Download Bioterrorism Agents and Barrier Protection

®
ENGAGEMENT
EVIDENCE
EVIDENCE
EDUCATION
BIOTERRORISM AGENTS
AND BARRIER
PROTECTION
EDUCATION
EVIDENCE
ENGAGEMENT
EDUCATION
A SELF STUDY GUIDE
Registered Nurses
Overview
Ansell Healthcare Products LLC has an ongoing commitment to the development of quality hand barrier products
and services for the healthcare industry. This self-study, Clinical Reference Manual: Bioterrorism Agents and
Barrier Protection is one in a series of continuing educational services provided by Ansell. This educational
module examines the history and evolution of bioterrorism, including an extensive review of the six primary
biological agents and their respective clinical presentations, as well as prevention strategies and infection control
measures and appropriate barrier protection for each of the agents.
Program Objectives
Bioterrorism Agents and Barrier Protection
Upon completion of this educational activity, the learner should be able to:
1. Discuss the history of bioterrorism.
2. Discuss the disease caused by Bacillus anthracis, Anthrax.
3. Discuss the disease caused by Variola virus, Smallpox.
4. Discuss the disease caused by Clostridium botulinum, Botulism.
5. Discuss the disease caused by Francisella.
6. Discuss the diseases referred to as Hemorrhagic Fever Viruses.
7. Discuss the disease caused by Yersinia pestis, Plague.
8: Describe the characteristics of good barrier protection for the different gloving materials available.
Intended Audience
The information contained in this self-study guidebook is intended for use by healthcare professionals
who are responsible for or involved in the following activities related to this topic:
• Educating healthcare workers
• Establishing institutional or departmental policies and procedures
• Decision-making responsibilities for hand-barrier products
• Maintaining regulatory compliance with agencies such as OSHA, ADA and CDC
• Managing employee health and infection control services
Instructions
Ansell Healthcare is a provider approved by the California Board of Registered Nursing,
Provider # CEP 15538 for 3 contact hour(s). Obtaining full credit for this offering depends
on completion of the self-study materials online as directed below.
This continuing education activity is approved for 3.75 CE credits by the Association of Surgical Technologists,
Inc., for continuing education for the Certified Surgical Technologist and Certified Surgical First Assistant.
This recognition does not imply that AST approves or endorses any product or products that are included in
the presentation.
Approval refers to recognition of educational activities only and does not imply endorsement of any product or
company displayed in any form during the educational activity.
To receive contact hours for this program, please go to the “Program Tests” area and complete the post-test.
You will receive your certificate via email.
AN 85% PASSING SCORE IS REQUIRED FOR SUCCESSFUL COMPLETION
Allow 4 to 6 weeks for processing and issuance of a certificate. Any learner who does not
successfully Any learner who does not successfully complete the post-test will be notified and given an opportunity
to resubmit for certification.
For more information about our educational programs or hand-barrier-related topics, please contact Ansell Healthcare
Educational Services at 1-732-3452162 or e-mail us at [email protected].
Planning Committee Members:
Lori Jensen, RN
Pamela Werner, RN, BSN, CNOR, MBA
The planning committee members declare that they have an affiliation and financial relationship as employees of
Ansell Healthcare, which could be perceived as posing a potential conflict of interest with development of this self-study
module. This module will include discussion of commercial products referenced in generic terms only.
i
Contents
What is Bioterrorism?...............................................................................................1
History and Evolution of Bioterrorism.......................................................................1
Bacillus anthracis, Anthrax.......................................................................................3
Variola virus, Smallpox.............................................................................................5
Clostridium botulinum, Botulism..............................................................................8
Hemorrhagic Fever Viruses....................................................................................10
Francisella tularensis, Tularemia............................................................................13
Yersinia pestis, Plague ..........................................................................................15
Personal Protective Equipment...............................................................................17
Post-Test................................................................................................................20
Bibliography...........................................................................................................21
Notes................................................................................................................22–23
ii
WHAT IS
BIOTERRORISM?
Bioterrorism is defined as the deliberate
or threatened use of bacteria, viruses, or
toxins to cause disease, death, disruption,
or fear. The most likely large-scale attack of
bioterrorism is expected to be an aerosolized
agent. Any of the Category A diseases have
the potential to be aerosolized: anthrax,
smallpox, botulism, viral hemorrhagic
fevers, tularemia, and plague.
HISTORY AND
EVOLUTION OF
BIOTERRORISM
Key bioterrorist events
• Geneva Protocol signed to prohibit research
and development of biological weapons.
• United States offensive biological weapons
program dismantled.
• Biological and Toxin Weapons
Convention signed.
Bioterrorism is not a new phenomenon
and has been used as a weapon for
centuries. In 700 BC, the Assyrians
poisoned the water wells of their enemies
with the poison rye ergot. In the 1300s,
during the siege of Kaffa (now in Ukraine),
the Tartars catapulted plague-infected
corpses over the walls of the city, which
probably led to the Black Death plague
epidemic that followed. It has been said
that during Pizarro’s conquest of South
America in the 1600s, he ensured his
victory by giving the natives “gifts” of
clothing that had been tainted with the
smallpox virus. In 1763, during the French
and Indian War and under the guise of
friendship, Native Americans were given
gifts of blankets that had been previously
used by patients that died of the smallpox
virus. In 1797, Napoleon attempted to
force the surrender of Mantua by infecting
the citizens with swamp fever. During
the Civil War, Confederate troops left
carcasses of dead animals, usually horses,
in the Union soldiers’ source of drinking
water. During World War II, allegations
were made against the Germans for
attempting to spread cholera in Italy and
plague in Leningrad, and use biological
bombs over Britain. Also, it was alleged
that the Germans deployed anthrax against
their enemies in both World Wars I and II.
Other significant events in the history of
bioterrorism include:
1925: The Geneva Protocol was signed.
This document prohibited research and
development of biological weapons,
although history has proven that
offensive biological programs continued
despite the treaty.
1940: Japanese dropped plague, by planes,
at Ninpo.
1969: President Nixon dismantled the United
States offensive biological weapons
program, although research related to
defense against biological weapons
continues to this day.
Protection against Bioterrorism
1972: The Biological and Toxin Weapons
Convention was signed and ratified by
140 nations. This agreement required
termination of all offensive weapons
research and destruction of existing
stockpiles of agents.
1
1978: In London, an alleged KGB agent
assassinated a Bulgarian exile
using ricin toxin.
1984: To alter the outcome of a local election,
Rajneesh cult members sprayed
salmonella on salad bars in Oregon,
causing more than 700 people to
become ill.
1995: A sarin nerve agent attack aimed at
subway passengers in Tokyo.
2001: Letters laden with anthrax were
mailed to media, news organizations,
and politicians.
Bioterrorism Agents and Barrier Protection
The threat of biologic weapons (BW) has
increased over the last two decades with a
number of countries working on offensive
weapons (USAMRIID). Biological weapons
have distinct advantages over traditional
weapons. First, they can attack a very
large area in a very short period of time
using aerosolized biological agents.
The detection of the biological release
would most likely be delayed since
these agents are odorless, colorless,
and tasteless. Unless the terrorists call
and announce the agent they released,
the public will not be aware until victims
become ill, which is usually days or weeks
later. Using biological agents as weapons
also has the advantage of a delayed
recognition in the medical community.
The diseases produced by biological
agents all present with very similar
symptoms in the beginning, usually
non-specific flu-like symptoms that
make early diagnosis difficult. Further,
many physicians have not seen these
diseases in their medical practice and
have only read about them in medical
textbooks. Another reason that the threat
of using biological agents as weapons has
increased is that biological weapons are
very inexpensive to create.
2
At a cost of $2000 or more for
conventional weapons, a $1 in biological
weapons could produce similar results.
(AORN 2004) While nuclear weapons
production requires specific facilities,
anthrax can be germinated in a basement
laboratory. Also, the knowledge to produce
and disseminate these agents is easily
accessible through current technology,
such as the Internet. Furthermore, at
the end of the Cold War, many Russian
scientists working in offensive biological
programs lost their jobs. The whereabouts
of these Soviet scientists is an unknown
factor and the whereabouts of their
products is unclear.
Biological agents can be delivered in
several different ways, including orally
in food, and through water or air. Today,
most experts predict the most likely
method of biological attack would be a
large-scale attack using an aerosolized
agent that may or may not be contagious.
Which biological agents would pose the
greatest threat when used as a weapon?
Potentially, thousands of agents could be
used in a bioterrorism attack. However,
the Centers for Disease Control (CDC) and
the US Army Medical Research Institute of
Infectious Diseases (USAMRIID) narrowed
the list based on a number of criteria,
including how easy it is to obtain and
produce the agent, the agent’s stability in
the environment, and whether the agent
is contagious and/or lethal. Next, the CDC
grouped the agents into three categories
based on the likelihood of their use as a
biological weapon. The categories are A,
B, and C. The CDC identified the Category
A agents as high priority agents that pose
a risk to national security.
Category A consists of six diseases:
anthrax, smallpox, botulism, viral
hemorrhagic fevers, tularemia, and
plague. This study guide will review
the six Category A diseases, providing
a description, clinical manifestations,
diagnosis, treatment, post-exposure
prophylaxis, and infection control,
including appropriate barrier protection.
Bacillus anthracis,
Anthrax
DEFINITION
Anthrax is caused by Bacillus anthracis,
a gram-positive spore-forming bacterium,
and is found in soil worldwide. Humans
contract the disease from close contact
with animals or animal products infected
with the bacteria. Of the three routes of
exposure – inhalation, cutaneous, and
gastrointestinal – inhalational anthrax
is the one that is of greatest concern as
a bioweapon. (USAMRIID 2005) Inhaled
spores typically germinate 1-6 days but
there have been reports of illness up to 6
weeks after exposure in the mediastinal
lymph nodes; therefore, the time period
between exposure and onset of symptoms
may be as long as several weeks.
Scanning electron micrograph (SEM)
of bacillus anthracis in lung tissue
There are three forms of anthrax:
Cutaneous
Most common natural form. Mortality of
10% to 20% if untreated; less than 1%
when treated.
Inhalation
Most lethal form, with mortality of 45%
to 87% following inhalation of spores.
Inhalation anthrax may be complicated by
hemorrhagic meningitis in 50% of cases
and GI hemorrhage in 80% of cases.
Most likely form of the disease to occur
in a bioterrorist event.
Gastrointestinal
Results from the ingestion of large
numbers of vegetative bacilli from poorly
cooked infected meat. Due to difficulty in
early diagnosis, mortality is high.
Clinical manifestations of the three forms of Anthrax
INCUBATION
PERIOD
EARLY
SIGNS/SYMPTOMS
Inhalational
(primary involvement
is the mediastinum)
1-6 up to 40 days.
Non-specific febrile syndrome
including fever, malaise,
headache, fatigue and
drenching sweats.
Abrupt development of severe
respiratory distress with dyspnea,
stridor, cyanosis, septicemia,
shock and death.
Cutaneous
1-2 days.
Small papular or vesicular
rash that may be pruritic.
Same as above.
Gastrointestinal
1-6 days.
Fever, focal abdominal pain,
vomiting.
Hematemisis.
ANTHRAX
LATER
SIGNS/SYMPTOMS
3
TREATMENT
Treatment consists of hospitalization,
intravenous antibiotics, and intensive
supportive care. Antibiotic treatment should
be administered as soon as the diagnosis
is suspected. Early initiation can reduce
mortality, which approaches 100% when
treatment is delayed.
POST-EXPOSURE PROPHYLAXIS
Anthrax lesion on the skin caused by the
bacterium Bacillus anthracis
DIAGNOSIS
Bioterrorism Agents and Barrier Protection
Rapid field tests results have
uncertain sensitivity and specificity
for inhalation anthrax, but a widened
mediastinum with or without infiltrates
on chest x-ray is highly suggestive in
a young or otherwise healthy person
with the typical presentation. Bloody
pleural effusions are also common.
Basic diagnostic testing should include
gram stain and culture of blood, which
can be obtained following your facility’s
standard routine. Confirmatory tests
must be performed by special reference
laboratory in the Laboratory Response
Network (LRN) (JAMA 2002). The state
laboratory needs to be notified ahead of
time that anthrax is a possibility. The local
health department will investigate and
give directions on how to obtain and send
the cultures. B. anthracis can be cultured
from the lesion for laboratory confirmation
in the cutaneous form. The local health
department will need to be notified and
provide directions to obtain and send
these cultures.
4
Antibiotics should be administered to
all persons that have been exposed or
potentially exposed to the release of
anthrax before symptoms have occurred.
Patient contacts (family, friends, and
healthcare workers) who were not
originally exposed to the release do
not require prophylaxis.
VACCINATION
The Department of Defense (DoD) and the
Department of Health and Human Services
have purchased a stockpile of vaccine
doses. Vaccination is currently required for
most military deployed to Iraq, Afghanistan
and S. Korea. It is not currently being
used on the general public. Researchers
continue to develop and test new Anthrax
vaccine(s) (USAMRIID 2005).
INFECTION CONTROL
All precautions are utilized to decrease the
spread of recognized and unrecognized
infection and to prevent exposure to all
bodily fluids.
Standard Precautions –
Is recommended for all forms of
B. Anthrax
1.Handwashing
Wash hands immediately after gloves are
removed, between patient contacts, and
when otherwise indicated to avoid transfer
of microorganisms to other patients or
environments. Hand wash with soap and water
or 2% CHG after spore contact. (Weber 2003)
• Gowns should be worn when entering the
room if it is anticipated that clothing will
have contact with the patient, environmental
surfaces, or items in the room. The gown
should be removed before leaving the
patient’s room.
• Patient transport should be limited to
essential purposes only.
• Noncritical patient-care equipment should be
dedicated whenever possible.
Variola Virus,
Smallpox
DEFINITION
Gloves should be worn as standard procedure
when handling contaminated items
2.Gloves
Wear gloves when touching blood,
bodily fluids, secretions, excretions, and
contaminated items; put on clean gloves just
before touching mucous membranes and
nonintact skin.
Change gloves between tasks and
procedures on the same patient after
contact with material that may contain a
high concentration of microorganisms.
Remove gloves promptly after use, before
touching noncontaminated items and
environmental surfaces, and before going
to another patient. Wash hands immediately
to avoid transfer of microorganisms to other
patients or environments.
3.Masks, Eye Protection, Face Shields
Wear a standard surgical mask and eye
protection or a face shield to protect mucous
membranes of the eyes, nose, and mouth
during procedures and activities that are
likely to generate splashes or sprays.
Transmission Based Precautions
Several sources recommend contact
precautions for cutaneous anthrax for
persons with draining lesions.
Contact Precautions
• Place patient in a private room.
• Gloves should be worn when entering
the room and removed before leaving the
room. Hands should be washed with an
antimicrobial agent or soap and water with
spore contact.
Smallpox is the most devastating
infectious disease in the history of
mankind. This “ancient scourge”
threatened 60% of the world population
even in 1967 when World Health
Organization (WHO) launched an
intensified plan to eradicate smallpox.
(AORN 2004) The variola virus that
emerged in human populations dates
back to the 12th Century BC.
Literature dating from approximately
3700 BC in Egypt and 1100 BC in China
suggests that the original sources of
smallpox were in Asia and Africa. There is
evidence that a major smallpox epidemic
occurred at the end of the eighteenth
Egyptian dynasty. Research from the
mummy of Pharaoh Ramses V, who died
in 1157 BC, indicates that he most likely
died of smallpox. From ancient Egypt,
traders spread the disease to India, and
then to Europe during the Middle Ages.
Spanish colonists brought smallpox to
the United States in the fifteenth and
sixteenth centuries. After an extensive
and successful eradication program, WHO
declared Endemic smallpox eradicated
in 1980. There was a suspected report
of smallpox in NYC in 2002, (cnn.com)
Successful efforts to prevent the spread
of smallpox through vaccination changed
the course of history of Western medicine.
Most people think that since smallpox
was eradicated, it is no longer a threat.
5
Variola Minor
This is a much less severe and less
common form of smallpox, with death
rates of 1% or less.
CLINICAL MANIFESTATIONS
OF SMALLPOX
Bioterrorism Agents and Barrier Protection
Transmission electron micrograph (TEM)
of the smallpox virus
However, when smallpox was eradicated,
two samples were maintained for research
purposes. These samples were kept at the
CDC and in a research facility in Russia.
The potential for secret stockpiles to
exist outside these facilities continues to
be an unknown factor. In the aftermath
of the events of September and October
2001, there is heightened concern that
the variola virus might be used as a
bioterrorism agent. (USAMRIID)
Variola Major
Is a severe and more common form of
smallpox, with a more extensive rash and
higher fever. The fatality rate is around
30%. There are four types of variola major
smallpox:
1. Ordinary: the most frequent form,
accounting for 90% of all cases.
2. Modified: a mild form occurring in persons
previously vaccinated for smallpox.
3. Malignant/ Flat: Characterized by lesions
that do not develop to the pustular stage.
4. Hemorrhagic: a very rare and very
fatal form.
6
Exposure to the virus is followed by an
incubation period during which people
do not have any symptoms, may feel fine
and do not shed the virus. The incubation
period averages about 12 to 14 days,
with a range from 7 to 17 days. During
this time people are not contagious
and cannot spread the virus to others.
Typically, a two-stage illness will follow.
First is the Prodrome stage, lasting from
2 to 4 days. During this stage, the person
will present with “flu-like” symptoms
including fever, malaise, head and body
aches, and sometimes vomiting. The fever
is usually high, in the range of 101° to
104° Fahrenheit. During this stage the
person may be contagious. Two to three
days later the affected person moves to
the eruptive stage. The smallpox rash is
very characteristic. The rash emerges
first as small red spots on the tongue and
in the mouth. These spots develop into
sores that break open and spread large
amounts of the virus into the mouth and
throat. At this time, a rash will also appear
on the skin starting on the face hands and
forearms. The rash will usually spread
to all parts of the body within 24 hours.
The fever usually breaks as the skin rash
appears and the patient may feel better.
Around the third day of the skin rash, the
rash becomes raised bumps. By the fourth
day, the bumps fill with thick, opaque fluid
and have a depression in the center that
looks like a belly button (this is a major
distinguishing characteristic of smallpox).
DIAGNOSIS
Smallpox is most frequently misdiagnosed
as varicella, or chickenpox, which is
caused by the herpes virus. The most
effective criteria for distinguishing the
two infections is an examination of the
following characteristics of the lesions:
The eruptive stage of smallpox
Fever will rise again and stay high until
scabs form over the bumps. The bumps
will become pustules that are raised,
round, and firm to the touch. The pustules
then begin to form a crust and then scab
over. The pustules and scab portion takes
approximately 5 days, and the person
remains very contagious during this time.
At this time the scabs begin to fall off,
leaving pitted scars. This takes another
6 to 7 days, and the person remains
contagious. About 3 weeks after the rash
first appeared, the scabs fall off and the
person is no longer contagious.
TRANSMISSION
Person-to-person transmission of smallpox
occurs through aerosol droplets expelled
from the oropharynx of infected persons,
or by direct contact with an infected
person. It is the highest after face-to-face
contact with a patient after developing
fever and during the first week of the
rash. The virus can also be spread through
contaminated bedding and clothing, and
through direct contact with infected bodily
fluids. It is not known to be transmitted by
insects or animals.
Time and Pattern of Appearance
The most obvious distinction between
smallpox and chickenpox is the manner
in which the skin lesions appear.
In chickenpox, the lesions occur in
successive “crops.” It is possible to
determine several different stages of
lesion maturation and development at the
same time. In smallpox, the lesions appear
simultaneously. All lesions have the same
maturation.
Density and Location
Chickenpox lesions tend to be denser
over the trunk, while smallpox lesions
are denser on the face and extremities.
Smallpox is almost always seen on the
palms and soles of the feet, which is
unusual for chickenpox.
Smallpox can be confirmed in the
laboratory by electron microscopic
examination of vesicular or pustule
liquid or scabs. Definitive laboratory
identification and characterization involves
growth of the virus in the cell culture,
and characterization of strains by use of
biologic assays, including polymerase
chain reaction, restriction fragment-length
polymorphism analysis, and EnzymeLinked Immunoabsorbent Assay (ELISA).
Culture for smallpox is available only at
the LRN National Labs, at the CDC and
USAMRIID and are performed under BLS-4
conditions. Notification of the local and
state health departments is necessary.
7
TREATMENT
Currently, there are no known effective
antivirals. Provide the patient supportive
care and antibiotics for secondary
infections. The discovery of a single
suspected case of smallpox must
be treated as an international health
emergency and immediately brought to
the attention of national officials through
local and state health authorities.
POST-EXPOSURE PROPHYLAXIS
Bioterrorism Agents and Barrier Protection
All contacts must be vaccinated within 3
to 5 days. Contacts include all household
members, patients, staff, and visitors
to the hospital at the same time as the
smallpox case.7 Monitor all patient
contacts for 17 days, and if one of
the contacts starts showing signs of a
fever, they should be isolated as soon
as possible. Patients become infectious
the day before the rash, so conduct a
thorough history of all contacts the day
before they broke out, and monitor all of
those contacts.
INFECTION CONTROL
Patient(s) should be isolated and all
precautions used until all scabs separate.
Standard Precautions
1.Handwashing
Wash hands immediately after gloves are
removed, between patient contacts, and
when otherwise indicated to avoid transfer
of microorganisms to other patients or
environments.
2.Gloves
Wear gloves when touching blood,
bodily fluids, secretions, excretions, and
contaminated items. Put on clean gloves just
before touching mucous membranes and
nonintact skin.
Change gloves between tasks and
procedures on the same patient after contact
with material that may contain a high
concentration of microorganisms. Remove
gloves promptly after use, before touching
8
noncontaminated items and environmental
surfaces, and before going to another
patient, and wash hands immediately to
avoid transfer of microorganisms to other
patients or environments.
3.Masks, Eye Protection, Face Shields
Wear a standard surgical mask and eye
protection or a face shield to protect mucous
membranes of the eyes, nose, and mouth
during procedures and activities that are
likely to generate splashes or sprays.
Transmission Based Precautions
Airborne Precautions
• Place patient in a single occupancy, Airborne
Infection Isolation Room (AIIR) (formally –
Negative Pressure Isolation Room)
• For mass exposure contain those exposed in a
designated area and utilize barrier precautions.
• Use external air exhaust or high efficiency
particulate air filters if the air is recirculated.
(CDC 2007)
Contact Precautions
• Place patient in a private room.
• Gloves should be worn when entering
the room and removed before leaving
the room. Hands should be washed with
an antimicrobial agent or a waterless
handwashing agent immediately after
removing gloves.
• Gowns should be worn when entering the
room if it is anticipated that clothing will
have contact with the patient, environmental
surfaces, or items in the room. The gown
should be removed before leaving the
patient’s room.
• Patient transport should be limited to
essential purposes only.
• Noncritical patient-care equipment should
be dedicated whenever possible.
Clostridium
botulinum, Botulism
DEFINITION
Botulism is a rare but serious paralytic
illness caused by a nerve toxin produced
by the bacterium Clostridium botulinum,
the most potent neuro toxin known to
humans. There are seven (7) neurotoxins
produced by this spore-forming bacillus.
The toxins, A through G, are the most
potent neurotoxins known. There are three
(3) main types of botulism that effect
humans: foodborne, infant and wound.
In the US an average of 145 cases a year
are reported:
• Foodborne - 15%
• Infant botulism - 65%
• Wound - 20% (CDC posted 2009)
It is possible that the aerosolized form of
botulism could be used as a biological
weapon. The paralytic symptoms
would appear after inhalation or the
contamination of food or water supplies.
(USAMRIID)
The clinical manifestations are similar
for each of the botulism routes and are
dependent on the route of exposure and
dose received.
DIAGNOSIS
The patient’s clinical history and
physical examination can be an
indicator of botulism, patient(s) seeking
medical services that exhibit progressive
symmetrical descending flaccid
paralysis strongly suggests botulism.
The most sensitive testing for botulism
is mouse neutralization (bioassay) of
the patient serum.
Botulism bacteria, 80x on 35mm film
TREATMENT
Treatment consists of mechanical
ventilation support if necessary and
supportive care. Respiratory failure due
to paralysis is the most serious concern
and is usually the cause of death. Antitoxin
is available, and is particularly effective
in foodborne cases. Early administration
of antitoxin can neutralize the circulating
toxins in the body. This can prevent
patients from worsening, but recovery
still takes many weeks.
PROPHYLAXIS
A toxiod of C. Botulism for types A, B, C,
D & E is available under Investigational
New Drug (IND) therapy only. The vaccine
has several contraindications due to
hypersensitivities inherent in its production.
Clinical manifestationS of BOTULISM
BOTULISM
Botulism (all forms)
INCUBATION
PERIOD
12-36 hours, longer if
exposed to low doses
of toxin
EARLY
SIGNS/SYMPTOMS
Generally no fever. Symmetric
cranial neuropathies, such as
drooping eyelids, difficulty
swallowing or speaking.
Mental status generally alert.
LATER
SIGNS/SYMPTOMS
Symmetric descending
weakness — generalized
weakness and progressive
to respiratory failure
Sensory exam generally normal.
Blurred vision.
9
INFECTION CONTROL
Standard precautions are adequate for
HCW as B. Toxin is not dermally active
and secondary aerosols are not a hazard
(USADRIIM).
Standard Precautions
1. Handwashing
Wash hands immediately after gloves
are removed, between patient contacts,
and when otherwise indicated to avoid
transfer of microorganisms to other
patients or environments.
Bioterrorism Agents and Barrier Protection
2. Gloves
Wear gloves when touching blood,
bodily fluids, secretions, excretions, and
contaminated items; put on clean gloves
just before touching mucous membranes
and nonintact skin.
Change gloves between tasks and
procedures on the same patient after
contact with material that may contain
a high concentration of microorganisms.
Remove gloves promptly after use,
before touching noncontaminated items
and environmental surfaces, and before
going to another patient, and wash
hands immediately to avoid transfer
of microorganisms to other patients
or environments.
3. Masks, Eye Protection, Face Shields
Wear a standard surgical mask and eye
protection or a face shield to protect mucous
membranes of the eyes, nose, and mouth
during procedures and activities that are
likely to generate splashes or sprays.
hemorrhagic
fever viruses
DEFINITION
Viral hemorrhagic fevers (VHFs) refer
to a group of illnesses that are caused
by several distinct families of viruses.
These viruses occur in different endemic
locations. Their transmission if from
10
rodent reservoir, dust contaminated
excreta, ticks, body fluid or contaminated
meats of infected animals and mosquito
borne. Each disease causes a febrile
syndrome characterized by hemorrhagic
complications, but mortality rates,
incubation periods, and susceptibility
to antiviral therapy vary depending on
the etiologic agent. While some types of
hemorrhagic fever can cause relatively
mild illnesses, many of these viruses
cause severe, life-threatening disease.
These organisms pose a biological threat
due to their potential to cause severe
morbidity. Except for dengue virus, all the
VHFs are laboratory infectious by aerosol.
The four (4) viral family of viruses
considered dangerous due to their
potential for weaponization by aerosol are:
Arenaviridae
• Lassa Fever
• Argentine, Bolovian, Venezuelan VHF
Caused by Tuninvirus, Machupo,
Guanarito and Sabia viruses
Bunyaviridae
• Hanta virus genus
• Congo Crimean VHF (Nairovirus genus)
• Rift Valley Fever virus (Phlebovirus genus)
Filoviridae
• Ebola
• Marburg
Flaviviridae
• Dengue
• Yellow
DIAGNOSIS
Definitive diagnosis requires the resources
found at reference laboratories that have
biocontainment capability.
Patients presenting with an acute febrile
illness and indications of vascular
involvement, especially if a detailed history
includes travel to an endemic area should
have VHF as a presumptive diagnosis.
Notification of the local health department
POST-EXPOSURE PROPHYLAXIS
is necessary. For decisions regarding
There is no post-exposure prophylaxis
obtaining and processing diagnostic
currently available for VHFs. There is
specimens, contact local, state, and
a licensed live attenuated yellow fever
regional laboratory authorities or the CDC.
vaccine and presently no other VHF agents
available for use in USA. (USAMRIID)
TREATMENT
Patients receive supportive therapy
INFECTION PREVENTION
because there is no established cure for
Patients with VHF have large quantities
VHFs. Ribavirin, an antiviral drug, has been
of infectious viruses in their blood and
effective in treating some individuals with
body fluids and secretions. Extreme care
Lassa fever. Treatment with convalescent-
should be taken to avoid sharps injuries.
phase plasma has been used with success
Strict adherence to all infection control
for some VHFs.
precautions, in addition to increased barrier
Comparison of VHF agents & diseases (USAMRIID)
Characteristic
features
Countermeasures
No
Often biphasic,
severe second phase
with bleeding, very
high bilirubin and
transaminases, jaundice,
renal failure
17-D live attenuated
vaccine very effective
in prevention, no postexposure countermeasure
available
3-5%
No
Flu-like syndrome with
addition of cough, GI
symptoms, hemorrhage,
bradycardia
Formalin - inactivated
vaccine available in India
Siberia
0.2-3%
No
Frequent sequelae of
hearing loss, neuropsych
complaints, alopecia
TBE vaccines (not avail.
in US) may offer some
cross-protection
Ebola
hemorrhagic
fever
Africa,
Phillipines
(Ebola
Reston)
50-90% for
Sudan/Zaire
Common
Severe illness,
maculopapular rash,
profuse bleeding and DIC
Anecdotal success
with immune serum
transfusion
Marburg
virus
Marburg
hemorrhagic
fever
Africa
23-70%
Yes
CCHF
CrimeanCongo
hemorrhagic
fever
Africa, SE
Europe,
Central Asia,
India
30%
Yes
Often prominent
petechial/ecchymotic rash
Anectotal success with
Ribavirin
No
Hemorrhagic disease rare,
classically associated with
retinitis and encephalitis.
Significant threat to
livestock - epidemics
of abortion and death
of young
Human killed vaccine DOD IND, live attenuated
vaccine in clinical trials
Effective locally produced
vaccines in Asia (not avail
in U.S.). Experimental
vaccine at USAMRIID.
Ribavirin effective in
randomized, controlled
clinical trial
Disease
Endemic
Area
Mortality
Yellow
fever
virus
Yellow fever
Africa, South
America
Overall
3-12%,
20-50%
if severe
second phase
develops
KFD virus
Kyasanur
Forest
Disease
Southern
India
OHF virus
OMSK
hemorrhagic
fever
Ebola virus
Virus
Flavivirus
Filoviruses
RVF
Rift Valley
fever
Africa
<0.5%
Hantavirus
(Hantaan,
Dobrava,
Seoul,
Puumala)
Hemorrhagic
fever with
renal
syndrome
(HFRS)
Europe,
Asia, South
America
(rare)
5% for Asian
HFRS
No
Prominent renal disease,
marked polyuric phase
during recovery, usually
elevated WBC
Lassa
virus
Lassa fever
West Africa
1-2%
Yes
Frequent inapparent/
mild infection, hearing
loss in convalescence
common
Ribavirin effective in
clinical trial with nonrandomized controls
Junin
Argentine
hemorrhagic
fever
Argentinean
pampas
30%
Rare
Prominent GI complaints,
late neurologic syndrome
Immune plasma, Ribavirin
effective Candid 1 vaccine
Machupo
Bolivian
hemorrhagic
Bolivia
25-35%
Rare
Similar to AHF
Protective but not avail.
in U.S. Immune plasma
effective, Ribavirin probably
effective, Candid 1 vaccine
protects monkeys
Bunyaviruses
Arenaviruses
Nosocomial
transmission
11
precautions as suggested by USAMRIID,
should be taken when VHFs are suspected.
Additional measures may include:
• AIIR with 6-12 air exchanges
• All entering room should wear:
– Double gloves
– Impermeable gowns
– Leg and shoe coverings
– Eye protection
– N-95 (HEPA) mask or positive pressure
air-purifying respirators (PAPR’s)
• Access restricted to necessary
caregivers
Bioterrorism Agents and Barrier Protection
Person-to-person spread of VHF is via
direct contact with body fluids, cadavers,
and symptomatic patients. Inadequate use
of infection precaution methods also can
be the cause of spread. All precautions
should be employed
INFECTION CONTROL
Appropriate isolation precautions for patients
with suspected or confirmed VHF include a
combination of airborne, contact, droplet,
and standard precautions. Although airborne
transmission of these agents appears to
be rare, airborne transmission theoretically
may occur; therefore, airborne precautions
should be instituted for all patients with
suspected VHF.
TRANSMISSION BASED PRECAUTIONS
Airborne Precautions
• Place the patient in a private room with AIIR.
• Use external air exhaust or high-efficiency
particulate air filters if the air is recirculated.
• Keep the door to the room closed.
• N-95 respirator.
Contact Precautions
• Place patient in a private room.
• Gloves should be worn when entering
the room and removed before leaving
12
the room. Hands should be washed with
an antimicrobial agent or a waterless
handwashing agent immediately after
removing gloves.
• Gowns should be worn when entering the
room if it is anticipated that clothing will
have contact with the patient, environmental
surfaces, or items in the room. The gown
should be removed before leaving the
patient’s room.
• Patient transport should be limited to
essential purposes only.
• Noncritical patient-care equipment should
be dedicated whenever possible.
Droplet Precautions
• Place the patient in a private room or in a
room with other patients who have the same
infection.
• When a private room and like infection
patients are unavailable, spatial separation
of a least three feet should be maintained.
• Healthcare workers should wear a standard
surgical mask when working within three
feet of the patient.
Standard Precautions
1. Handwashing
Wash hands immediately after gloves are
removed, between patient contacts, and
when otherwise indicated to avoid transfer
of microorganisms to other patients or
environments.
2. Gloves
Wear gloves when touching blood, bodily fluids,
secretions, excretions, and contaminated
items; put on clean gloves just before
touching mucous membranes and nonintact
skin. Change gloves between tasks and
procedures on the same patient after contact
with material that may contain a high
concentration of microorganisms. Remove
gloves promptly after use, before touching
noncontaminated items and environmental
surfaces, and before going to another
patient, and wash hands immediately to
avoid transfer of microorganisms to other
patients or environments.
3. Masks, Eye Protection, Face Shields
Wear a standard surgical mask and eye
protection or a face shield to protect mucous
membranes of the eyes, nose, and mouth
during procedures and activities that are
likely to generate splashes or sprays. Place
all persons who have had close or high-risk
contact with a patient suspected of having
VHF during the 21 days following onset of
symptoms under medical surveillance. If
multiple patients with suspected VHF are
admitted to one healthcare facility, group
them in the same part of the hospital to
minimize exposure to other patients and
healthcare workers.
Francisella
tularensis, Tularemia
DEFINITION
Tularemia is an acute onset infectious
disease caused by Francisella tularensis.
There are several forms of the disease;
Typhoidal tularemia with pneumonia, and
rarely ulceroglandular or oculoglandular
forms of the disease, as well as others.
The natural occurring form of the disease
may present in infected animals and is
transmitted by bites of infected ticks,
deerflies or mosquitos. Inhaling or
ingesting, as may be delivered by dry
aerosol or sprayed over food and water
sources as a potential BW may cause the
disease. The potential use of this Category
A agent is of grave concern because it
Tularemia is commonly transmitted
through tick bites
can be extremely virulent at low doses.
Inhalation of, as low as 10 colony-forming
units can cause disease.
Tularemia occurs throughout much of
North America, Europe, and Asia.
It is resistant for months in cold
temperatures below freezing.
Clinical manifestations
of Tularemia
Tularemia is mostly a disease of rural
exposure due to its animal hosts. Persons
that hunt and farm are more likely to be
exposed to naturally occurring disease.
Most cases occur June to September.
Winter cases occur among hunters and
trappers when they handle infected animal
hides and carcasses.
Cases occurring in urban areas or in
those with no risk factors should alert
Clinical manifestationS of TULAREMIA
TULAREMIA
Pneumonic tularemia
INCUBATION
PERIOD
3-5 days; can range
from 1-14 days.
EARLY
SIGNS/SYMPTOMS
Abrupt onset, fever, headache,
chills, rigors, body aches, sore
throat, dry cough, dyspnea,
tachypnea, pleuritic pain, or
hemoptysis.
LATER
SIGNS/SYMPTOMS
Illness may be rapidly progressive
and severe or may be indolent with
progressive weakness and weight loss
over several weeks to months. The
progression of pneumonia tends to be
slower than that of pneumonic plague.
If untreated, can progress to respiratory
failure, meningitis, sepsis, shock,
and death.
13
TREATMENT
The disease can be fatal if not treated
with the right antibiotics. Administration of
parenteral antibiotics.
POST-EXPOSURE PROPHYLAXIS
Bioterrorism Agents and Barrier Protection
Post-exposure prophylaxis with antibiotics
should be initiated following confirmed or
suspected bioterrorism exposure, and for
post-exposure management of healthcare
workers and others who had unprotected
face-to-face contact with symptomatic
patients. There is an investigational live
attenuated vaccine. Research to find and
evaluate new and better vaccine is on going.
INFECTION CONTROL
Wearing gloves is an effective
precaution against infection
healthcare personnel to the possibility of a
biological attack. Treatment of tularemia is
critical to avoid progression to respiratory
failure; meningitis; kidney, spleen, or liver
involvement; sepsis; shock; and death.
DIAGNOSIS
There is no rapid diagnostic testing
available for tularemia. F. tularensis
may be diagnosed through recovery
of organisms in culture from blood, ulcers,
conjunctival exudates, sputum, gastric
washings and throat swabs. It requires
the use the use of special diagnostic and
safety procedures. Results can be read
out in several hours if the designated
reference laboratory in the National
PH Laboratory Network is notified and
receives the appropriate collected
specimens. Notify local health department.
Person-to-person transmission of
tularemia has not been documented;
therefore, standard precautions would be
appropriate for patients with tularemia.
Standard Precautions
1. Handwashing
Wash hands immediately after gloves are
removed, between patient contacts, and
when otherwise indicated to avoid transfer
of microorganisms to other patients or
environments.
2. Gloves
Wear gloves when touching blood,
bodily fluids, secretions, excretions, and
contaminated items; put on clean gloves just
before touching mucous membranes and
nonintact skin. Change gloves between tasks
and procedures on the same patient after
contact with material that may contain a high
concentration of microorganisms. Remove
gloves promptly after use, before touching
noncontaminated items and environmental
surfaces, and before going to another
patient, and wash hands immediately to
avoid transfer of microorganisms to other
patients or environments.
3. Masks, Eye Protection, Face Shields
Wear a standard surgical mask and eye
14
Yersinia pestis bubonic plague x250
protection or a face shield to protect mucous
membranes of the eyes, nose, and mouth
during procedures and activities that are
likely to generate splashes or sprays
YersiniA pestis, Plague
DEFINITION
Plague is a disease caused by Yersinia
pestis, a bacterium found in rodents and
their fleas in many areas around the
world. Under natural conditions, plague
is transmitted to humans via rodent fleas
infected with the bacterium, although
humans can also contract it by direct
contact with infected animal body tissues
or by inhaling infected droplets.
There are three (3) forms of plague that
may affect humans:
• Bubonic
• Septicemic
• Primary pneumonic (USAMRIID 2005)
Y. Pestis is contagious in the pneumonic
form of the disease which makes it an
ideal form for use as a biological weapon.
The mortality for untreated pneumonic
plague approaches 100%. The organism
incubates for up to six (6) days and is dose
dependent. Onset of primary pneumonic
plague is acute and fulminent. See chart
below for specifics. Pneumonic plague
can be readily spread person-to-person.
Most of the secondary cases are to home
caregivers (80%), medical professionals
(14%), and persons in close contact up to
six (6) feet.
Clinical manifestations
of PLAGUE
Pneumonic plague will infect the lungs
as a result of inhalation of the organisms
(primary pneumonic) or spread there due to
septicemic (secondary pneumonic) plague.
DIAGNOSIS
From an epidemiological perspective the
arrival of an increasing number of patients
with rapidly progressing pneumonia
accompanied by bloody sputum should
create a high degree of suspicion.
This would be the manifestation of the
intentional release of pneumonic plague.
A delay in diagnosis and treatment is
associated with high fatality rates.
There are no readily available rapid tests
to detect plague. Definitive diagnosis is
made by culture from clinical specimen.
Clinical manifestationS of PLAGUE
PLAGUE
INCUBATION
PERIOD
EARLY
SIGNS/SYMPTOMS
LATER
SIGNS/SYMPTOMS
Pneumonic plague
1-6 days, dose
dependent.
High fever, chills, HA, malaise,
myalgias.
Increasing dyspnea, stridor, cyanosis,
rapidly progressive respiratory failure,
circulatory collapse.
Bubonic
2-8 days.
Acute and fulminant onset
of non-specific symptoms.
Characteristic Bubo.
15
Bioterrorism Agents and Barrier Protection
Select a strong, comfortable medical glove related to the procedure or task at hand
Report the possibility of plague to the local
health department. Other tests need to
be coordinated through the local health
department.
TREATMENT
Although early treatment is important,
plague is not believed to be as contagious
as once thought. Persons transmit the
plague infection most at the end stage
of the disease. Parenteral antibiotics,
given early, in the first 20-24 hours, clears
the sputum of the plague bacillus. (CDC)
POST-EXPOSURE PROPHYLAXIS
Those individuals with face-to-face contact
(within 6 ft) to person or persons with
pneumonic plague or exposed to the
aerosol of a potential BW attack should
receive antibiotic prophylaxis for 7 days.
No vaccine is currently available for plague.
Research is ongoing to develop new and
improved plague vaccines, particularly in
light of the current bioterrorist threat and
concerns about intentional dissemination
of aerosolized plague organisms.
INFECTION CONTROL
Droplet precautions, a transmission
based technique, in addition to Standard
Precautions should be implemented
until affected patients have been on the
appropriate antibiotic of 48 hours.
A biohazard clean suit is an example of
personal protective equipment
16
Droplet Precautions
•Place the patient in a private room or
in a room with other patients who have
the same infection. Special air handling
capabilities is not required.
•When a private room and like infection
patients are unavailable, spatial
separation of a least three feet should
be maintained.
•Healthcare workers should wear a
standard surgical mask when working
within three feet of the patient. A mask
is to be donned prior to entering the
patient room.
Standard Precautions
1. Handwashing
Wash hands immediately after gloves
are removed, between patient contacts,
and when otherwise indicated to avoid
transfer of microorganisms to other
patients or environments.
2. Gloves
Wear gloves when touching blood,
bodily fluids, secretions, excretions,
and contaminated items. Put on clean
gloves just before touching mucous
membranes and nonintact skin.
Change gloves between tasks and
procedures on the same patient after
contact with material that may contain a
high concentration of microorganisms.
Remove gloves promptly after use,
before touching noncontaminated
items and environmental surfaces, and
before going to another patient. Wash
hands immediately to avoid transfer
of microorganisms to other patients or
environments.
3. Masks, Eye Protection, Face Shields
Wear a standard surgical mask and eye
protection or a face shield to protect
mucous membranes of the eyes, nose,
and mouth during procedures and
activities that are likely to generate
splashes or sprays. In all forms of
plague, avoid surgery, autopsy, or
any other procedure that could cause
aerosolization. If it is absolutely
necessary to perform these procedures,
wear an N-95 mask and perform the
procedure in a negative pressure room.
Personal Protective
Equipment (PPE)
DEFINITION
Informed use of PPE is a critical
component of a hospital’s infection
prevention and bioterrorism response
program. Where there is likelihood of
contact with potentially infectious material,
appropriate PPE includes gloves, gowns,
laboratory coats, face shields, masks, eye
protection, and ventilation devices.
PPE refers to a variety of barriers and/or
respirators to protect mucus membranes,
airways, skin , and clothing from contact
with infectious agents.
Medical Gloves
When selecting a medical glove, an
important consideration should be
the barrier requirement related to the
procedure or task at hand. Be aware of
the level of exposure risk that the patientcare activities will require. Procedures that
involve exposure to blood, bodily fluids,
and other potentially infectious material
require a glove that provides appropriate
barrier protection.
Latex MEDICAL GLOVES
Natural rubber latex (NRL), commonly
referred to as “latex”, remains the gold
standard for hand barrier protection due
to its strength, proven barrier protection,
elasticity, fit, feel, comfort, and relatively
low cost. With the availability of lowprotein, powder-free gloves, many
clinicians are confidently continuing to
wear gloves made of latex. Latex gloves
17
are recommended as the first choice
for barrier protection in the healthcare
environment, except for wearers who are
allergic to latex proteins. In the event of
bioterrorist activity, clinical personnel can
have confidence in the barrier properties
of the latex glove to protect them. Doublegloving in a bioterrorist event is also
recommended. Latex is available in both
surgical and examination gloves.
Latex-Free Medical Gloves
Bioterrorism Agents and Barrier Protection
For healthcare workers allergic to latex, the
preferred recommendation as an alternative
for medical examination gloves would be
a latex-free material of nitrile or neoprene,
and a latex-free material of neoprene
or polyisoprene for surgical gloves.
In independent testing for barrier properties,
studies showed that nitrile, neoprene,
and latex gloves are comparable in barrier
properties during in-use performance testing.
Nitrile
Nitrile is a petroleum-based, cross-linked
film. It is extremely strong with puncture
resistance superior to all glove films.
Nitrile’s elasticity is very good and the
gloves tend to conform to the shape of the
wearer’s hands, providing good comfort
and fit. There are no latex proteins in
nitrile; therefore, there is no chance of
latex allergy with use. Nitrile exhibits
excellent chemical resistance and is
recommended as a preferred alternative
to latex for a bioterrorist event. Nitrile is
available in examination gloves.
Neoprene (Polychloroprene)
Neoprene is a petroleum-based crosslinked film that provides a similar fit, feel,
and barrier protection to latex. Neoprene
contains no latex proteins, and is available
without chemical accelerators, making
it a great choice for those with Type IV
chemical allergy. It is a strong material,
with good resistance to many chemicals,
and provides great comfort. Neoprene’s
elasticity is close to that of latex with very
high memory. The film is able to retain its
18
original shape and is somewhat puncture
resistant. Neoprene is available in both
surgical and examination gloves.
Polyisoprene
Polyisoprene is a petroleum-based, crosslinked film. Polyisoprene provides high
strength, elasticity, and comfort. It contains
no latex proteins, but contains some curing
agents that can cause allergic reactions.
Polyisoprene is durable and is somewhat
puncture resistant. Polyisoprene provides
good barrier protection but is more
permeable than latex, and is recommended
as a preferred alternative to latex in a
bioterrorist event if nitrile or neoprene are
not available. Polyisoprene is available in
surgical gloves.
Polyvinyl Chloride (PVC)
Many hospitals provide a latex-free
material called Polyvinyl chloride (PVC),
commonly known as “vinyl”, as a choice
for exam gloves. PVC is a petroleumbased film, but it is not molecularly crosslinked. Because it lacks cross-linking,
the individual molecules of vinyl tend
to separate when the film is stretched
or flexed. This causes small holes and
breaches to form during glove donning
and normal use. Repeated studies have
demonstrated that vinyl gloves have higher
failure rates when tested in simulated
and actual conditions. (CDC 2007) Vinyl is
the weakest of the glove films, with poor
elasticity, memory and fit. In 2007 the
CDC released the Guideline for Isolation
Precautions: Preventing Transmission of
Infectious Agents in Healthcare Settings.
This document also emphasized the poor
barrier properties of vinyl gloves. It reads,
“While there is little difference in the
barrier properties of unused intact gloves,
studies have shown repeatedly that vinyl
gloves have higher failure rates than
latex or nitrile gloves when tested under
simulated and actual clinical conditions.”
For this reason either latex or nitrile gloves
are preferable for clinical procedures that
require manual dexterity and/or will involve
more than brief patient contact. Because of
these poor physical properties, vinyl would
not be an acceptable choice to use when
handling the diseases caused by biological
agents. Polyvinyl chloride is only available in
examination gloves.
Selecting a Glove That is
Right For You
Glove selection is serious business. The two
primary considerations should be barrier
protection and allergen content. If a glove does
not provide an intact barrier, it is not doing its
job. To maximize barrier effectiveness, you
may wish to choose a glove manufacturer that
is reliable and experienced, to ensure that
your gloves will be of consistent quality and
regularly available.
Conclusion
“Biological weapons are widely available,”
states former FL Governor and US Senator
Bob Graham, and “The number of people who
can manipulate pathogens has increased.”
The healthcare community is on the forefront
of access, preparedness and recognition.
We need to keep our skills and knowledge
current to be able to service our communities.
Local Law Enforcement Authorities *
Local or County Health Department *
State Health Department *
CDC Emergency Response Hotline:
CDC Bioterrorism Preparedness & Response Program:
CDC Emergency Preparedness Resources:
Strategic National Stockpile:
FBI (general point of contact):
FBI (suspicious package info):
USAMRIID General Information:
USAMRICD Training Materials:
U.S. Army Medical NBC Defense Information:
Johns Hopkins Center for Civilian Biodefense:
Infectious Diseases Society of America:
Epidemiologic Clues of a
BW or terrorist attack
• The presence of a large epidemic with a
similar disease or syndrome, especially in
a discrete population
• Many cases of unexplained diseases or
deaths
• More severe disease than is usually
expected for a specific pathogen or failure
to respond to therapy
• Unusual routes of exposure for a pathogen,
such as the inhalational route for diseases
that normally occur through other
exposures
• A disease that is unusual for a given
geographic area or transmission season
• Disease normally transmitted by a vector
that is not present in the local area
• Multiple simultaneous or serial epidemics
of different diseases in the same
population
• A single case of disease be an uncommon
agent (smallpox, some viral hemorrhagic
fevers, inhalational anthrax, pneumonic
plague)
• A disease that is unusual for an age group
• Unusual strains or variants of organisms or
antimicroboal resistance patterns different
from those known to be circulating
• A similar or exact genetic type among
agents isolated from distinct sources at
different times or locations
• Higher attack rates among those exposed
in certain areas, such as inside a building
if released indoors, or lower rates in those
inside a sealed building if released outside
• Disease outbreaks of the same illness
occurring in noncontiguous areas
• A disease outbreak with zoonotic impact
• Intelligence of a potential attack, claims
by a terrorist or aggressor of a release,
and discovery of munitions, tampering,
or other potential vehicle of spread (spray
device, contaminated letter)
(USAMRIID 2005)
770-488-7100
404-639-0385
http:www.bt.cdc.gov
Access through State Health Dept
202-324-3000
http://www.fbi.gov/pressrel/pressrel01/mail3.pdf
http://www.usamriid.army.mil
http://ccc.apgea.army.mil
http://www.nbc-med.org
http://www.hopkins-biodefense.org
www.idsociety.org/bt/toc.htm
Table 3. Points of Contact and Training Resources. * Clinicians & Response Planners are encouraged to post this
list in a an accessible location. Specific local and state points of contact should be included.
19
Bibliography
Davis D, Bor B. Biological Contamination and
Bioterrorism Preparedness: Key Considerations for
Infection Control Practitioners. Inf Control Today.
July 2002: 40-44.
Sinclair R, Boone S, Greenberg D, Keim P, Gerba
G. Persistence of Category A Select Agents in the
Environment. App Environ Micro. 2008: pg 555-563.
Pattillo M. Bioterrorism. Advance for Nurses.
Oct 2005: 17-22.
Cosgrove S, Perl T, Song X, Sisson S. Ability of
Physicians to Diagnose and Manage Illness Due
to Category A Bioterrorism Agents. Arch Int Med.
2005;165: 2002-2006
Beasley A, Kenenally S, Mickel N, Korowicki K, McCann
S, Arundell J, Simmons W, Williams H. Treating Patients
with Smallpos in the Operatign Room. AORN Journal.
2004;80: 681-689.
Chronological History of Bioterrorism- History of
Bioterrorism. Biological Terrorism Response Manual.
http://www.bio-terry.com/HistoryBioTerr.html.
accessed 25 May 2010.
Phillips M. Bioterrorism: A Brief History. DCMS online.
2005: 32-35
www.dcmsonline accessed 25 May 2005.
Percentage of Hospitals with Staff Members Trained
to Respond to Selected Terrorism-Related Diseases of
Exposures. MMRW 2007; 56: 401.
US Army Medical Research Institute of Infectious
Diseases (USAMRIID). Medial Management of Biological
Casualties Handbook. Sixth Edition. Apr 2005
Weiss M, Weiss P, Weiss J. Antrax Vaccine and Public Health
Policy. Am J Public Health. Nov 2007; 97: 1945-1951.
Inglesby T, et al. Anthrax as a Biological Weapon, 2002
Updated Recommendations for Management. JAMA.
2002; 287: 2236-2252.
MMRW. Human Plague-Four States, 2006, MMWR
2006; 55: 940-943.
McLendon M, Apicella M, Allen L. Francisella tularensis:
Taxonomy, Genetics, and Immunopathogenesis of a
Potential Agent of Bioterrorism, Annu Rev Microbiol.
2006;60:167-185.
Dennis d, etal. Tularemia as a Biological Weapon,
Medical and Public Management. JAMA 2001;285:
2763-2773.
WHO- http://www.who.int/mediacentre/factsheets/
smallpox/en/ Smallpox. accessed 13 June 2010.
Chickenpox and Smallpox, How to Recognize the
Difference http://www.idph.state.il.us/Bioterrorism/
smallpoxchickenpox15.htm accessed 13 June 2010
Travelers’ Health Yellow Book, http://wwwnc.cdc.gov/
travel/yellowbook/2010/chapter-5/viral-hemorrhagicfevers.aspx. Accessed 14 June 2010
CDC. Guidelines for Isolation Orecautions: Preventing
Transmission of Infectious Agents in the Healthcare
Setting 2007. http://www.cdc.gov/hicpac/pdf/isolation/
Isolation2007.pdf
CDC Summary of Annual US Botulism Cases.
http://botulismtoolkit.com/?p=736
Weber DJ. Journal of the American Medical
Association 2003;289:1274
Reidel S. Biological warefare and Bioterrism: a historical
review. BUMC Proceedings. 2004;17:400-4006.
®
Ansell Healthcare Products LLC.
111 Wood Avenue South, Suite 210
Iselin, NJ 08830 USA
Toll-free: (800) 952-9916
www.ansell.com
©2011 Ansell Limited. All Rights Reserved.
23