1. Patricia Bolivar Public Health Epidemiology PhD. Candidate Walden University PUBH 8165-01 Dr. Raymond Thron Fall 2010

2.  Plague is an infectious disease of antiquity that persist in modern times caused by Yersinia pestis a rod shaped, non-motile, non-sporulating, gram negative bacterium of the family Enterobacteraceae ( the same family friendly E. coli and many normal flora organisms belong to).  USAMRIID”s Medical Management of Biological Casualties Handbook Sixth Edition  http:// www.usamriid.army.mil

3.  Y. pestis is endemic in various rodents, including rats, ground squirrels, prairie dogs, mice, and rabbits.  Two epidemic forms: urban plague and sylvatic plague.  Transferred to other rodents and humans by fleas.  Incubation period 1 -7 days  Nelson, B. (1980) California Department of Health Services  http:// www.cdph.ca.gov

5. Domestic pets. Hunting, trapping, rural residence in places where plague is endemic. Person- to person transmission can occur after contact with a suppurating lesion (bubonic plague) or via respiratory droplets(respiratory plague. Naturally occurring plague typically begins as bubonic plague; intentionally release (bioterrorism) would manifest chiefly as pneumonic. Winn, J. Konan’s Color Atlas Textbook of Clinical Microbiology. Sixth Edition

6. Signs and Symptoms include fever, chills, malaise, sore throat, and headache. A lymphadenitis develops, inguinal lymph nodes are affected in 90% of the cases. Infection can progress to shock and pneumonia. 1. Bubonic: Most naturally occurring in the U.S. 85% 2. Septicemic: 13% 3. Pneumonic :1-2 % 4. USAMRIID”s Medical Management of Biological Casualties Handbook. Sixth Edition 5. http:// www.usamriid.army.mil

7.  First Pandemic: Named after the Roman emperor Justinian Plague of the 6 th century.. It began in Egypt and spread through Middle East and Mediterranean Europe.  Second Pandemic: The Black Death 14 th century. Originated in the area of the Black Sea, spread to Europe, Great Britain, Scandinavia, and Western Russia.  Third Pandemic: Started in 1855 in China  spread to Bombay, Egypt, Portugal, Japan, Paraguay and Eastern Africa, to Manila, Sydney and San Francisco.  Winn, J. Konan’s Color Atlas Textbook of Clinical Microbiology. Sixth Edition

8.  After plague appeared in Hong Kong in 1894 it spread rapidly, reaching San Francisco by boat in 1900.  In 1900s it appeared in Brazil, New Orleans, New York.  1980s epidemic plague occurred each year in Africa, Asia, or South America.  There is no plague in Australia or Europe  Currently 1,000 to 2,000 cases each year worldwide Centers for Disease Control and Prevention, 2010 http://www.cdc.gov/ncidod/dvbid/plague/

10. Specimens determined by clinical presentation Bronchial wash (sputum not advised) Blood- culture or serology Tissue/bubo aspirate Biopsy specimen  Bolivar, P. (2010) Los Angeles County Public Health Laboratory  http://www.lapublichealth.org/lab/

12.  Widespread availability of Y. pestis in microbe banks around the world.  Natural availability of the Y. pestis bacteria in endemic areas.  Techniques for mass production and aerosol dissemination of Y. pestis have been developed.  Fatality rate of untreated pneumonic plague is extremely high.  Potential for secondary spread from person to person following an attack.  Y. pestis can be disseminated in aerosol form with relative ease.  low infectious dose: based on animal data, estimates of infectivity via the respiratory route vary from 100 to 20,000 organismsinfectious dose  Antibiotic resistant strains of Y. pestis exist in nature. Ingles by T.V., JAMA 2010 http://www.bt.cdc.gov/agent/plague/

13.  Routine plague surveillance in the Los Angeles National Forest.  Prompt response to positive serological results.  Public Health and U.S. Forestry Service close of campgrounds when risk higher.  Flea suppression.  Capturing and testing the squirrels post-dust operations.  Provide Public Health advice and education. The Voice, County of Los Angeles Public Health, 2010 http://www.lapublichealth.org/eh/

14. Management: Close access to the area http://www.lapublichealth.org/eh / Alan, A. and Chow, A. Photos, 2010

15. Public Health staff set up 138 bait stations Ground squirrel

16. Capturing and Testing the Squirrels Combing for fleas

17. Collecting the squirrel blood for follow up testing Reopening the area

18.  2010 Los Alamos Campground  2009 Palomar Mountain  2007 San Gabriel Mountains  1996 Stonyvale picnic area  1995 Vogel Flats Los Angeles Times, 2010 http://www.lapublichealth.org/eh/

19.  Antibiotics Streptomycin, Gentamicin, Doxycicline, or Ciprofloxacin  Supportive therapy Hemorrhagic monitoring, endotoxic shock is common  Infection control  Prophylaxis No vaccine is currently available.  USAMRIID”s Medical Management of Biological Casualties Handbook Sixth Edition  http:// www.usamriid.army.mil

20. Any questions? Los Angeles County Public Health Laboratory (562) 658-1360 or 1363

21.  Alan, A. and Chow, A. Photos: The Los Alamos Campgrounds, staff at the central staging area, staff sets up the vials for blood-testing, a squirrel scampers through the campgrounds, dust bait stations,and Plague Warning signs. Retrieved from Los Angeles County Public Health The Voice: Newsletter for Employees of the Los Angeles county Department of Public Health, July 2010  Bolivar, P. (2010) Sentinel Laboratories Training presentation and working experience as Principal Investigator for the Bioterrorism Response Unit of Los Angeles County Public Health Laboratory.   Centers for Disease Control and Prevention (2005). Division of Vector-Borne Infectious Diseases : Information on plague. Retrieved October 21, 2010 from mhtml:file//P:\Plague Information  Centers for Disease Control and Prevention and World Health Organization (2000) Laboratory Manual of Plague Diagnostic Tests. Ft. Collin, Colorado

22.  Ingles T.V., Dennis, D.T., and Henderson, D.A. Plague as a Biological Weapon: medical and public management. JAMA. 2000; 283(17):2281-2290. Retrieved October 21, 2010 from mhtml:file//P:\Plague Fact Sheet.mht  Los Angeles Times. (July 4, 2010): Campground closed after ground squirrel tests positive for plague. Retrieved August 13, 2010 from http://articles.latimes.com/2010/jul/04/local/la-me- plague-squirrel-20100704http://articles.latimes.com/2010/jul/04/local/la-me- plague-squirrel-20100704  Nelson, B. (1980) Plague studies in California- The roles of various species of sylvatic rodents in plague ecology in California. Vector Biology and control Section, California Department of Health Services, Berkeley, California. Retrieved October 1, 2010 from http://digitalcommons.unl.edu/vpc9/30 http://digitalcommons.unl.edu/vpc9/30  Nagano, S. Protecting the Public from the Plague. Los Angeles County Public Health The Voice: Newsletter for Employees of the Los Angeles county Department of Public Health, July 2010.  USAMRIID’s Medical Management of Biological Casualties Handbook (2005). Sixth Edition Forth Detrick Frederick, Maryland  Winn, W., Allen, S., Janda, W and Koneman, E. (2006) Konan’s Color Atlas Textbook of Clinical Microbiology Sixth Edition. Lippincott Williams and Wikins. Baltimore, MD

23. 1. Environmental Health http://www.lapublichealth.org/eh/http://www.lapublichealth.org/eh/ 2. CDC Plague http://www.cdc.gov/ncidod/dvbid/plague/http://www.cdc.gov/ncidod/dvbid/plague/ 3. Emergency Preparedness and Response: Plague information http://www.bt.cdc.gov/agent/plague/ http://www.bt.cdc.gov/agent/plague/ 4. Plague: The Bacterium http://www.cdc.gov/ncidod/dvbid/plague/bacterium.htm http://www.cdc.gov/ncidod/dvbid/plague/bacterium.htm 5. USAMRIID’s Medical Management of Biological Casualties Handbook http://www.usamriid.army.milhttp://www.usamriid.army.mil 6. California Department of Health Services http:// www.cdph.ca.govhttp:// www.cdph.ca.gov