Bioterrorism Agents Epidemiology Program Overview

Bioterrorism Background Deliberate release of viruses, bacteria or other germs May be difficult to detect May not cause immediate illness Separated into three categories by CDC Category A Category B Category C

High Priority Agents Category A Easily spread; high death rates Anthrax, botulism, plague, smallpox, tularemia, and selected hemorrhagic fever viruses Category B Moderately easy to disseminate Brucellosis, food safety threats, Q fever, and other agents Category C Could be engineered for mass dissemination Emerging infectious diseases

Category A Bioterrorism Agents Agent Clinical Manifestations Communicability Anthrax Cutaneous, Inhalation, Gastrointestinal Not person-to-person Botulism Foodborne, Infant, Wound, Inhalation Not person-to-person Plague Bubonic, Pneumonic, Septicemic Droplet (pneumonic) Smallpox Ordinary, modified, flat, hemorrhagic Airborne, droplet, direct contact Tularemia Glandular, Septicemic, Oropharyngeal, Intestinal, Typhoidal, Pneumonic Not person-to-person Viral Hemorrhagic Fevers Filoviruses and Arenaviruses Airborne +, droplet, contact

Anthrax Infection through contact with infected animals/animal products or intentional exposure Possible indicators of bioterrorism Severe acute febrile disease with fulminant course and death Gram-positive bacilli in skin biopsy, blood smears, CSF Chest radiographs showing widened mediastinum

Botulism Occurrence Single cases occur sporadically Foodborne botulism – 1 VA case reported in 2007 Public health staff coordinate receipt of antitoxin Possible indicators of bioterrorism: Outbreak of multiple cases of descending, flaccid paralysis; Outbreak with unusual toxin type (e.g., C, D, F, G or type E not acquired from aquatic food) Outbreak with common geographic features but without common dietary exposure Multiple simultaneous outbreaks with no common source

Plague Caused by the bacterium Yersinia pestis Infection through bite of infected fleas, close contact with infected animals; inhalation of infective aerosols Possible indicators of bioterrorism: Cases in locations without enzootic infection Cases in persons without known risk factors (e.g., travel history, exposure to rodents/fleas) Sudden outbreak of illness in patients presenting with severe pneumonia and sepsis

Smallpox High risk of smallpox: Febrile prodrome, and Classic smallpox lesions, and Lesions in the same stage of development Moderate risk of smallpox: Febrile prodrome plus: One other high-risk criteria or Four or more of the following: Centrifugal distribution of lesions; First lesions in pharynx or oral mucosa; Patient appears toxic; Slow evolution of rash; Lesions on the palms and soles

Smallpox If moderate or high-risk for smallpox: Rapidly report to DSI and communicate with other programs (EP&R, OCOM) Collect information on CDC worksheet: Evaluating Patients for Smallpox osis/pdf/spox-patient-eval-wksheet.pdf Coordinate specimen collection/submission to DCLS Make infection control recommendations Consider activation of Smallpox Response Plan

Tularemia Occurrence About 200 cases/year in the U.S. 1 case reported in Virginia in 2010; Several in 2011 Possible indicators of bioterrorism: Increase in cases of acute, febrile illness Cases progressing to pharyngitis, bronchiolitis, pneumonitis, pleuritis, hilar lymphadenitis Laboratory findings: Small, gram-negative coccobacilli

Viral Hemorrhagic Fevers (VHF) Caused by several families of viruses Filoviruses (Ebola, Marburg) Arenaviruses (Lassa, Machupo) Infection through contact with rodents (Lassa, Machupo); animal hosts for Ebola and Marburg unknown; person-to-person Clinical presentation Fever; fatigue; dizziness; rash; myalgias; bleeding; shock; multi-organ failure

VHF and Bioterrorism Patients without relevant travel history and exposure Suspected index case: Temperature >101 F for less than three weeks; Severe illness; At least two of the following: hemorrhagic or purpuric rash, epistaxis, hematemesis, hemoptysis, blood in stool, or other hemorrhagic signs/symptoms; and No predisposing factors for hemorrhagic manifestations

Category A Agents Public Health Response Rapidly reportable Require immediate public health follow-up Consult with DSI and coordinate/communicate with EP&R and OCOM Collect information on relevant Case Report Forms Coordinate collection/submission of specimens to DCLS Make infection control recommendations Respiratory form of the diseases = consider BT May see naturally occurring cases Botulism: infant/foodborne Bubonic/pneumonic plague in those with travel and exposure history in western states Tularemia: Exposure to rabbits, ticks

Category B Agents Public Health Response Laboratory Reports from Private Labs Q Fever Brucella species Follow-up: Collect information on patient’s symptoms, why the test was ordered, evaluate possible exposures, consider confirmatory testing at DCLS. Record information on relevant Case Report Forms. Ensure that isolates are forwarded to DCLS