1. BIOLOGICAL AGENTS  CDC has prioritized them in Lists A - C  A List:  Easily transmitted/disseminated  High mortality rate  Potential for public panic  Public Health impact requiring preparedness

2. “A” LIST  Smallpox*  Anthrax*  Plague  Botulism toxin  Tularemia  Viral Hemorrhagic Fevers*  *person to person transmission possible

3.  Primarily disease of animals who ingest anthrax spores from soil, (spores can last in soil for decades)  Natural transmission to humans by contact with infected animals or contaminated animal products  Cutaneous form most common form of anthrax (usually occupational); 224 cases in U.S. between 1944 – 1994 Anthrax: Overview CDC: Gram stain of B. anthracis

4. Anthrax: Cutaneous Inoculation of spores under skin through cut/abrasion  Incubation: hours to 7 days (average 5 days)  Small bump (3 – 5 days)  ulcer surrounded by blisters 24-28h later  Toxin production leads to local edema  Painless black scab over ulcer  Painful, swollen lymph nodes possible  Death 20% untreated; rare treated USAMRIID: Eschar with surrounding edema

5. Anthrax: Inhalational  Inhalation of spores, which then grow into bacteria  Incubation: 1 to 43 days  Initial symptoms (2-5 d)  fever, cough, myalgia, malaise  Terminal symptoms (1-2d )  high fever, shortness of breath  Most of signs occur in lungs: swollen lymph nodes and fluid accumulation  rapid progression to shock / death because toxins released by the anthrax bacteria  Mortality rate ~100% despite aggressive Rx CDC: CXR with widened mediastinum of inhalational anthrax

6. Anthrax: Post-exposure Treatment  Ciprofloxacin or Doxycycline Antibiotics for 60 days without vaccine  Antibiotics for 30 days with 3 doses of vaccine (animal studies)

7. Antibiotic Adverse Effects  Cipro: Nausea, vomiting, abdominal pain, dizziness, headache, restlessness, confusion  Doxy: GI disturbances, diarrhea, teeth staining in children < 6 y/o  Compliance?  Between 25 – 75% of Washington D.C. postal workers in 2001 did not complete course because of side effects of antibiotics

8. Anthrax: Vaccine  FDA approved for persons 18-65 years of age  Not entirely sure how fully it protects against inhalational anthrax  Six shots over 18 months  3 shots (0, 2, and 4 weeks ) may be effective for post-exposure treatment

9. Plague: Overview  Bacterial disease found in certain animals:  rats, squirrels, chipmunks, rabbits, and carnivores  Usual infection through contact with rodents/fleas that have bitten animals carrying plague  About 10-15 cases / year in U.S.  mainly SW states  bubonic most common form  only 1-2 cases / yr. of pneumonic form CDC: Wayson’s Stain of Y. pestis showing bipolar staining

10. USAMRIID: Inguinal/femoral buboes Plague: Bubonic  Incubation: 2-6 days  Sudden onset headache, fatigue, muscle aches, fever, tender lymph nodes  Lymph nodes in area of flea bite will swell (Buboes)  Not contagious

11. USAMRIID: Pneumonic infiltrate of pneumonic plague Plague: Pneumonic  Incubation: 1-3 days  Sudden onset headache, fatigue, fever, muscle aches, cough  Pneumonia progresses rapidly to shortness of breath, patient coughs up blood  Death from respiratory collapse and spread of infection to blood  Can be contagious

12. Plague: Prophylaxis  Bubonic contacts  Consider Doxycycline, Tetracycline, or sulfa drug for 7 days  other close contacts, fever watch for 7 days (treat if febrile)  Pneumonic contacts  consider Doxycycline, Tetracycline, orulfa drug for 7 days  Vaccine no longer manufactured in U.S.  not protective against pneumonic plague

13. Tularemia: Overview  Acquired through contact with blood/tissue of infected animals, or bites of infected deerflies, mosquitoes, or ticks  About 200 cases/year in U.S.  most in rural South central and Western states  majority of cases in summer (tick exposure)  No person-to-person transmission

14. Tularemia: Clinical Forms  Many different types of infections in lymph nodes, can also occur in eyes  Pneumonia  Possible presentation for bioterrorist attackBT

15. Tularemia: Pneumonic  Incubation: 3 to 5 days (range 1-21 days)  Abrupt onset fever, chills, headaches, muscle aches, non-productive cough  Patchy pneumonia on chest x-ray  Mortality 30% if untreated; < 10% if treated with antibiotics USAMRICD: Pneumonic infiltrates of pneumonic tularemia

16. Tularemia: Treatment/Prophylaxis  Treatment  Streptomycin or Gentamicin  Tetracyclines  Post Exposure Prophylaxis  Fever watch for 7 days (preferable)  Doxycycline or Tetracycline for 14 days if febrile (Cipro also possible)  Vaccine investigational  Not available for general use  Role in treatment of disease or post- exposure prophylaxis unknown