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					Bioterrorism
  The Basics for
General Practitioners
      Bioterrorism

The use, or threatened use, of a
micro-organism or the product of a
micro-organism in order to generate
fear, morbidity or mortality in a
population.
     Bioterrorism Agents
• Category A Diseases
  – Anthrax (Bacillus anthracis)
  – Smallpox (Variola virus)
  – Plague (Yersinia pestis)
  – Tularemia (Francisella tularensis)
  – Botulism (botulinum toxin)
  – Viral Hemorrhagic Fever
    Delivery Mechanisms

• Aerosol route
  – Easiest to disperse
  – Highest number of people exposed
  – Most infectious
  – Undetectable to humans
• Food / Waterborne less likely
  – Larger volumes required
  – More technically difficult
          Roles of Clinicians
• General Concepts
  – High level of suspicion
    • Hoofbeats could be a zebra

  – Unusual epidemiologic trends
    •   Case clustering
    •   Severe, fulminant disease in otherwise healthy
    •   Unusual for the region
    •   Similar disease in animals
           Roles of Clinicians
• For specific Bioterrorism (BT) diseases
  –   Recognize typical BT disease syndromes
  –   Perform appropriate diagnostic testing
  –   Initiate appropriate treatment/prophylaxis
  –   Report suspected cases to proper authorities
       1) Local health department
       2) Hospital epidemiologist
       3) Infectious Disease consultants
Anthrax
Bacillus anthracis
                  History

• Sporadic disease in 20th century U.S.
• Experience as biological weapon
  – U.S., 2001
     • Most letter-associated
     • 22 cases (18 confirmed), 5 deaths
  – Sverdlovsk, Russia, 1979
     • Accidental release from weapons facility
     • ≥77 cases, 66 deaths
           Epidemiology
• Forms of disease
  – Inhalational (<5% cases; 45-89% mortality)
  – Cutaneous (95%; <1-20% mortality)
  – Gastrointestinal (<5%; >50% mortality)
• Risk Factors
  – Exposure to infected animals
  – Exposure to aerosolized spores
            Microbiology

• Bacillus anthracis
  – Aerobic, large Gram positive bacillus
  – Non-motile, non-hemolytic
  – Potential mislabeling as contaminant
  – Forms hardy spores
     • Triggered by harsh environment
     • Inert but infectious
     • 1m size
Figure is not shown because the copyright permission granted
  to the Centers for the Study of Bioterrorism and Emerging
       Infections does not include usage on our website




               Jernigan, et al. EID. 2001;7:933-944.
Figure is not shown because the copyright permission granted
  to the Centers for the Study of Bioterrorism and Emerging
       Infections does not include usage on our website




               Dixon, et al. NEJM. 1999;341:815-26.
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  to the Centers for the Study of Bioterrorism and Emerging
       Infections does not include usage on our website




              Dixon, et al. NEJM. 1999;341:815-26.
Clinical Features - Inhalational
 • Incubation
   – Range 2-43, median 4-7 days
 • Prodrome
   – “flu-like” - fever, malaise, dry cough
   – Nausea, vomiting, diarrhea
   – Lack of nasal symptoms
 • Fulminant
   – Respiratory failure, shock, toxemia
Figure is not shown because the copyright permission granted
  to the Centers for the Study of Bioterrorism and Emerging
       Infections does not include usage on our website




              Inglesby, et al. JAMA. 1999;281:1735-45
  Clinical Features – Inhalational
Differential Diagnosis        Expect if anthrax
 – Influenza, viral URI’s     Rapid diagnostics –
                              Abnormal CXR
                              No nasal symptoms
 – Pneumonia                  Usually no sputum
    •   Community-acquired       May be no infiltrate
    •   Atypical
    •   Pneumonic tularemia
    •   Pneumonic plague
 – Mediastinitis              No prior surgery
 – Thoracic aortic aneurysm   Fever
 – Bacterial meningitis       Gram+ rods in CSF
Clinical Features - Cutaneous
• Most common areas of exposure
  – Hands/arms
  – Neck/head
• Incubation period
  – 3-5 days (maximum 12 d.)
• Mild constitutional symptoms
• Systemic disease rare
  – Lymphangitis/lymphadenopathy
  – Sepsis, multiorgan failure, death
Clinical Features - Cutaneous
• Progression of painless lesions

     Papule/macule – pruritic
             24-48 hrs
     Vesicle/bulla – clear or serosanguinous

     Ulcer – nonpitting, gelatinous edema
             days
     Eschar – black, depressed, rarely scars
Figure is not shown because the copyright permission granted
  to the Centers for the Study of Bioterrorism and Emerging
       Infections does not include usage on our website




       Photo courtesy of the Tropical Medicine Institute, UPCH
     Clinical Features - GI
• Oropharyngeal
  – Oral/esophageal ulcer, regional adenopathy
  – Edema/stridor, sore throat, fever, sepsis
• Intestinal
  – Early - nausea, vomiting, malaise
  – Late - hematochezia, acute abdomen, ascites
• Differential diagnosis
  – Gastroenteritis (early)
  – Any source of acute abdomen, peritonitis (late)
              Diagnosis

• High index of suspicion necessary
• Early diagnosis difficult
• Gold Standard - culture blood, fluids
  – Prior to antibiotics
• Confirmation by reference labs
  – PCR, special stains, serology, etc
• Nasal swabs not a diagnostic tool
           Treatment
• Hospitalization
• IV antibiotics
  – Empiric until sensitivities known
• Intensive supportive care
  – Electrolyte and acid-base
    imbalances
  – Mechanical ventilation
  – Hemodynamic support
• Steroids
  – Consider for severe disease
                   Treatment
• Empiric therapy for inhalational (Adults)
  – Ciprofloxacin 400 mg IV q12° OR
    Doxycycline 100 mg IV q12° AND
    One or two other antibiotics
     - clindamycin         - penicillin
    - vancomycin           - chloramphenicol
    - rifampin             - imipenem

  – Avoid macrolides, cephalosporins, sulfa
                 Treatment
• Empiric therapy for inhalational (Children)
  Ciprofloxacin 10-15 mg/kg/d IV q12° (max 1 g/d)
                  OR
  Doxycycline 2.2 mg/kg IV q12° (adult dose >8yo/45 kg)
                  AND
    One or two antibiotics (same as adult)
  – Weigh risks (arthropathy, dental enamel)
            Treatment
• Empiric therapy for cutaneous
  – Same as inhalational regimen if:
    • Systemic disease
    • Extensive edema
    • Head/neck lesions
  – Localized cutaneous
    • Ciprofloxacin 500mg po bid OR
    • Doxycycline 100mg po bid
• Empiric therapy for GI
  – Same as inhalational
                 Treatment
• Antibiotic therapy – all forms
  – Adjust per sensitivities
  – Duration
     • 60 days - delayed spore germination
     • Follow closely after cessation
  – Switch to oral
     • Clinical improvement, able to tolerate po
     • 1 or 2 drugs including cipro or doxy initially
     • Children can complete course with amoxicillin
  – No role for vaccine in treatment
Post-Exposure Prophylaxis

• Indications
  – Exposure to anthrax spores
  – Not for contacts of cases
• Oral antibiotics
  – Ciprofloxacin 500 mg po bid OR
  – Doxycycline 100 mg po bid
  – Duration 60-100 days
• +/- Vaccination
           Vaccination

• Inactivated, cell-free vaccine
• Effective
  – >95% animals vs. inhalational
  – Protective for humans vs. cutaneous
• Well-tolerated
  – Uncommon adverse effects
  – No reported deaths
• Limited supply
         Infection Control
• Person-to-person transmission
  – None for inhalational
  – Rarely reported for cutaneous
• Patient handling
  – Standard precautions
  – Gloves for draining lesions
• Laboratory safety
  – BSL-2 for clinical specimens
  – BSL-3 for environmental or large volume
Smallpox
 Variola Virus
                  History
• Ancient scourge – many millions killed
• Global eradication in 1977
• Bioweapon potential
  – Prior use in French-Indian War
  – Produced by USSR
• Stocks still exist
           Epidemiology

•   No animal reservoir/vector
•   Mortality 25-30%
•   Transmission via droplets/aerosol
•   Person-to-person transmission
    – Secondary attack rate 25-40%
    – Up to 3-20 contacts infected
    – Hi risk of nosocomial spread
            Microbiology

• Variola virus
  – Orthopoxviridae family
    • Variola strains
       – Variola major – high mortality
       – Variola minor – low mortality, 20th Century
    • Vaccinia
       – Current smallpox “vaccine”
    • Other pox viruses (cowpox, monkeypox)
           Pathogenesis
Virus contacts respiratory/oral mucosa
 Carried to nodes
   Viremia
    Organ seeding
      WBCs infected
       Dermal invasion
        Vesicle
         Sepsis
         Clinical Features
• Stages of disease
  – Incubation
     • Asymptomatic
     • 12-14 days (range 7-17)
  – Prodromal
     • Nonspecific febrile prostrating flu-like illness
     • 3-5 days
  – Eruptive
     • Characteristic rash – location, grouping,
       depth
     • Marker of infectiousness
Courtesy of National Archives
Courtesy of National Archives
Courtesy of World Health Organization
       Clinical Features

• Differential Diagnosis
  – Chickenpox (varicella)
    • Vesicles
       – Shallow
       – Asynchronous development
    • Distribution of rash
       – Centripetal
       – Spares palms/soles
            Diagnosis

• Clinical
• Traditional confirmation
  – Electron microscopy
  – Culture
• Newer rapid tests
  – Reference labs (e.g. CDC)
  – PCR, RFLP
             Treatment

• No effective antivirals
• Supportive care
  – Fluid balance
  – Electrolytes
  – Hemodynamic support
• Antibiotics for secondary infections
• Isolation
    Post-Exposure Prophylaxis
• Vaccine
  – Reduces incidence 2-3 fold
  – Decreases mortality by ~50%
• Vaccinia immune globulin (VIG)
  – 3 fold decrease in incidence and mortality
  – Passive immunity for 2 weeks
• Cidofovir – antiviral agent
  – Effective vs other poxviruses in animals
                Vaccination

• Vaccinia virus
• Stock
  – ~15million doses
  – >20 years old, still viable
• Efficacy
  – 10 fold reduction secondary attack rate
  – Substantial protection for 3-10 years
  – Multiple vaccinations boost duration
           Vaccination

• Adverse Effects
  – 3/100,000 vaccinees
• Death
  – 1/million vaccinees
• Highest risk
  – Primary vaccinees
  – Infants
           Vaccination

• Serious complications
  – Encephalitis
  – Vaccinia gangrenosum/necrosum
  – Eczema vaccinatum
• Mild complications
  – Generalized vaccinia
  – Autoinoculation
• VIG can treat/prevent
Fenner F., D. A. Henderson, et al. Smallpox and its Eradication. Geneva: WHO;
                    1988. Original photo by C. H. Kempe.
               Infection Control
• Isolation of Cases
  – Contact precautions
     • Gloves, gowns
  – Airborne precautions
     • Negative pressure HEPA filtered room, N95 masks
  – Home isolation an option
     • Avoids nosocomial spread
• Assign immune persons for care
         Infection Control
• Management of Case Contacts
  – Rash = Infectious, fever precedes rash
  – Contact identification
     • Exposure to case patient after fever onset
        – Contact with secretions or face-to-face <3 meters
     • All patients and staff in hospital with a case
  – Immediate vaccination
  – Observation (not isolation)
     • 17 day fever watch – isolate if >38°C
     • Quarantine may be necessary
Plague
Yersinia pestis
               History
• 3 Pandemics
  – Justinian - 6th century Africa/Asia
  – Black Death – 14th century Europe
  – Worldwide – 19th/20th century
• Potential for use as bioweapon
  – Unit 731 Manchuria
  – Former USSR production
            Epidemiology
• Distribution
  – Global – ~1700 cases/yr
  – Southwestern U.S. – 5-10 cases/yr
• Routes of transmission
  – Flea bites
  – Animal contact
  – Inhalation – animals, people, BT aerosol
            Epidemiology
• Forms of Disease
  – Pneumonic (2-12% of cases)
    • Inhalation (1°) or hematogenous (2°)
    • Mortality 57% (>90% if treatment delayed)
    • Most likely route for bioterrorism
  – Bubonic (84%)
    • Flea bite or animal handling
    • Mortality <5% (40-60% untreated)
  – Septicemic (13%)
    • Mortality 30-50% (>90% untreated)
              Microbiology
• Enterobacteriaceae family, Yersinia genus
  – Y.pestis, Y.enterocolitica, Y.pseudotuberculosis
• Aerobic Gram negative (cocco)bacillus
  – Intracellular
  – Bipolar staining (special stains)
• Highly virulent
  – F1 antiphagocytic capsule
  – LPS endotoxin
CDC. Available at http://www.ohd.hr.state.or.us/phl/bt/plague/levelaprocedures.pdf.
                             Accessed June 21, 2002.
          Pathogenesis
• Primary pneumonic plague
  Organisms inhaled
   Lobular lobar pneumonia
    Pulmonary necrosis
      Bacteremia
        Multiorgan seeding, failure
         Sepsis
         Clinical Features
• Primary pneumonic plague
  – Incubation 1-4 days (range 1-6)
  – Initial symptoms
     • Influenza-like syndrome (F/C/HA/myalgias)
     • N/V/D, abdominal pain common
  – 2nd day
     • Severe pneumonia – cough, hemoptysis, SOB
     • Multi-organ disease, sepsis
     • Skin manifestations – purpura, acral gangrene
  – Differential Diagnosis – any severe pneumonia
Figure is not shown because the copyright permission granted
  to the Centers for the Study of Bioterrorism and Emerging
       Infections does not include usage on our website




              Inglesby, et al. JAMA. 2000;283:2281-2290
         Clinical Features
• Bubonic Plague
  – Constitutional symptoms
  – Lymphadenopathy
    • “bubo”
    • May drain
• Septicemic Plague
  – Same flu-like illness progressing to sepsis
  – No discernible adenopathy
              Diagnosis
• High index of suspicion necessary
  – No readily available rapid tests
• Samples - blood, sputum, CSF, bubo fluid
• Preliminary – bipolar staining bacilli
• Confirmation
  – Culture – requires special biochemicals
  – Serology - retrospective
  – Rapid tests (PCR, DFA, etc) at reference labs
             Treatment
• Parenteral antibiotics
  – Aminoglycosides – 1st choice
    • Streptomycin 1 g IM bid (adults)
    • Gentamicin 5 mg/kg IV q24°
  – Tetracyclines
    • Doxycycline 100 mg IV q12°
  – Fluoroquinolones
    • Ciprofloxacin 400 mg IV q12° (adults)
  – Chloramphenicol – for meningitis
             Treatment
• Ineffective antibiotics
  – ß-lactams (penicillins, cephalosporins)
  – Rifampin
  – Aztreonam
  – Macrolides
• Switch to oral
• Duration
  – 10-14 days or at least 3 days afebrile
  Post-Exposure Prophylaxis
• Oral Antibiotics
  – Doxycycline 100 mg po bid
  – Ciprofloxacin 500 mg po bid
  – Duration 7 days
• Who should receive PEP?
  – Exposed to initial aerosol release
  – Asymptomatic contact of pneumonic case
     • Household, Hospital
     • Within two meters
            Vaccination

• No available vaccine in U.S. since 1999
• Previous vaccine
  – Killed virulent strain
  – Effective versus bubonic only
  – Minor adverse effects
           Infection Control
• Pneumonic Plague
  – Respiratory (droplet) isolation
    • Surgical mask when within 3 feet
  – Isolate until treated 48 hours
    • Must have clinical improvement
• Bubonic Plague
  – Contact isolation if draining buboes
• Specimens – BSL-2 (BSL-3 for hi-risk)
Tularemia
Francisella tularensis
               History

• Discovered early 20th century
  – Tulare county, California
  – “deerfly” fever
• Bioweapon potential
  – Incapacitating
  – Former US and USSR production
  – Prior use
    • Unit 731, Manchuria
              Epidemiology
• Distribution
  – Moderate climates – U.S., Europe, Russia, Japan
  – 125 annual U.S. cases – mostly Midwest
• Zoonosis
  – Small mammals (rabbits)
• Transmission
  – Skin contact - e.g. infected animal
  – Arthropod bite - ticks
  – Aerosolization - BT attack; lawn mowers
• Mortality
  – <2% overall, 30-60% untreated pneumonic
          Epidemiology
• Forms of disease
  – Pneumonic (<5% of cases)
    • Expected in aerosol release
  – Ulceroglandular (45-85%)
  – Glandular (5-25%)
  – Oculoglandular (<5%)
  – Oropharyngeal (<5%)
  – Typhoidal (<5-15%)
               Microbiology
• Pleomorphic Gram negative coccobacillus
  – Usually not visible in clinical specimens
  – Small (0.2 m), aerobic
  – Non-motile, non-sporulating
• Fastidious
  – Slow growth (2-3+ days)
  – Requires cysteine-enriched media
• 2 major strains (A and B)
  – A predominates in U.S., higher mortality
             Pathogenesis
• Inoculation virulent organisms
• Local infection at site
  – Lung – bronchiolitis, pneumonitis, pleuritis
• Migrate to regional lymph nodes
• Hematogenously seed multiple organs
• Suppurative immune response
       Clinical Features
• All forms of disease
  – Incubation 2-5 days (range 1-21)
  – Acute onset
  – Initial flu-like illness
    • Fevers, chills, sweats, headache
  – Lower back myalgias
  – Pulmonary symptoms
    • Cough, dyspnea, chest pain (40%)
  – Pulse/temperature dissociation (40%)
            Clinical Features
• Pneumonic form
  – Symptoms
    • Nonproductive cough, +/- hemoptysis
    • Dyspnea, pleuritic pain
  – Chest radiograph
    • Infiltrates – patchy, bilateral
    • Effusions common
• Ulceroglandular form
  – Ulcer – painful maculopapule, pustule, ulcer
CDC/Emory University/Dr. Sellers. PHIL1344
             Diagnosis
• High index of suspicion
• No readily available rapid tests
  – Gram stain unhelpful
• Gold Standards
  – Serology (retrospective)
  – Culture (insensitive, hazardous, slow)
• Rapid presumptive tests
  – DFA, IFA, PCR, IHC at reference labs
              Treatment

• Supportive care
• Parenteral antibiotics ASAP
  – Aminoglycosides
    • Streptomycin 1 g IM q12°
    • Gentamicin
       – Once-daily or traditional dosing
  – Tetracyclines – higher relapse rate
    • Doxycycline 100 mg IV q12°
    • Tetracycline - oral
                 Treatment
• Parenteral antibiotics
  – Others
     • Chloramphenicol – for meningitis
     • Ciprofloxacin
• Ineffective agents
  – ß-lactams, macrolides
• Duration of therapy
  – 10 (aminoglycosides) – 21 (tetracyclines) days
  – Switch to oral therapy when clinically improved
   Post-Exposure Prophylaxis
• Who should receive PEP?
  – Suspected very recent exposure (<3 days)
  – Not contacts of cases
• Antibiotics
  – Oral doxycycline or ciprofloxacin
  – Duration - 14 days
• Fever watch without antibiotics
  – Suspected exposure in last 3-14 days
           Vaccination

• Live, attenuated vaccine
  – Commercially available
    • For researchers
  – No proven efficacy versus pneumonic
  – Minimal adverse effects
         Infection Control
• No documented person-person spread
  – Standard precautions
• Laboratory specimens
  – Routine handling for clinical specimens
  – Alert microbiology lab if tularemia suspected
     • Pure culture hazardous to lab personnel
     • Requires BSL-2 handling with safety cabinet
Botulism
 Botulinim toxin
                  History
• Neurologic disease from botulinum toxin
  – Most lethal substance known
• History as bioweapon
  – Japanese in WWII (Unit 731)
  – Former US and USSR programs
  – Iraqi deployed weapons
  – Japanese cult in early 1990’s
                     Epidemiology
• Found worldwide
• U.S. incidence
  – ~100 cases annually (1/4 foodborne)
• Mechanisms of intoxication
  –   No person-to-person transmission
  –   Toxin ingestion (foodborne)
  –   Toxin generated from wound infection (wound)
  –   Toxin from intestinal colonization (infant, intestinal)
  –   Toxin inhalation (aerosol release)
• Mortality <10%
            Microbiology
• Clostridium botulinum
  – Large, anaerobic Gram positive bacillus
  – Spore-forming
  – Rarely infects humans
  – Produces potent neurotoxin
    • 7 types (A-G)
    • Types A,E,B most common in U.S.
    • Same general mechanism
Figure is not shown because the copyright permission granted
  to the Centers for the Study of Bioterrorism and Emerging
       Infections does not include usage on our website




             Arnon S, et al. JAMA. 2001;285:1059-70.
         Clinical Features
• Incubation 12-72 hours
  – Probably faster if inhalational exposure
• Classic syndrome
  – Acute symmetric cranial nerve palsies
     • Blurry vision, ptosis, dysphasia
  – Descending flaccid paralysis
     • Complete skeletal muscle paralysis
     • Respiratory (ventilatory) failure
  – Autonomic – urinary retention, orthostasis
  – Afebrile, normal mentation
               Clinical Features
• Differential Diagnosis
  –   Myasthenia Gravis – anticholinesterase response
  –   Guillaine-Barre Syndrome - ascending
  –   Stroke – asymmetric, abnormal brain imaging
  –   Tick paralysis – ascending, presence of tick
  –   Poliomyelitis – asymmetric, preceding viral illness
• Other features
  – Foodborne – nausea, diarrhea, dry mouth
  – Infant - constipation
               Diagnosis
• High index of suspicion necessary
  – No readily available rapid confirmatory tests
• Clinical diagnosis
• Laboratory confirmation
  –   Specimens – blood, stool
  –   At reference labs
  –   Mouse bioassay
  –   ELISA
               Treatment
• Supportive care
  – Mechanical ventilation, nutritional support
  – Prevention of secondary infections
  – Avoid aminoglycosides, clindamycin
• Passive immunization (antitoxin)
  – Halts paralysis, doesn’t reverse
  – Must be given ASAP
  – Equine antitoxin (Types A, B and E toxins)
     • Serum sickness (9%), anaphylaxis (2%)
  – Heptavalent antitoxin (Types A-G)
     • Investigational, less hypersensitivity
 Post-Exposure Prophylaxis

• Antitoxin not recommended
  – High incidence hypersensitivity
  – Limited supplies
• Clinical monitoring
  – Extreme vigilance for symptoms
  – At least 72 hours
  – Antitoxin immediately for any symptoms
            Vaccination

• Botulinum toxoid
  – No role for post-exposure prophylaxis
    • Immunity develops over months
  – Excellent efficacy
    • Not tested versus aerosol exposure
  – Few adverse effects
       Infection Control

• No person-to-person transmission
• Patient handling
  – Standard precautions
• Clinical specimens
  – Standard precautions
Viral Hemorrhagic
      Fevers
                  History
• Variety of viral illnesses
  – Similar syndrome with fevers and bleeding
• No known use as bioweapon
• Great potential for fear
  – High mortality/morbidity
  – Attention in media, entertainment
           Epidemiology
• Multiple RNA viruses, similar syndrome
  – Filoviruses
     • Ebola, Marburg
  – Arenaviruses
     • Junin [Argentinian HF], Machupo [Bolivian
       HF], Guanarito [Venezuelan HF], Lassa
  – Flaviviruses
     • Dengue [Dengue HF], Yellow Fever
  – Bunyaviruses
     • Hantaviruses [HF with Renal Syndrome],
       Congo-Crimean HF, Rift Valley Fever
          Epidemiology
• Transmission variable
  – Endemic (sporadic or epidemic)
  – Arthropod bites
  – Contact with infected animals
  – Person-to-person
    • Blood, body fluids
       – Filoviruses, CCHF, probably arenaviruses
    • Respiratory route
       – Uncommon
       – All but dengue infectious as aerosol

• Mortality up to 90%
Atlanta, Georgia: Electron Micrograph: Ebola virus causing African Hemorrhagic
               Fever. (Courtesy of the National Archives, 82-424)
             Pathogenesis
• Entry
    – Mucous membrane, needlestick
    – Inhaled
•   Viremia and spread to liver, spleen, lungs
•   Mucosal shedding preceded by fever
•   Incubation period 2 days-3 weeks
•   Vascular endothelium disruption
    – Loss of integrity of vascular endothelium
    – Edema
• Coagualation system defects
    – Hemorrhage, fibrin deposition
          Clinical Features
• Early symptoms - Fever, myalgias, malaise
• Severity - mild to fulminant
• Hallmarks
  – Disrupted vascular permeability
     • Edema, shock in severe cases
  – Bleeding diathesis
     • Mucous membrane hemorrhage, petechiae
• Thrombocytopenia, leukopenia, hepatitis
• DDX – malaria, typhoid, rickettsia, DIC
  Figure is not shown because the copyright permission granted
    to the Centers for the Study of Bioterrorism and Emerging
         Infections does not include usage on our website




Textbook of Military Medicine. Courtesy of Robert Swanepoel, PhD, DTVM, MRCVS,
     National Institute for Communicable Diseases, Sandringham, South Africa.
               Diagnosis
• High index of suspicion
  – No readily available rapid specific test
• Presumptive
  – Clinical diagnosis in outbreak setting
• Confirmation – only at reference labs
  – Serology
    • Retrospective
  – Culture from blood
    • Requires BSL-4 lab
  – PCR, etc
                  Treatment
• Supportive therapy
  – Volume, electrolyte, hemodynamic support
  – Treatment of hemorrhage
  – Minimize sedation
• Ribavirin
  – Useful for some (CCHF, Lassa)
  – No useful for others (filo-,flavivirus HF’s)
 Post-Exposure Prophylaxis

• Close monitoring for all
• Oral ribavirin
  – Investigational
     • CCHF
     • Lassa fever
• No role for vaccination
  – Immunity takes too long to develop
            Vaccination

• Vaccines available
  – Yellow Fever
    • Effective for travelers to endemic areas
    • Safe
       – Rare adverse effects
  – Others in various stages of
    development
            Infection Control
• All patients strict isolation
  – Respiratory droplet precautions
     • Surgical mask
  – Contact (barrier) precautions
     • Including face shield or goggles
• Those with the highest potential of spread
  (severe cough, hemorrhage, diarrhea)
  – Airborne precautions
     • Negative pressure room
     • HEPA filtered respirator
          Other Resources
• Web sites
  – www.bioterrorism.slu.edu (SLU-CSBEI)
  – www.bt.cdc.gov (CDC)
  – www.hopkins-biodefense.org/ (JH-CCB)
  – www.apic.org (APIC)
  – www.usamriid.army.mil (USAMRIID)

				
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