Bioterrorism Rapid Response Information

 

 

Recognizing Bioterrorism-Related Illnesses

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).

Any unusual illness or disease clusters should be reported immediately to your county health department.

 

Recognizing and Diagnosing Illnesses Possibly Due to Bioterrorism - Table 1

Disease

Incubation Period

Early Symptoms

Clinical Syndrome

Diagnostic Samples

Diagnostic Tests

Inhalational Anthrax

1-7 days (possibly up to 60 days)

Non-specific: fever, malaise, cough, dyspnea, headache, vomiting, abdominal and chest pain.

Widened mediastinum, pleural effusion on chest x-ray. Rapid onset of severe respiratory distress, respiratory failure, and shock.

Blood, serum, CSF, pleural or ascetic fluids.

Gram stain or Wright stain; blood culture.

Specialized labs: IHC, serology, DFA, PCR.

Cutaneous Anthrax

1-12 days.

Painless or pruritic papule.

Papule evolves into a vesicular or ulcerative lesion, then forms a black eschar after 3-7 days.

Swab of lesion, skin biopsy, blood.

Gram stain, culture of lesion; blood culture.

Specialized labs: PCR, serology.

Botulism

Foodborne: 12-72 hours.

Range,

2 hours – 8 days.

Inhalational: 12-80 hours.

Usually none. If foodborne, possibly nausea, vomiting, abdominal cramps or diarrhea.

Afebrile, ptosis, diplopia, dysathria, dysphonia, dysphagia, symmetrical descending paresis or flaccid paralysis. Generally normal mental status. Progresses to airway obstruction and respiratory failure.

Nasal swab (if obtained immediately following inhaled exposure), serum, gastric aspirate, stool, food sample when indicated.

Specialized labs: Mouse bioassay for toxin.

 

Recognizing and Diagnosing Illnesses Possibly Due to Bioterrorism - Table 2

Disease

Incubation Period

Early Symptoms

Clinical Syndrome

Diagnostic Samples

Diagnostic Tests

Brucellosis

Very variable, 5-60 days.

Fever (often intermittent), headache, chills, heavy sweats, arthralgias.

Systemic illness, may become chronic with fever and weight loss. May have suppurative lesions. Bone/joint lesions common.

Blood serum, bone marrow, tissue.

Culture, serology, PCR.

Equine Encephalitides (Eastern, Western, Venezuelan)

2-6 days, Venezuelan.

5-15 days, others.

Non-specific: Sudden onset of malaise, fever, rigors, severe headache, photophobia, myalgias of legs and back.

Fever, headache, stiff neck, nausea, vomiting, sore throat, diarrhea lasting several days often followed by prolonged period of weakness and lethargy. Central nervous system symptoms may develop.

Serum, CSF.

Viral culture, serology, PCR.

Pneumonic Plague

1-6 days.

Non-specific: high fever, cough, chills, dyspnea, headache, hemoptysis, nausea, vomiting, diarrhea.

Fulminant pneumonia, often with hemoptysis, rapid progression of respiratory failure, septicemia and shock. Presence of hemoptysis may help distinguish from inhalational anthrax.

Blood, sputum, lymph node aspirate, serum.

Gram, Wright, or Wayson stain; culture.

Specialized labs: serology, DFA, PCR.

 

Recognizing and Diagnosing Illnesses Possibly Due to Bioterrorism - Table 3

Disease

Incubation Period

Early Symptoms

Clinical Syndrome

Diagnostic Samples

Diagnostic Tests

Q Fever

10-40 days.

Fever, headache, chills, heavy sweats, arthralgias.

Self-limited febrile illness lasting 2 days to 2 weeks, may present like atypical pneumonia (Legionella).

Serum, sputum.

Serology, culture difficult.

Ricin (toxin from castor bean oil)

18-24 hours.

Inhalation: fever weakness, cough, hypothermia, hypotension, cardiac collapse.

In high doses, short incubation and rapid onset suggestive chemical agent.

Blood, tissue.

Serology, IHC staining of tissue.

Smallpox

12 days;

Range: 7-17 days.

Non-specific: fever, malaise, headache, prostration, rigors, vomiting, severe backache.

Maculopapular, vesicular, then postular lesions all at same developmental stage in any one location. Begins on face, mucous membranes, hands and forearms; may include palms and soles.

Vesicular or postular fluid, pharyngeal swab, scab material, serum.

Specialized labs: PCR, viral culture, electron or light microscopy, serology.

 

Recognizing and Diagnosing Illnesses Possibly Due to Bioterrorism - Table 4

Disease

Incubation Period

Early Symptoms

Clinical Syndrome

Diagnostic Samples

Diagnostic Tests

Staphylococcal Enterotoxin B

3-12 hours for inhalation.

Minutes to hours for ingestion.

Inhalation: fever, chills headache, myalgias, cough, nausea.

Short incubation and rapid onset suggestive of chemical agent.

Inhalation: dyspnea, retrosternal pain may develop.

Ingestion: nausea, vomiting, diarrhea.

Inhalation: serum, urine.

Ingestion: stool, vomitus.

Specialized labs: Ag-ELISA, Ab-ELISA serology.

Tularemia

3-5 days; range: 1-14 days.

Non-specific: fever, fatigue, chills, cough, malaise, body aches, headache, chest discomfort, GI symptoms.

Pneumonitis, ARDS, pleural effusion, hemoptysis, sepsis. Ocular lesions, skin ulcers, oropharyngeal or glandular disease possible.

Serum, urine, blood, sputum, pharyngeal washing, fasting gastric aspirate, other.

Gram stain, culture; DFA or IHC staining of secretions, exudates or biopsy specimens.

Viral Hemorrhagic fevers (Ebola, arenavirus, filoviruses)

2-21 days; varies among viruses.

Fever, myalgias, petechiae, easy bleeding, red itchy eyes, hematemesis.

Febrile illness complicated by easy bleeding, petechiae, hypotension and shock.

Serum, blood.

Viral culture, PCR, serology.

 

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.