days – of likelihood of co- infection of humans with
days, orally and in faeces, thus facilitating
Hong Kong’s entire poultry population, avian and influenza strains, and thus reduce
estimated at around 1.5 million birds, the risk that genes will be exchanged.
Public Health Update - 3/5/2005
Workers involved in the culling of poultry Training Courses to ensure that NPS
flocks must be protected, by proper personnel do not loose their professional National Capital
clothing and equipment, against infection. credentials at either the 24- Hour or 40- CAPT Richard Durrett (202)619- 7070
These workers should also receive antiviral Hour OSHA/NFPA certification levels.
Southeast
drugs as a prophylactic measure.
To date, this training program has resulted CDR Brian Cagle (404) 562- 3124 ext 549
When cases of avian influenza in humans in over 1600 NPS trained and certified
occur, information on the extent of Spill/Terrorism Incident Intervention Midwest
influenza infection in animals as well as Personnel. CDR Robert Reiss (402) 221- 3786
humans and on circulating influenza
viruses is urgently needed to aid the Intermountain
assessment of risks to public health and to CAPT John Collins (303) 969- 2922
guide the best protective measures.
CAPT Joe Winkelmaier (505) 988- 6040
Thorough investigation of each case is also
essential. While WHO and the members of LT George Larsen (307) 344- 2273
its global influenza network, together with LTJG Adam Kramer (929) 226- 0168
other international agencies, can assist with
many of these activities, the successful Pacific West
containment of public health risks also CDR Paul Robinson (510) 817- 1375
depends on the epidemiological and CDR John Leffel (206) 220- 4270
laboratory capacity of affected countries
and the adequacy of surveillance systems
Alaska
already in place. The training sessions outlined above
CDR John Leffel (206) 220- 4270
ensure NPS compliance with OSHA 29
Cumulative Number of Confirmed CFR 1910.120 (Hazardous Waste
Human Cases of Avian Influenza Operations and Emergency Response WASO Staff
A/(H5N1) since 28 January 2004 (HAZWOPER) Regulations and NFPA 472 Director, Office of Public Health
(Professional Competencies for Ist CAPT Chuck Higgins (202) 513- 7217
2 February 2005 Responders). This training when
completed by NPS Law Enforcement, Deputy Director, Office of Public Health
Country/ Total Maintenance, Park Police, Wildland Fire &
Deaths LCDR Jason Thomas (202) 513- 7226
Territory cases Natural Resources Personnel allows them
Cambodia 1 1 to respond to small spills of known
Program Analyst
chemicals/fuels; perform contaminated site
Thailand 17 12 work; or respond to larger chemical or fuel Sonya Coakley (202) 513- 7215
Viet Nam 37 29 spills as part of a coordinated Hazardous
Materials Spill Response Team. The Individual Park Public Health Staff
Total 55 42 Weapons of Mass Destruction (WMD) GATE LT Craig Ungerecht (718) 354- 4693
training component is designed for LE SEKI Paul Schwarz (559) 565- 3144
Notes
Rangers,Park Police, Emergency Medical LAME J. Shannon Swann (702) 293- 8985
and Public Works Personnel who are
Total number of cases includes YOSE Bernice Dommer (209) 379- 1033
mandated to have a minimum of 8- Hours
number of deaths.
of WMD training to meet Homeland
WHO reports only laboratory-
Security and Department of Justice
confirmed cases.
Training requirements as outlined in
A Variety of Contributions: HSPD5 former (Patroit Act).
Highlighting the Work of Public
CAPT Schroeder also developed NPS
Health Service Officers Assigned training courses on the Incident Command
to NPS System and Clandestine Drug Lab Hazards.
He is currently certified as an OSHA,
CAPT Alan Schroeder, Assigned to the FEMA, NIMS, Homeland Security, and
Facilities Management Program Department of Justice Trainer for all of the
(361) 949- 8173 ext. 234 course that are presented at National Parks.
CAPT Schroeder is responsible for the NPS Secondary duties include Fueling System
Service- Wide Hazardous Waste Audits of National Parks that may spill fuel
Operations Ist Responder and Weapons of during water transport and Service- Wide
Mass Destruction Trainer/Course. PMIS Project Review for Park & Regional
Hazardous Waste Management Funding
On a FY basis, he instructs (12- 15) 24- Hour Requests.
Ist Responder Operations Training
Courses; (1- 2) 40- Hour Site Technician Regional Public Health Consultants In Partnership for nearly 100 years, the
Training Course; and either instructs or Northeast National Park Service and the United States
coordinates (15- 20) 8- Hour Hazardous Public Health Service have worked together to
CAPT Barry Hartfield (978) 970- 5033
Waste Operations Annual Refresher protect the health of visitors in Americas Parks!
Public Health Update - 3/5/2005
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