Northwest Center for Public Health Practice University of Washington School of Public Health and Community Medicine 1 Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce

UW Northwest Center for Public Health Practice 2 AcknowledgementsAcknowledgements This presentation, and the accompanying instructor’s manual, were prepared by Jennifer Brennan Braden, MD, MPH, at the Northwest Center for Public Health Practice in Seattle, WA, for the purpose of educating public health employees in the general aspects of bioterrorism preparedness and response. Instructors are encouraged to freely use all or portions of the material for its intended purpose. The following people and organizations provided information and/or support in the development of this curriculum. A complete list of resources can be found in the accompanying instructor’s guide. Patrick O’Carroll, MD, MPH Project Coordinator Centers for Disease Control and Prevention Judith Yarrow Design and Editing Health Policy and Analysis; University of WA Washington State Department of Health Jeff Duchin, MD Jane Koehler, DVM, MPH Communicable Disease Control, Epidemiology and Immunization Section Public Health - Seattle and King County Ed Walker, MD; University of WA Department of Psychiatry

UW Northwest Center for Public Health Practice 3 Diseases of Bioterrorist Potential: Tularemia & Viral Hemorrhagic Fevers CDC, AFIP

UW Northwest Center for Public Health Practice 4 Diseases of Bioterrorist Potential Learning Objectives Describe the epidemiology, mode of transmission, and presenting symptoms of disease caused by the CDC-defined Category A agents Describe the epidemiology, mode of transmission, and presenting symptoms of disease caused by the CDC-defined Category A agents Identify the infection control and prophylactic measures to implement in the event of a suspected or confirmed Category A case or outbreak Identify the infection control and prophylactic measures to implement in the event of a suspected or confirmed Category A case or outbreak Describe the epidemiology, mode of transmission, and presenting symptoms of disease caused by the CDC-defined Category A agents Describe the epidemiology, mode of transmission, and presenting symptoms of disease caused by the CDC-defined Category A agents Identify the infection control and prophylactic measures to implement in the event of a suspected or confirmed Category A case or outbreak Identify the infection control and prophylactic measures to implement in the event of a suspected or confirmed Category A case or outbreak

UW Northwest Center for Public Health Practice 5 Francisella Tularensis Causative agent of tularemia Causative agent of tularemia Non-motile, non-spore-forming gram negative cocco-bacillus found in diverse animal hosts Non-motile, non-spore-forming gram negative cocco-bacillus found in diverse animal hosts Studied by U.S. and others as potential BW weapon Studied by U.S. and others as potential BW weapon Resistant to freezing temperatures, sensitive to heat and disinfectants Resistant to freezing temperatures, sensitive to heat and disinfectants Causative agent of tularemia Causative agent of tularemia Non-motile, non-spore-forming gram negative cocco-bacillus found in diverse animal hosts Non-motile, non-spore-forming gram negative cocco-bacillus found in diverse animal hosts Studied by U.S. and others as potential BW weapon Studied by U.S. and others as potential BW weapon Resistant to freezing temperatures, sensitive to heat and disinfectants Resistant to freezing temperatures, sensitive to heat and disinfectants

UW Northwest Center for Public Health Practice 6 Francisella Tularensis Epidemiology Humans infected by various modes: Humans infected by various modes: Handling contaminated animal tissues or fluids Handling contaminated animal tissues or fluids Bite of infective deer flies, mosquitoes, or ticks Bite of infective deer flies, mosquitoes, or ticks Direct contact with or ingestion of contaminated water, food, or soil Direct contact with or ingestion of contaminated water, food, or soil Inhalation of infective aerosols (most likely BT route) Inhalation of infective aerosols (most likely BT route) About 200 cases of tularemia/year in U.S. About 200 cases of tularemia/year in U.S. Most in South-central and Western states Most in South-central and Western states Most in rural areas Most in rural areas Majority of cases in summer Majority of cases in summer Humans infected by various modes: Humans infected by various modes: Handling contaminated animal tissues or fluids Handling contaminated animal tissues or fluids Bite of infective deer flies, mosquitoes, or ticks Bite of infective deer flies, mosquitoes, or ticks Direct contact with or ingestion of contaminated water, food, or soil Direct contact with or ingestion of contaminated water, food, or soil Inhalation of infective aerosols (most likely BT route) Inhalation of infective aerosols (most likely BT route) About 200 cases of tularemia/year in U.S. About 200 cases of tularemia/year in U.S. Most in South-central and Western states Most in South-central and Western states Most in rural areas Most in rural areas Majority of cases in summer Majority of cases in summer

UW Northwest Center for Public Health Practice 7 Francisella Tularensis Epidemiology Low infectious dose: organisms produce disease Low infectious dose: organisms produce disease Incubation period: probably 3-5 days following aerosol exposure (range 1-21 days) Incubation period: probably 3-5 days following aerosol exposure (range 1-21 days) Case fatality rate Case fatality rate Treated: <1-3% Treated: <1-3% Untreated: 30-60% (pneumonic), 5% (ulceroglandular) Untreated: 30-60% (pneumonic), 5% (ulceroglandular) Recovery followed by permanent immunity Recovery followed by permanent immunity No person-to-person transmission No person-to-person transmission Low infectious dose: organisms produce disease Low infectious dose: organisms produce disease Incubation period: probably 3-5 days following aerosol exposure (range 1-21 days) Incubation period: probably 3-5 days following aerosol exposure (range 1-21 days) Case fatality rate Case fatality rate Treated: <1-3% Treated: <1-3% Untreated: 30-60% (pneumonic), 5% (ulceroglandular) Untreated: 30-60% (pneumonic), 5% (ulceroglandular) Recovery followed by permanent immunity Recovery followed by permanent immunity No person-to-person transmission No person-to-person transmission

UW Northwest Center for Public Health Practice 8 Tularemia: Case Definition An illness characterized by several distinct forms, including the following An illness characterized by several distinct forms, including the following Ulceroglandular (cutaneous ulcer with regional lymphadenopathy) Ulceroglandular (cutaneous ulcer with regional lymphadenopathy) Glandular (regional lymphadenopathy with no ulcer) Glandular (regional lymphadenopathy with no ulcer) Oculoglandular (conjunctivitis with preauricular lymphadenopathy) Oculoglandular (conjunctivitis with preauricular lymphadenopathy) Oropharyngeal (stomatitis or pharyngitis or tonsillitis & cervical adenopath) Oropharyngeal (stomatitis or pharyngitis or tonsillitis & cervical adenopath) An illness characterized by several distinct forms, including the following An illness characterized by several distinct forms, including the following Ulceroglandular (cutaneous ulcer with regional lymphadenopathy) Ulceroglandular (cutaneous ulcer with regional lymphadenopathy) Glandular (regional lymphadenopathy with no ulcer) Glandular (regional lymphadenopathy with no ulcer) Oculoglandular (conjunctivitis with preauricular lymphadenopathy) Oculoglandular (conjunctivitis with preauricular lymphadenopathy) Oropharyngeal (stomatitis or pharyngitis or tonsillitis & cervical adenopath) Oropharyngeal (stomatitis or pharyngitis or tonsillitis & cervical adenopath) MMWR 1997;46(RR-10)

UW Northwest Center for Public Health Practice 9 Tularemia: Case definition, cont. An illness characterized by several distinct forms, including the following An illness characterized by several distinct forms, including the following Intestinal (intestinal pain, vomiting, diarrhea) Intestinal (intestinal pain, vomiting, diarrhea) Pneumonic* (primary pleuropulmonary disease) Pneumonic* (primary pleuropulmonary disease) Typhoidal (febrile illness w/o early localizing signs & symptoms Typhoidal (febrile illness w/o early localizing signs & symptoms Clinical diagnosis supported by evidence or history of a tick or deerfly bite, exposure to tissues of a mammalian host of F. tularensis, or exposure to potentially contaminated water. Clinical diagnosis supported by evidence or history of a tick or deerfly bite, exposure to tissues of a mammalian host of F. tularensis, or exposure to potentially contaminated water. An illness characterized by several distinct forms, including the following An illness characterized by several distinct forms, including the following Intestinal (intestinal pain, vomiting, diarrhea) Intestinal (intestinal pain, vomiting, diarrhea) Pneumonic* (primary pleuropulmonary disease) Pneumonic* (primary pleuropulmonary disease) Typhoidal (febrile illness w/o early localizing signs & symptoms Typhoidal (febrile illness w/o early localizing signs & symptoms Clinical diagnosis supported by evidence or history of a tick or deerfly bite, exposure to tissues of a mammalian host of F. tularensis, or exposure to potentially contaminated water. Clinical diagnosis supported by evidence or history of a tick or deerfly bite, exposure to tissues of a mammalian host of F. tularensis, or exposure to potentially contaminated water. *most likely BT presentation MMWR 1997;46(RR-10)

UW Northwest Center for Public Health Practice 10 Tularemia: Case Definition, cont. Laboratory criteria for diagnosis Laboratory criteria for diagnosis Presumptive : Presumptive : Elevated serum antibody titer(s) to F. tularensis antigen (w/o documented 4-fold or greater change) in a patient with no history of tularemia vaccination OR Elevated serum antibody titer(s) to F. tularensis antigen (w/o documented 4-fold or greater change) in a patient with no history of tularemia vaccination OR Detection of F. tularensis in a clinical specimen by fluorescent assay Detection of F. tularensis in a clinical specimen by fluorescent assay Confirmatory: Confirmatory: Isolation of F. tularensis in a clinical specimen OR Isolation of F. tularensis in a clinical specimen OR 4-fold or greater change in serum antibody titer to F. tularensis antigen 4-fold or greater change in serum antibody titer to F. tularensis antigen Laboratory criteria for diagnosis Laboratory criteria for diagnosis Presumptive : Presumptive : Elevated serum antibody titer(s) to F. tularensis antigen (w/o documented 4-fold or greater change) in a patient with no history of tularemia vaccination OR Elevated serum antibody titer(s) to F. tularensis antigen (w/o documented 4-fold or greater change) in a patient with no history of tularemia vaccination OR Detection of F. tularensis in a clinical specimen by fluorescent assay Detection of F. tularensis in a clinical specimen by fluorescent assay Confirmatory: Confirmatory: Isolation of F. tularensis in a clinical specimen OR Isolation of F. tularensis in a clinical specimen OR 4-fold or greater change in serum antibody titer to F. tularensis antigen 4-fold or greater change in serum antibody titer to F. tularensis antigen MMWR 1997;46(RR-10)

UW Northwest Center for Public Health Practice 11 Tularemia: Case Classification Probable: Clinically compatible with lab results indicative of a presumptive infection Probable: Clinically compatible with lab results indicative of a presumptive infection Confirmed: Clinically compatible with confirmatory lab results Confirmed: Clinically compatible with confirmatory lab results Probable: Clinically compatible with lab results indicative of a presumptive infection Probable: Clinically compatible with lab results indicative of a presumptive infection Confirmed: Clinically compatible with confirmatory lab results Confirmed: Clinically compatible with confirmatory lab results MMWR 1997;46(RR-10)

UW Northwest Center for Public Health Practice 12 Ulceroglandular Tularemia Clinical Features 75-85% of naturally occurring cases 75-85% of naturally occurring cases General symptoms – high fever, malaise, muscle aches, headache, chills & rigors, sore throat General symptoms – high fever, malaise, muscle aches, headache, chills & rigors, sore throat Cutaneous papule appears at inoculation site concurrent with generalized symptoms Cutaneous papule appears at inoculation site concurrent with generalized symptoms Papule --> pustule --> tender indolent ulcer with or without eschar Papule --> pustule --> tender indolent ulcer with or without eschar Tender regional lymphadenopathy Tender regional lymphadenopathy 75-85% of naturally occurring cases 75-85% of naturally occurring cases General symptoms – high fever, malaise, muscle aches, headache, chills & rigors, sore throat General symptoms – high fever, malaise, muscle aches, headache, chills & rigors, sore throat Cutaneous papule appears at inoculation site concurrent with generalized symptoms Cutaneous papule appears at inoculation site concurrent with generalized symptoms Papule --> pustule --> tender indolent ulcer with or without eschar Papule --> pustule --> tender indolent ulcer with or without eschar Tender regional lymphadenopathy Tender regional lymphadenopathy

UW Northwest Center for Public Health Practice 13 Ulceroglandular Tularemia

UW Northwest Center for Public Health Practice 14 Pneumonic Tularemia Clinical Features Initial clinical picture: systemic illness with prominent signs of respiratory disease Initial clinical picture: systemic illness with prominent signs of respiratory disease Abrupt onset fever, chills, headaches, muscle aches, non-productive cough, sore throat Abrupt onset fever, chills, headaches, muscle aches, non-productive cough, sore throat Nausea, vomiting, diarrhea in some cases Nausea, vomiting, diarrhea in some cases Mortality 30% untreated; < 10% treated Mortality 30% untreated; < 10% treated Initial clinical picture: systemic illness with prominent signs of respiratory disease Initial clinical picture: systemic illness with prominent signs of respiratory disease Abrupt onset fever, chills, headaches, muscle aches, non-productive cough, sore throat Abrupt onset fever, chills, headaches, muscle aches, non-productive cough, sore throat Nausea, vomiting, diarrhea in some cases Nausea, vomiting, diarrhea in some cases Mortality 30% untreated; < 10% treated Mortality 30% untreated; < 10% treated

UW Northwest Center for Public Health Practice 15 Tularemia Treatment & Prophylaxis Vaccine: live attenuated vaccine under FDA review – availability uncertain Vaccine: live attenuated vaccine under FDA review – availability uncertain For known aerosol exposures, 14d oral antibiotics recommended For known aerosol exposures, 14d oral antibiotics recommended If covert attack, observe for development of fever for 14 days and treat with antibiotics if febrile If covert attack, observe for development of fever for 14 days and treat with antibiotics if febrile Post-exposure antibiotics – most effective when given w/in 24 hours of exposure Post-exposure antibiotics – most effective when given w/in 24 hours of exposure Vaccine: live attenuated vaccine under FDA review – availability uncertain Vaccine: live attenuated vaccine under FDA review – availability uncertain For known aerosol exposures, 14d oral antibiotics recommended For known aerosol exposures, 14d oral antibiotics recommended If covert attack, observe for development of fever for 14 days and treat with antibiotics if febrile If covert attack, observe for development of fever for 14 days and treat with antibiotics if febrile Post-exposure antibiotics – most effective when given w/in 24 hours of exposure Post-exposure antibiotics – most effective when given w/in 24 hours of exposure

UW Northwest Center for Public Health Practice 16 Tularemia Infection Control Standard precautions Standard precautions No patient isolation necessary due to lack of human-to-human transmission No patient isolation necessary due to lack of human-to-human transmission Alert lab of suspicion for tularemia Alert lab of suspicion for tularemia Standard precautions Standard precautions No patient isolation necessary due to lack of human-to-human transmission No patient isolation necessary due to lack of human-to-human transmission Alert lab of suspicion for tularemia Alert lab of suspicion for tularemia

UW Northwest Center for Public Health Practice 17 Tularemia Summary of Key Points In naturally occurring tularemia, infection virtually always occurs in a rural setting. Infection in an urban setting with no known risk factors or contact with infected animals suggests a possible deliberate source. In naturally occurring tularemia, infection virtually always occurs in a rural setting. Infection in an urban setting with no known risk factors or contact with infected animals suggests a possible deliberate source. Tularemia is not transmitted person to person. In naturally occurring tularemia, infection virtually always occurs in a rural setting. Infection in an urban setting with no known risk factors or contact with infected animals suggests a possible deliberate source. In naturally occurring tularemia, infection virtually always occurs in a rural setting. Infection in an urban setting with no known risk factors or contact with infected animals suggests a possible deliberate source. Tularemia is not transmitted person to person.

UW Northwest Center for Public Health Practice 18 Tularemia Summary of Key Points The most likely presentations of tularemia in a BT attack are pneumonic and typhoidal disease, as opposed to cutaneous disease in naturally occurring cases. Tularemia can be treated and prevented with antibiotics. The most likely presentations of tularemia in a BT attack are pneumonic and typhoidal disease, as opposed to cutaneous disease in naturally occurring cases. Tularemia can be treated and prevented with antibiotics.

UW Northwest Center for Public Health Practice 19 Viral Hemorrhagic Fevers Diverse group of illnesses caused by RNA viruses from 4 families: Diverse group of illnesses caused by RNA viruses from 4 families: Arenaviridae, Bunyaviridae, Filoviridae, Flaviridae Arenaviridae, Bunyaviridae, Filoviridae, Flaviridae Differ by geographic occurrence and vector/reservoir Differ by geographic occurrence and vector/reservoir Share certain clinical and pathogenic features Share certain clinical and pathogenic features Potential for aerosol dissemination, with human infection via respiratory route (except dengue) Potential for aerosol dissemination, with human infection via respiratory route (except dengue) Target organ: vascular bed Target organ: vascular bed Mortality %, depending on agent Mortality %, depending on agent Diverse group of illnesses caused by RNA viruses from 4 families: Diverse group of illnesses caused by RNA viruses from 4 families: Arenaviridae, Bunyaviridae, Filoviridae, Flaviridae Arenaviridae, Bunyaviridae, Filoviridae, Flaviridae Differ by geographic occurrence and vector/reservoir Differ by geographic occurrence and vector/reservoir Share certain clinical and pathogenic features Share certain clinical and pathogenic features Potential for aerosol dissemination, with human infection via respiratory route (except dengue) Potential for aerosol dissemination, with human infection via respiratory route (except dengue) Target organ: vascular bed Target organ: vascular bed Mortality %, depending on agent Mortality %, depending on agent

UW Northwest Center for Public Health Practice 20 Viral Hemorrhagic Fevers Category A agents Category A agents Filoviruses Filoviruses Arenaviruses Arenaviruses Category C agents Category C agents Hantaviruses Hantaviruses Tick-borne hemorrhagic fever viruses Tick-borne hemorrhagic fever viruses Yellow fever Yellow fever Category A agents Category A agents Filoviruses Filoviruses Arenaviruses Arenaviruses Category C agents Category C agents Hantaviruses Hantaviruses Tick-borne hemorrhagic fever viruses Tick-borne hemorrhagic fever viruses Yellow fever Yellow fever

UW Northwest Center for Public Health Practice 21 Viral Hemorrhagic Fevers Transmission Zoonotic diseases Zoonotic diseases Rodents and arthropods main reservoir Rodents and arthropods main reservoir Humans infected via bite of infected arthropod, inhalation of rodent excreta, or contact with infected animal carcasses Humans infected via bite of infected arthropod, inhalation of rodent excreta, or contact with infected animal carcasses Person-to-person transmission possible with several agents Person-to-person transmission possible with several agents Primarily via blood or bodily fluid exposure Primarily via blood or bodily fluid exposure Rare instances of airborne transmission with arenaviruses and filoviruses Rare instances of airborne transmission with arenaviruses and filoviruses Rift Valley fever has potential to infect domestic animals following a biological attack Rift Valley fever has potential to infect domestic animals following a biological attack Zoonotic diseases Zoonotic diseases Rodents and arthropods main reservoir Rodents and arthropods main reservoir Humans infected via bite of infected arthropod, inhalation of rodent excreta, or contact with infected animal carcasses Humans infected via bite of infected arthropod, inhalation of rodent excreta, or contact with infected animal carcasses Person-to-person transmission possible with several agents Person-to-person transmission possible with several agents Primarily via blood or bodily fluid exposure Primarily via blood or bodily fluid exposure Rare instances of airborne transmission with arenaviruses and filoviruses Rare instances of airborne transmission with arenaviruses and filoviruses Rift Valley fever has potential to infect domestic animals following a biological attack Rift Valley fever has potential to infect domestic animals following a biological attack

UW Northwest Center for Public Health Practice 22 Viral Hemorrhagic Fevers Summary of Agents Virus FamilyVirus/SyndromeGeographic occurrence Reservoir or Vector Human- human transmission ? ArenaviridaeJunin (Argentine HF)S.AmericaRodentsLassa Fever – yes, via body fluids; others – not usually Machupo (Bolivian HF)S.America Guanarito (Brazilian HF) S.America Sabia (Venezuelan HF)S.America Lassa (Lassa Fever)West Africa FlaviridaeYellow FeverTropical Africa,Latin America MosquitoesYellow Fever – blood infective up to 5d of illness; Others - No Dengue FeverTropical areas Kyanasur Forest Disease IndiaTicks Omsk HFSiberia

UW Northwest Center for Public Health Practice 23 Viral Hemorrhagic Fevers Summary of Agents Virus FamilyVirus/SyndromeGeographic occurrence Reservoir or Vector Human- human transmission? BunyaviridaeCongo-Crimean HF Crimea, parts of Africa, Europe & Asia TicksCongo- Crimean Hemorrhagic Fever – yes, through body fluids; Rift Valley Fever, Hantaviruses – no Rift Valley FeverAfricaMosquitoes Hantaviruses (Hemorrhagic Renal Syndrome/ Hantavirus Pulmonary Syndrome) DiverseRodents FiloviridaeEbola HFAfricaUnknownYes, body fluid transmission Marburg HFAfrica

UW Northwest Center for Public Health Practice 24 Viral Hemorrhagic Fevers Clinical Presentation Clinical manifestations nonspecific, vary by agent Clinical manifestations nonspecific, vary by agent Incubation period 2-21 days, depending on agent Incubation period 2-21 days, depending on agent Onset typically abrupt with filoviruses, flaviviruses, and Rift Valley fever Onset typically abrupt with filoviruses, flaviviruses, and Rift Valley fever Onset more insidious with arenaviruses Onset more insidious with arenaviruses Clinical manifestations nonspecific, vary by agent Clinical manifestations nonspecific, vary by agent Incubation period 2-21 days, depending on agent Incubation period 2-21 days, depending on agent Onset typically abrupt with filoviruses, flaviviruses, and Rift Valley fever Onset typically abrupt with filoviruses, flaviviruses, and Rift Valley fever Onset more insidious with arenaviruses Onset more insidious with arenaviruses

UW Northwest Center for Public Health Practice 25 Viral Hemorrhagic Fevers Initial Symptoms High fever High fever Headache Headache Malaise Malaise Weakness Weakness Exhaustion Exhaustion High fever High fever Headache Headache Malaise Malaise Weakness Weakness Exhaustion Exhaustion Dizziness Dizziness Muscle aches Muscle aches Joint pain Joint pain Nausea Nausea Non-bloody diarrhea Non-bloody diarrhea Prodromal illness lasting < 1 week may include:

UW Northwest Center for Public Health Practice 26 Viral Hemorrhagic Fevers Clinical Signs Flushing, conjunctival injection (“red eye”) Flushing, conjunctival injection (“red eye”) Pharyngitis Pharyngitis Rash Rash Flushing, conjunctival injection (“red eye”) Flushing, conjunctival injection (“red eye”) Pharyngitis Pharyngitis Rash Rash Edema Edema Hypotension Hypotension Shock Shock Mucous membrane bleeding Mucous membrane bleeding

UW Northwest Center for Public Health Practice 27 VHF Surveillance: Clinical Identification of Suspected Cases Clinical criteria: Clinical criteria: Temperature 101  F(38.3  C) for <3 weeks Temperature 101  F(38.3  C) for <3 weeks Severe illness and no predisposing factors for hemorrhagic manifestations Severe illness and no predisposing factors for hemorrhagic manifestations 2 or more of the following: 2 or more of the following: Hemorrhagic or purple rash Hemorrhagic or purple rash Epistaxis Epistaxis Hematemesis Hematemesis Hemoptysis Hemoptysis Blood in stools Blood in stools Other hemorrhagic symptoms Other hemorrhagic symptoms No established alternative diagnosis No established alternative diagnosis Clinical criteria: Clinical criteria: Temperature 101  F(38.3  C) for <3 weeks Temperature 101  F(38.3  C) for <3 weeks Severe illness and no predisposing factors for hemorrhagic manifestations Severe illness and no predisposing factors for hemorrhagic manifestations 2 or more of the following: 2 or more of the following: Hemorrhagic or purple rash Hemorrhagic or purple rash Epistaxis Epistaxis Hematemesis Hematemesis Hemoptysis Hemoptysis Blood in stools Blood in stools Other hemorrhagic symptoms Other hemorrhagic symptoms No established alternative diagnosis No established alternative diagnosis JAMA 2002;287 Adapted from WHO

UW Northwest Center for Public Health Practice 28 Viral Hemorrhagic Fevers Treatment Supportive care Supportive care Correct coagulopathies as needed Correct coagulopathies as needed No antiplatelet drugs or IM injections No antiplatelet drugs or IM injections Investigational treatments, available under protocol: Investigational treatments, available under protocol: Ribavirin x 10 days for arenaviridae and bunyaviridae Ribavirin x 10 days for arenaviridae and bunyaviridae Convalescent plasma w/in 8d of onset for AHF Convalescent plasma w/in 8d of onset for AHF Supportive care Supportive care Correct coagulopathies as needed Correct coagulopathies as needed No antiplatelet drugs or IM injections No antiplatelet drugs or IM injections Investigational treatments, available under protocol: Investigational treatments, available under protocol: Ribavirin x 10 days for arenaviridae and bunyaviridae Ribavirin x 10 days for arenaviridae and bunyaviridae Convalescent plasma w/in 8d of onset for AHF Convalescent plasma w/in 8d of onset for AHF

UW Northwest Center for Public Health Practice 29 Viral Hemorrhagic Fevers Management of Exposed Persons Medical surveillance for all potentially exposed persons, close contacts, and high-risk contacts (i.e., mucous membrane or percutaneous exposure) x 21 days Medical surveillance for all potentially exposed persons, close contacts, and high-risk contacts (i.e., mucous membrane or percutaneous exposure) x 21 days Report hemorrhagic symptoms (slide 47) Report hemorrhagic symptoms (slide 47) Record fever 2x/day Record fever 2x/day Report temperatures  101  F(38.3  C) Report temperatures  101  F(38.3  C) Initiate presumptive ribavirin therapy Percutaneous/mucocutaneous exposure to blood or body fluids of infected: Percutaneous/mucocutaneous exposure to blood or body fluids of infected: Wash thoroughly with soap and water, irrigate mucous membranes with water or saline Wash thoroughly with soap and water, irrigate mucous membranes with water or saline Medical surveillance for all potentially exposed persons, close contacts, and high-risk contacts (i.e., mucous membrane or percutaneous exposure) x 21 days Medical surveillance for all potentially exposed persons, close contacts, and high-risk contacts (i.e., mucous membrane or percutaneous exposure) x 21 days Report hemorrhagic symptoms (slide 47) Report hemorrhagic symptoms (slide 47) Record fever 2x/day Record fever 2x/day Report temperatures  101  F(38.3  C) Report temperatures  101  F(38.3  C) Initiate presumptive ribavirin therapy Percutaneous/mucocutaneous exposure to blood or body fluids of infected: Percutaneous/mucocutaneous exposure to blood or body fluids of infected: Wash thoroughly with soap and water, irrigate mucous membranes with water or saline Wash thoroughly with soap and water, irrigate mucous membranes with water or saline

UW Northwest Center for Public Health Practice 30 Viral Hemorrhagic Fevers Management of Exposed Persons Patients convalescing should refrain from sexual activity for 3 months post-recovery (arenavirus or filovirus infection) Patients convalescing should refrain from sexual activity for 3 months post-recovery (arenavirus or filovirus infection) Only licensed vaccine: Yellow Fever Only licensed vaccine: Yellow Fever Investigational vaccines: AHF, RV, HV Investigational vaccines: AHF, RV, HV Possible use of ribavirin to high risk contacts of CCHF and LF patients Possible use of ribavirin to high risk contacts of CCHF and LF patients Patients convalescing should refrain from sexual activity for 3 months post-recovery (arenavirus or filovirus infection) Patients convalescing should refrain from sexual activity for 3 months post-recovery (arenavirus or filovirus infection) Only licensed vaccine: Yellow Fever Only licensed vaccine: Yellow Fever Investigational vaccines: AHF, RV, HV Investigational vaccines: AHF, RV, HV Possible use of ribavirin to high risk contacts of CCHF and LF patients Possible use of ribavirin to high risk contacts of CCHF and LF patients

UW Northwest Center for Public Health Practice 31 Viral Hemorrhagic Fevers Infection Control Viral Hemorrhagic Fevers Infection Control Airborne & contact precautions for health care, environmental, and laboratory workers Airborne & contact precautions for health care, environmental, and laboratory workers Negative pressure room, if available Negative pressure room, if available 6-12 air changes/hour 6-12 air changes/hour Exhausted outdoors or through HEPA filter Exhausted outdoors or through HEPA filter Personal protective equipment Personal protective equipment Double gloves Double gloves Impermeable gowns, leg and shoe coverings Impermeable gowns, leg and shoe coverings Face shields and eye protection Face shields and eye protection N-95 mask or PAPR N-95 mask or PAPR Airborne & contact precautions for health care, environmental, and laboratory workers Airborne & contact precautions for health care, environmental, and laboratory workers Negative pressure room, if available Negative pressure room, if available 6-12 air changes/hour 6-12 air changes/hour Exhausted outdoors or through HEPA filter Exhausted outdoors or through HEPA filter Personal protective equipment Personal protective equipment Double gloves Double gloves Impermeable gowns, leg and shoe coverings Impermeable gowns, leg and shoe coverings Face shields and eye protection Face shields and eye protection N-95 mask or PAPR N-95 mask or PAPR

UW Northwest Center for Public Health Practice 32 Viral Hemorrhagic Fevers Infection Control Viral Hemorrhagic Fevers Infection Control Dedicated medical equipment for patients Dedicated medical equipment for patients If available, point-of-care analyzers for routine laboratory analyses If available, point-of-care analyzers for routine laboratory analyses If unavailable, pretreat serum w/Triton X-100 If unavailable, pretreat serum w/Triton X-100 Lab samples double-bagged & hand-carried to lab Lab samples double-bagged & hand-carried to lab Prompt burial or cremation of deceased with minimal handling Prompt burial or cremation of deceased with minimal handling Autopsies performed only by trained personnel with PPE Autopsies performed only by trained personnel with PPE Dedicated medical equipment for patients Dedicated medical equipment for patients If available, point-of-care analyzers for routine laboratory analyses If available, point-of-care analyzers for routine laboratory analyses If unavailable, pretreat serum w/Triton X-100 If unavailable, pretreat serum w/Triton X-100 Lab samples double-bagged & hand-carried to lab Lab samples double-bagged & hand-carried to lab Prompt burial or cremation of deceased with minimal handling Prompt burial or cremation of deceased with minimal handling Autopsies performed only by trained personnel with PPE Autopsies performed only by trained personnel with PPE

UW Northwest Center for Public Health Practice 33 Viral Hemorrhagic Fevers Summary of Key Points A thorough travel and exposure history is key to distinguishing naturally occurring from intentional viral hemorrhagic fever cases. A thorough travel and exposure history is key to distinguishing naturally occurring from intentional viral hemorrhagic fever cases. Viral hemorrhagic fevers can be transmitted via exposure to blood and bodily fluids. Viral hemorrhagic fevers can be transmitted via exposure to blood and bodily fluids. A thorough travel and exposure history is key to distinguishing naturally occurring from intentional viral hemorrhagic fever cases. A thorough travel and exposure history is key to distinguishing naturally occurring from intentional viral hemorrhagic fever cases. Viral hemorrhagic fevers can be transmitted via exposure to blood and bodily fluids. Viral hemorrhagic fevers can be transmitted via exposure to blood and bodily fluids.

UW Northwest Center for Public Health Practice 34 Viral Hemorrhagic Fevers Summary of Key Points Contact and airborne precautions are recommended for health care workers caring for infected patients. Contact and airborne precautions are recommended for health care workers caring for infected patients. Post-exposure management consists of surveillance for fever and hemorrhagic symptoms, and possibly ribavirin therapy for symptomatic individuals. Contact and airborne precautions are recommended for health care workers caring for infected patients. Contact and airborne precautions are recommended for health care workers caring for infected patients. Post-exposure management consists of surveillance for fever and hemorrhagic symptoms, and possibly ribavirin therapy for symptomatic individuals.

UW Northwest Center for Public Health Practice 35 Case Reports Tularemia Tularemia Viral Hemorrhagic Fevers Viral Hemorrhagic Fevers Tularemia Tularemia Viral Hemorrhagic Fevers Viral Hemorrhagic Fevers MMWR Morb Mortal Wkly Rep 2001;50(33) MMWR Morb Mortal Wkly Rep 2001;50(5)

UW Northwest Center for Public Health Practice 36 ResourcesResources Centers for Disease Control & Prevention Centers for Disease Control & Prevention Bioterrorism Web page: Bioterrorism Web page: CDC Office of Health and Safety Information System (personal protective equipment) CDC Office of Health and Safety Information System (personal protective equipment) USAMRIID -- includes link to on-line version of Medical Management of Biological Casualties Handbook USAMRIID -- includes link to on-line version of Medical Management of Biological Casualties Handbook Johns Hopkins Center for Civilian Biodefense Studies Johns Hopkins Center for Civilian Biodefense Studies Centers for Disease Control & Prevention Centers for Disease Control & Prevention Bioterrorism Web page: Bioterrorism Web page: CDC Office of Health and Safety Information System (personal protective equipment) CDC Office of Health and Safety Information System (personal protective equipment) USAMRIID -- includes link to on-line version of Medical Management of Biological Casualties Handbook USAMRIID -- includes link to on-line version of Medical Management of Biological Casualties Handbook Johns Hopkins Center for Civilian Biodefense Studies Johns Hopkins Center for Civilian Biodefense Studies

UW Northwest Center for Public Health Practice 37 ResourcesResources Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information St. Louis University Center for the Study of Bioterrorism and Emerging Infections St. Louis University Center for the Study of Bioterrorism and Emerging Infections Public Health - Seattle & King County Public Health - Seattle & King County Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information St. Louis University Center for the Study of Bioterrorism and Emerging Infections St. Louis University Center for the Study of Bioterrorism and Emerging Infections Public Health - Seattle & King County Public Health - Seattle & King County

UW Northwest Center for Public Health Practice 38 ResourcesResources Washington State Department of Health Washington State Department of Health Communicable Disease Epidemiology Communicable Disease Epidemiology (206) OR (206) OR (877) (24 hour emergency) (877) (24 hour emergency) Association for Professionals in Infection Control Association for Professionals in Infection Control MMWR Rec & Rep. Case definitions under public health surveillance. MMWR Rec & Rep. Case definitions under public health surveillance. Washington State Department of Health Washington State Department of Health Communicable Disease Epidemiology Communicable Disease Epidemiology (206) OR (206) OR (877) (24 hour emergency) (877) (24 hour emergency) Association for Professionals in Infection Control Association for Professionals in Infection Control MMWR Rec & Rep. Case definitions under public health surveillance. MMWR Rec & Rep. Case definitions under public health surveillance. 1997;46(RR-10):