Healthcare providers should be alert to illness patterns and diagnostic clues that might signal an act of bioterrorism (BT). The following clinical and epidemiological clues are suggestive of a possible BT event:

• A rapidly increasing disease incidence.
• An unusual increase in the number of people seeking care, especially with fever, respiratory or gastrointestinal symptoms.
• Any suspected or confirmed communicable disease that is not endemic in California (e.g., plague, anthrax, smallpox or viral hemorrhagic fever).
• Any unusual age distributions or clustering of disease (e.g., chickenpox or measles in adults).
• Simultaneous outbreaks in human and animal populations.
• Any unusual temporal and/or geographic clustering of illness (e.g., persons who attended the same public event).

Treatment and Prophylaxis - Table 1

Agent	Treatment	Prophylaxis
Anthrax Inhalation/Cutaneous	Ciprofloxacin; doxycycline Combination therapy of ciprofloxacin or doxycyline, plus one or two other antimicrobials should be considered with inhalation anthrax. PCN should be considered if strain is susceptible.	Ciprofloxacin or doxycycline, with or without vaccination. If susceptible, PCN or amoxicillin should be considered.
Botulism	Supportive care – ventilation may be necessary. Trivalent equine antitoxin (serotypes A, B, E – available from CDC) should be administered immediately following clinical diagnosis.	None.
Brucellosis	Doxycycline plus streptomycin or rifampin. Alternatives: ofloxacin plus rifampin; doxycycline plus gentamicin; TMP/SMX plus gentamicin.	Doxycycline plus streptomycin or rifampin.
Equine Encephalitides (Eastern, Western, Venezuelan)	Supportive care – analgesics, anticonvulsants as needed.	None.

Treatment and Prophylaxis - Table 2

Agent	Treatment	Prophylaxis
Pneumonic Plague	Streptomycin; gentamicin. Alternatives: doxycycline; tetracycline; ciprofloxacin; and chloramphenicol.	Tetracycline; doxycycline; ciprofloxacin.
Q-Fever	Tetracycline; doxycycline	Tetracycline; doxycycline (may delay but not prevent illness).
Ricin	Supportive care. Treatment for pulmonary edema. Gastric decontamination if toxin is ingested.	None.
Smallpox	Supportive care. Cidofovir shown to be effective in vitro.	Vaccination given within 3-4 days of exposure can prevent or decrease the severity of disease.
Staphylococcal Enterotoxin B	Supportive care.	None.
Tularemia	Streptomycin; gentamicin. Alternative: ciprofloxacin.	Tetracycline; doxycycline; ciprofloxacin.
Viral Hemorrhagic Fevers	Supportive care. Ribavirin may be effective for Lassa fever, Congo-Crimean hemorrhagic fever, Rift Valley fever.	Ribavirin may be effective for Lassa fever, Congo-Crimean hemorrhagic fever. Rift Valley fever.

Infection Control Precautions for Biological Agents

Agent	Precaution Category	Personal Protective Equipment GL=Gloves GO=Gowns M=Mask	Private Room
Anthrax	Standard. Contact precautions for Cutaneous and gastrointestinal anthrax if diarrhea is not contained.	GL=when entering the room. GO=if likely contact with patient, equipment or environment.	No.
Botulism	Standard precautions.		No.
Brucellosis	Standard precautions.		No.
Plague (pneumonic)	Standard. Droplet precautions until on appropriate therapy for 72 hours. Contact precautions if draining buboes present.	GL=when entering the room. GO=if likely contact with patient, equipment or environment. M=surgical mask.	Yes. Cohort if necessary.
Q Fever	Standard precautions.		No.
Smallpox	Standard, contact and airborne precautions.	GL, GO=when entering the room. M=N-95 respirator.	Yes Negative pressure.
Tularemia	Standard. Contact precautions if lesions present.	GL=when entering the room. GO=if likely contact with patient, equipment or environment.	No.
Viral Hemorrhagic Fever	Standard and contact precautions. Airborne precautions, especially in late stages.	GL, GO=when entering the room. M=N-95 respirator.	Yes. Negative pressure.
Venezuelan Equine Encephalitis	Standard precautions.		No.

Infection Control Precautions

Standard Precautions

Standard precautions apply to blood, all body fluids, secretions, nonintact skin, mucous membranes and excretions, except sweat. Gloves and gowns should be used to prevent exposure to blood and other potentially infectious fluids. Mask and eye protection or face shield should be used during procedures or activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions. Appropriate hand hygiene is always necessary.

Additional Precautions for the Following

Droplet Precautions

Provide private room or cohort patients with same infectious agent. Use a mask if within three feet of a patient.

Contact Precautions

Provide private room or cohort patients with same infectious agent. Use gloves when entering the room and a gown if clothing is likely to have contact with patient, environmental surfaces or patient care equipment.

Airborne Precautions

Requires a negative pressure isolation room and appropriate respiratory protection such as the N95 respirator which has been fit-tested.

Decontamination Guidelines

In general, persons exposed to a biological agent need only to remove clothing, if heavily contaminated, and use shampoo, soap and water on themselves (shower). The clothing should be bagged and laundered normally in hot water. No precautions for effluent water are needed. Diluted bleach solutions should NEVER be used on people, only environmental surfaces.

For more information on responding to events in California, contact the California Department of Health services at (916) 650-6416 or contact your Local Health Department.

Information adapted from the New York State Department of Health.