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Information about infectious

Published on January 5, 2008

Author: Arkwright26


INFECTIOUS AGENTS IN AN ERA OF BIOTERRORISM:  INFECTIOUS AGENTS IN AN ERA OF BIOTERRORISM Jay Paulsen, M.D., M.P.H. FEDERAL OCCUPATIONAL HEALTH DOI Safety & Occupational Health Conference Phoenix, Arizona April 1, 2003 Hot Health Issues in the DOI Overview:  Overview This session will provide the participant with a whirlwind tour of some infectious agents that may be of interest because of: Their potential control by vaccines, and Their potential threat if used as biological weapons. Topics of Discussion:  Topics of Discussion Some important non-bioterrorism organisms Some specific bioterrorism organisms, by category Whether or not there is a vaccine for the organism or its toxin Agency response planning Non-bioterrorism organisms:  Non-bioterrorism organisms Common organisms (bacteria, viruses) that are not likely to be used as bioterrorism agents, primarily because of the way they are transmitted, the relative lack of severity of the resulting disease, or the level of current public immunity. Hepatitis A:  Hepatitis A Liver disease from the hepatitis A virus (HAV) First isolated in 1979 Isolated cases or widespread epidemics, ave. 27,000 cases/year ~100 deaths/year (0.3% of cases) Fecal-oral spread Hepatitis A (continued):  Hepatitis A (continued) 15-50 day (ave. 28 day) incubation Signs/symptoms: jaundice, fatigue, abdominal pain, loss of appetite, nausea, diarrhea, fever; Prevented by largely by handwashing Good vaccines (2 shot series, 6-12 months apart) Immune globulin for short-term protection Hepatitis B:  Hepatitis B Liver disease from the hepatitis B virus (HBV) Can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death Spread by body fluids >20,000 cases/yr.; ~80,000 infections ~5,000 deaths, from cirrhosis, hepatocellular carcinoma Hepatitis B (continued):  Hepatitis B (continued) ~6 wks – 6 mos. incubation (ave. 120 days) About 30% of persons have no signs or symptoms. Signs/symptoms: jaundice, fatigue, abdominal pain, loss of appetite, nausea, vomiting, joint pain Good vaccines (3 shot series: 0, 1 and 6 months) Influenza:  Influenza Caused by one of the 3 types of influenza virus (A serious, B mild, and C rare) Contagious, spread by droplet, aerosol, contact Comes on suddenly, with fever, headache, tiredness, dry cough, sore throat, nasal congestion, body aches Lasts 1-2 weeks, may have life-threatening complications Influenza (continued):  Influenza (continued) 10% to 20% in U.S. contract it each year Average of about 36,000 people in U.S. die Risk groups: 65 years and older, chronic medical conditions, and very young children Good vaccine, changes each year, one shot in fall or winter 4 drugs approved for treatment: amantadine, rimantadine, zanamivir and oseltamivir Lyme Disease:  Lyme Disease Caused by a bacterium, Borrelia burgdorferi Transmitted by infected deer ticks, Ixodes sp. Incubation period from infection to rash: typically 7-14 days (3 to 30) Nonspecific symptoms: fever, malaise, fatigue, headache, muscle aches, and joint aches About 15,000 cases each year Lyme Disease (continued):  Lyme Disease (continued) “Bull's-eye” rash, erythema migrans Lyme – early complications:  Lyme – early complications Neurologic: Lymphocytic meningitis, cranial neuropathy (especially facial nerve palsy), and radiculoneuritis Musculoskeletal: migratory joint and muscle pains, arthritis Cardiac: rare but may include myocarditis, transient AV blocks Lyme – late complications:  Lyme – late complications Intermittent arthritis in one or more joints, such as the knee Chronic polyneuropathy, or encephalopathy (with cognitive disorders, sleep disturbance, fatigue, and personality changes) May be severe, chronic, and disabling May occur following treatment for Lyme disease Rarely, if ever, fatal Lyme Disease Distribution:  Lyme Disease Distribution Lyme – avoiding it:  Lyme – avoiding it Avoid getting tick bites!! Avoid tick prone areas, or… Prevent infestation (repellents, clothing), or at least… Prevent infective bites (remove ticks) Antibiotics, if infected Doxycycline or amoxacillin generally effective early Cefuroxime or erythromycin if allergic to penicillin or cannot take tetracyclines Later in the disease, may require IV ceftriaxone or penicillin for 4 weeks or more Vaccine (LymeRix) now off the market Rabies:  Rabies Caused by a central nervous system attacking virus Usually spread by the bite of a rabid animal 10% of animal cases in domestic animals (dogs, cats, cows) 90% of animal cases in wild animals (raccoons, skunks, bats, foxes) One or two deaths per year in U.S. ~40,000 Post-exposure prophylaxis series per year 18,000 Pre-exposure prophylaxis series Rabies (continued):  Rabies (continued) Rabies (continued):  Rabies (continued) Nonspecific, flu-like (malaise, fever, or headache for 2-10 days) May have discomfort or paresthesia exposure site Progressing within days to cerebral dysfunction, anxiety, confusion, agitation, delirium, abnormal behavior, hallucinations, and insomnia Nearly always fatal once symptoms appear, treatment is supportive (only 6 documented cases of human survival from clinical rabies, all had either pre- or postexposure prophylaxis) Rabies (continued):  Rabies (continued) Pre-exposure Vaccine for Prophylaxis Provided based on assessment of exposure risk Three doses vaccine, given on days 0, 7, and 21 or 28 Post-exposure Prophylaxis (PEP) Provided based on assessment of exposure risk One dose of immune globulin and five doses of vaccine, given on days 0, 3, 7, 14, and 28 West Nile Virus:  West Nile Virus A flavivirus commonly found in Africa, West Asia, and the Middle East Closely related to St. Louis encephalitis virus found in the United States Probably been in the eastern U.S. since the early summer of 1999 West Nile Virus (continued):  West Nile Virus (continued) West Nile Virus (continued):  West Nile Virus (continued) Spread by infected mosquitoes Can infect people, horses, many types of birds, and some other animals. No evidence of spread from person to person or from animal to person Incubation period is usually 3 to 14 days West Nile Virus (continued):  West Nile Virus (continued) For 2002, reported as of 3/12/03: 4161 confirmed cases, and 277 deaths About 20% of those who are infected develop West Nile fever Most have mild symptoms, including fever, headache, and body aches, occasionally a skin rash on the trunk and swollen lymph glands Lasts a few days West Nile Virus (continued):  West Nile Virus (continued) About 1 in 150 infected persons develop more severe disease, including encephalitis or meningitis, with headache, high fever, neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, and paralysis May last several weeks, although neurological effects may be permanent West Nile Virus (continued):  West Nile Virus (continued) Prevention? staying indoors at dawn, dusk, and in the early evening, which are peak mosquito biting times apply insect repellent containing DEET (N,N-diethyl-meta-toluamide) when outdoors wear long-sleeved clothes and long pants treated with repellents containing permethrin or DEET No vaccine yet available Other Common Vaccine-Preventable Diseases:  Other Common Vaccine-Preventable Diseases Measles Mumps MMR Vaccine Rubella Meningococcal Disease M. Vaccine Pneumococcal Disease P. PS Vaccine Polio Inactivated Polio Vaccine Tetanus Td Vaccine Varicella Varicella Vaccine Yellow Fever Yellow Fever Vaccine Categories of Potential Bioterrorism Agents:  Categories of Potential Bioterrorism Agents The U.S. public health system and primary healthcare providers must be prepared to address various biological agents, including pathogens that are rarely seen in the United States. Category A Category B Category C Category definitions (A):  Category definitions (A) High-priority agents include organisms that pose a risk to national security because they: can be easily disseminated or transmitted from person to person; result in high mortality rates; potential for major public health impact (might cause public panic and social disruption); and require special action for public health preparedness. Anthrax:  Anthrax Caused by the spore-forming bacterium Bacillus anthracis Serious forms of human anthrax are: inhalation anthrax cutaneous anthrax intestinal anthrax Three virulence factors of B. anthracis: are edema toxin, lethal toxin and a capsular antigen Spores may be used as an aerosolized or foodborne agent Anthrax (continued):  Anthrax (continued) Inhalation anthrax Initial symptoms may be confusing, except… Common cold (runny nose, WBC nl, lymphs high, normal CXR) Anthrax (no runny nose, WBC high, normal lymphocyte count, abnormal CXR) After several days, breathing problems, shock Often fatal if not treated in time Anthrax (continued):  Anthrax (continued) Ingestion anthrax Nausea, loss of appetite, vomiting, and fever Followed by abdominal pain, vomiting of blood, and severe diarrhea May be fatal if not treated in time Anthrax (continued):  Anthrax (continued) Cutaneous anthrax Most common naturally occurring type of infection Usually occurs after skin contact with contaminated meat, wool, hides, or leather from infected animals The incubation period ranges from 1-12 days Anthrax (continued):  Anthrax (continued) Early treatment is essential (delay lessens chances for survival) Usually is susceptible to penicillin, doxycycline, and fluoroquinolones (e.g., Ciprofloxacin, or “Cipro”) A six-dose vaccine exists; can prevent infection; not recommended for general public;currently not available (low risk, cost, logistics, annual booster, available antibiotics) Combination anthrax / plague vaccine under development Botulism:  Botulism Muscle-paralyzing disease Caused by a toxin made by a spore-forming bacterium called Clostridium botulinum Three main kinds: Foodborne (ingested) Infant Wound Spores may be used as an aerosolized or foodborne agent Botulism (continued):  Botulism (continued) Foodborne or inhalation botulism symptoms: 12 - 36 hours after ingestion (< 6 hours - 2 weeks) Double or blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, muscle weakness (descends through body, e.g., shoulders then upper arms, lower arms, thighs, calves, etc.) Paralysis of breathing muscles can kill unless breathing is assisted Botulism (continued):  Botulism (continued) Treated with anti-toxin and supportive care Vaccine (botulinum toxoid) exists, but is only at investigational stage; 4-dose series, boosters every 2 years Plague:  Plague AD 541, started in Egypt, then Europe and Asia, killed 50% to 60% of population AD 1346, Europe, killed 33% of European population (20 to 30 million people) and lasted more than 130 years (the “Black Death”) AD 1855, China, then all inhabited continents, killed more than 12 million people in India and China Plague (continued):  Plague (continued) Caused by bacteria, Yersinia pestis Usually spread by bite of Xenopsylla chepsis (oriental rat flea) Is enzootic in the U.S. (e.g., prairie dogs) Bacteria may be used as an aerosolized agent Plague (continued):  Plague (continued) Plague (continued):  Plague (continued) Pneumonic plague: lung infection; airborne bacteria or droplet spread; direct or close contact Bubonic plague: most common form, due to flea bites or skin breaks; involves swollen, tender lymph nodes (“buboes”), fever, headache, chills, weakness (may cause pneumonic plague) Septicemic plague: bacteria multiply in the blood; may be complication of pneumonic or bubonic plague, or cause pneumonic plague; involves fever, chills, prostration, abdominal pain, shock, and bleeding into skin and other organs Plague (continued):  Plague (continued) Early treatment (pneumonic plague) essential Antibiotics must be given within 24 hours of first symptoms Streptomycin, gentamicin, the tetracyclines, and chloramphenicol are effective Antibiotic treatment for 7 days for those with direct, close contact with infected patients Vaccine not currently available in the U.S. Smallpox:  Smallpox Outbreaks have occurred for thousands of years Disease now eradicated (last case in the U.S. in 1949; last naturally occurring case in the world in Somalia in 1977) But the virus still exists…. Smallpox (continued):  Smallpox (continued) Two clinical forms Variola minor: less common, much less severe, death rates historically of 1% or less Variola major: severe and most common form, more extensive rash, higher fever, death rate about 30% Smallpox (continued):  Smallpox (continued) Four types of variola major: ordinary (most frequent, 90% or more of cases) we’ll focus on this type modified (mild and occurring in previously vaccinated persons) flat (rare and very severe, usually fatal) hemorrhagic (rare and very severe, usually fatal) Smallpox (continued):  Smallpox (continued) Transmission requires prolonged face-to-face contact, or direct contact with bodily fluids, resulting in periods of: Incubation (7-17 days), not contagious No symptoms Prodrome (2-4 days), may be contagious Fever, aches, malaise, vomiting Early rash (about 4 days), most contagious Rash in mouth, then on the body Pustular rash (about 5 days), contagious Rash feels like BBs under skin Pustules and scabs (about 5 days), contagious Crust forms on pustules, then scabs Smallpox (continued):  Smallpox (continued) Resolving scabs (about 6 days), contagious Scabs falling off, leave pits that will be scars Scabs resolved, not contagious Scabs all detached Highly effective vaccine available Tularemia:  Tularemia Caused by Francisella tularensis Found in rodents, rabbits, and hares Humans can get tularemia by: the bite of an infected insect or other arthropod (usually a tick or deerfly) handling infected animal carcasses eating or drinking contaminated food or water breathing in F. tularensis Not spread from person to person Tularemia (continued):  Tularemia (continued) Symptoms (may appear 3-5 days, or as long as 14 days, after exposure): sudden fever, chills, headaches, muscle aches, joint pain, dry cough, progressive weakness, and pneumonia may progress to pneumonia, chest pain, and bloody sputum, with difficulty breathing Tularemia (continued):  Tularemia (continued) Or, depending on exposure route, may include: skin ulcers swollen and painful lymph glands swollen and painful eyes sore throat A vaccine is not currently available in the U.S. Viral hemorrhagic fevers:  Viral hemorrhagic fevers A group of illnesses caused by distinct families of viruses (including Ebola, Lassa, Marburg, Rift Valley, and others) Includes severe multi-system problems, but hallmark is vascular system damage Often accompanied by bleeding (that by itself is rarely life-threatening) May cause relatively mild illnesses, or severe, life-threatening disease Viral hemorrhagic fevers (continued):  Viral hemorrhagic fevers (continued) Their survival is dependent on an animal or insect host Geographically restricted to the areas where their host species live May be spread by arthropods, body fluids, or airborne droplets Other than for yellow fever and Argentine hemorrhagic fever, no vaccines exist Category definitions (B):  Category definitions (B) Second highest priority agents include those that: are moderately easy to disseminate; result in moderate morbidity rates and low mortality rates; and programmatic requirements: specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance. Category B Agents:  Category B Agents In general, human vaccines for these agents are not available in the U.S., but antibiotics and other treatments may be effective. Brucellosis (Brucella species) Epsilon toxin (from Clostridium perfringens) Food safety threats (e.g., Salmonella species, Escherichia coli O157:H7, Shigella) Glanders (Burkholderia mallei) ) Melioidosis (Burkholderia pseudomallei) Psittacosis (Chlamydia psittaci) Category B Agents (continued):  Category B Agents (continued) Q fever (Coxiella burnetii) Ricin toxin (from Ricinus communis, castor beans) Staphylococcal enterotoxin B Typhus fever (Rickettsia prowazekii) Viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis]) Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum) Category definitions (C):  Category definitions (C) Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of: availability; ease of production and dissemination (i.e., difficult); and potential for high morbidity and mortality rates and major health impact. Category C Agents:  Category C Agents Include: Hantavirus – discovered in 1993, rodents, significant mortality Nipah virus – discovered in 1999, zoonotic, significant mortality No vaccines are currently available Agency Response Planning:  Agency Response Planning Public Health Emergency Preparedness and Response web site: ( References:  References Centers for Disease Control and Prevention (CDC), Public Health Emergency Preparedness & Response ( CDC, Health Topics from A to Z (

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