Biological Weapons: Essential Information on Category B Agents

1
Biological Weapons Essential Information on
Category B Agents

• Felissa R. Lashley, RN, PhD, FAAN, FACMG
• Professor, College of Nursing, and
• Interim Director, Nursing Center for Bioterrorism
  and Infectious Disease Preparedness
• College of Nursing
• Rutgers, The State University of New Jersey

2

• This module on the use of biological agents as
  bioweapons covers general material, the
  classification of biological agents as to their
  use in bioterrorism and gives the most important
  information regarding the Category B Agents
  according to the Centers for Disease Control and
  Prevention (CDC) classification. Separate modules
  address Category A and Category C agents and
  details re isolation precautions. This module was
  supported in part by USDHHS, HRSA Grant No.
  T01HP01407.

3

• The format and information in this module
• focuses on the use of the agent or outbreak of
• disease particularly in regard to bioterrorism
• including emphasis on management with
• nursing applications and infection control
• material. Detailed material on general
• transmission of disease, infection control and
• isolation precautions is in a separate module
• and this should be consulted. Aspects of
• preparedness are also in a separate module.
• Note that for the care of persons exposed to
• any biological agent, the nurse should be sure
• he/she is adequately protected first.

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Objectives

• At the completion of this module, participants
• will be able to
• 1. Identify at least 10 factors that make a
  biological agent or biological toxin suitable for
  use as a bioterror agent.
• 2. List the 3 CDC categories for critical
  biological agents and why they are so
  categorized.
• 3. Identify and list CDC Category B biological
  agents with potential for use in a bioterrorism
  attack.
• 4. Describe the signs and symptoms of infection
  with Category B agents.
• 5. Discuss isolation precautions for each
  Category B agent.

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Using Biological Agents as Bioweapons
6
Biological Agents and Bioterrorism

• Includes microorganisms, especially certain
  bacteria and viruses, and biological toxins such
  as botulinum toxin, which act like chemical
  agents.
• May be directed at humans, plants, animals, and
  be a threat to crops, livestock, food products
  (agroterrorism) during processing, distribution,
  storage and transportation which could cause
  illness and also have severe economic
  consequences such as bovine spongiform
  encephalopathy, and foot and mouth disease.

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Biological Agents and Bioterrorism-2

• Biological agents can be used as weapons in
• Biocrimes
• Bioterrorism
• Biowarfare
• Definition North Atlantic Treaty Organization
  (NATO) defines a biological weapon as the
  provision of any infectious agent or toxin by any
  means of delivery in order to cause harm to
  humans, animals, or plants.

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Biological Agents and Bioterrorism-3

• Various definitions for bioterrorism have been
  given. The following may be used the
  intentional use or threat of use of biological
  agents on a population to achieve political,
  social, religious, ethnic, or ideological ends by
  causing illness, death and wide scale panic and
  disruption. The aim may not be maximum damage
  but rather a political statement.

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Biological Agents and Bioterrorism-4

• The technology exists to modify existing
  biological agents, or weaponize them, to, for
  example, make it easier to disseminate and/or
  cause greater harm in their dissemination.
• The use of biological agents for bioterrorism has
  been referred to as the poor mans nuclear
  bomb.
• All involve the use of biological agents in order
  to obtain an outcome political, social,
  economic, theological, personal.

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Agents with Potential for USE in BIOTERRORISM

• Varies according to source
• NATO handbook lists 39 agents
• World Health Organization (WHO) has another list
• CDC lists biological agents in various
  categories, A, B, and C
• National Institute for Allergy and Infectious
  Diseases (NIAID), National Institutes of Health
  (NIH) also lists categories A, B, and C, but they
  differ somewhat from how CDC categorizes agents
  and lists a greater number of agents
• Others

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The Following are Desirable Characteristics for
Biological Agents to be Used for Harmful Intent

• Generate high levels of panic among poulation
• Easy to obtain
• Inexpensive
• Easy to produce in mass quantities
• Can be relatively easily weaponized or altered
  for maximum effect (even with genetic
  manipulation)
• High infectivity
• High person-to-person contagion
• High mortality

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The Following are Desirable Characteristics for
Biological Agents to be Used for Harmful Intent-2

• Lack of effective treatment
• Need for intensive care, straining resources
• High potential for casualties/morbidity
• Result in lengthy illness with prolonged care
  needed
• Non-specific symptoms, especially early, delaying
  recognition
• Long incubation periods
• Hard to diagnose
• Great degree of helplessness from effect

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Examples of Historical Uses of the Deliberate
Release of Biological Agents

• Known as early as the 6th century BC
• Soldiers dropped corpses of those who died of
  plague over city walls during siege of Kaffa to
  start a plague epidemic and force surrender.
• British soldiers used variola contaminated
  blankets to spread smallpox to American Indians
  during the French and Indian Wars (1754-1767).

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Examples of Historical Uses of the Deliberate
Release of Biological Agents-2

• Followers of Bhagwan Shree Rajneesh intentionally
  contaminated salad bars in the The Dalles, Oregon
  with Salmonella. The purpose was to keep people
  from voting in a local election in November,
  1984. More than 750 people were affected.
• The Aum Shinrikyo group in Japan attempted to
  carry out attacks using aerosolized anthrax
  spores and botulinum toxin before releasing sarin
  in the Tokyo subway in 1995.

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Examples of Historical Uses of the Deliberate
Release of Biological Agents-3

• Intentional distribution of anthrax spores mainly
  through the US mail to various people occurred in
  the fall of 2001. In all, there were 22 known
  cases of anthrax 11 were inhalational.
• Picture from CDC. Inhalational
• anthrax.

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Categories of Critical Biological Agents as
Specified by CDC

• Three Categories of Agents
• Category A Agents Pose the greatest threat to
  national security
• Category B Agents Second highest priority to
  national security.
• Category C Agents Third highest priority agents
  include emerging pathogens that could be
  engineered for mass dissemination in the future.

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Category A Agents

• Pose a threat to national security because they
• Can be easily disseminated or transmitted
  person-to-person
• Cause high mortality with potential for major
  public health impact
• Might cause public panic and social disruption
• Require special action for public health
  preparedness

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Category B Agents

• Second highest priority to national security
• Are moderately easy to disseminate
• Cause moderate morbidity and low mortality
• Require specific enhancements of CDCs diagnostic
  capacity and enhanced disease surveillance

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Category C Agents

• 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
• Potential for high morbidity and mortality and
  major health impact

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CDC Category B Agents

• These agents include the following organisms with
  the disease in parentheses.
• Alphaviruses
• Eastern and western equine encephalomyelitis
• Venezuelan encephalomyelitis
• Brucella species (brucellosis)
• Burkholderia mallei (glanders)

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CDC Category B Agents-2

• Clostridium perfringens epsilon toxin
• Coxiella burnetti (Q fever)
• Ricin toxin from Ricinus communis, the castor
  bean
• Staphyloccus enterotoxin B
• A subset of Category B agents includes food- or
  water-borne pathogens.

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CDC Category B Agents-3

• The following are food or waterborne pathogens
  that are a subset of Category B agents that
  includes but are not limited to
• Cryptosporidium parvum (cryptosporidiosis)
• Escherichia coli O157H7
• Salmonella species
• Shigella dysenteriae (dysentery)
• Vibrio cholerae (cholera)
• Source CDC. (2000). Biological and chemical
  terrorism
• Strategic plan for preparedness response. MMWR,
  49 (RR
• -04), 1-14.

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ALPHAVIRUSESVenezuelan Equine Encephalitis
(VEE) ComplexEastern Equine Encephalitis
(EEE)Western Equine Encephalitis (WEE)

• Description
• Alphaviruses in the Togaviridiae family.
• Are closely related, and cause illness, ranging
  from mild flu-like symptoms to encephalitis.
• Are listed as Category B agents by CDC, and
  Category C agents by NIAID.
• VEE was tested as a potential biowarfare agent in
  the 1950s and 1960s.

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Alphaviruses-2

• Epidemiology
• VEE, WEE, and EEE cause encephalitis in equines
  (horses, donkeys) and humans.
• EEE can produce illness in some birds such as
  pheasants, quails, and ostriches as well as
  puppies, and the virus transmission cycle is
  between birds and mosquitoes.
• WEE has been isolated from various mammals and
  pheasants and sparrows.
• Human cases are relatively infrequent in the
  non-bioterrorism context.
• Those below 15 years of age and over 50 years of
  age are at greatest risk.

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Alphaviruses-3

• Epidemiology cont.
• VEE occurs in Central and South America, Mexico,
  and along the Gulf Coast of the US.
• EEE occurs in the Eastern seaboard of the US, the
  Gulf Coast and some inland midwest locations.
• WEE occurs mainly in the western US, South
  America, and Canada, but the virus has been
  isolated in Wyoming and Nebraska.

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Alphaviruses-4

• Transmission
• Usually transmitted by mosquito bite.
• Could be transmitted by aerosol if weaponized.
• Only 10-100 VEE organisms are needed to produce
  infection in humans.
• No direct human-to-human or horse-to- human
  transmission has been documented, but is
  theoretically possible through respiratory
  droplets.

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Alphaviruses-5

• Incubation period
• 4-10 days
• Clinical manifestations
• EEE
• Sudden onset of fever, myalgia and headache.
• Some persons progress to encephalitis, seizures
  and coma.
• In those who survive, many develop permanent
  brain damage which may be severe enough to
  require permanent care.

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Alphaviruses-6

• Clinical manifestations cont.
• WEE
• Most infections are asymptomatic or are mild and
  nonspecific.
• Others present with a sudden onset with fever,
  headache, nausea, vomiting, anorexia and malaise
  which may be followed by altered mental status,
  photophobia, weakness and meningeal irritation
  with neck rigidity and paralysis.
• Children under 1 year of age are most vulnerable
  to severe infection.
• Permanent sequelae occur in 5 to 30 of children.

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Alphaviruses-7

• Clinical manifestations cont.
• VEE
• Usually manifests as a mild flu-like illness but
  can progress to fatal encephalitis.
• Symptoms include spiking fevers, chills, malaise,
  severe headache, photophobia, leg pain, back pain
  followed by nausea, vomiting, cough, sore throat
  and diarrhea.
• Conjunctival injection may be seen.
• About 4 of children and less than 1 of adults
  develop CNS signs.
• In those children who recover, seizure disorders
  and neurological defects may be seen.
• Infection in pregnancy can lead to spontaneous
  abortions, stillbirths and congenital anomalies
  in the fetus.

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Alphaviruses-8

• Mortality rate
• EEE about 35.
• WEE about 3-10.
• VEE about 1 overall, but 35 of children and
  10 of adults who develop encephalitis will die.
• Treatment
• Supportive.
• May need anticonvulsants, maintenance of fluid
  and electrolyte balance, maintain adequate
  respiration, and analgesics for pain.

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Alphaviruses-9

• Nursing considerations
• Supportive including maintenance of fluid and
  electrolytes, maintenance of adequate
  respiration, and analgesia for pain.
• Observe carefully.
• Prevent secondary bacterial infections.
• Standard isolation precautions are considered
  adequate since patient-to-patient transmission
  has not been proven.
• Some recommend droplet precautions for VEE since
  person-to-person transmission is theoretically
  possible via respiratory droplets.
• Vaccination
• Equine vaccine available for EEE and one is
  investigational for humans.
• For WEE and VEE, vaccines are available for
  laboratory workers but has frequent side effects.

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Brucella species (Brucellosis)Also known as
undulant fever, Malta fever, Mediterrean fever

• Etiology
• Brucella melitensis also Brucella abortus B.
  suis and B. canis.
• Tiny gram-negative aerobic coccobacilli are
  non-spore forming.
• Epidemiology
• About 100 human cases per year in US, but is
  common in other parts of the world.
• Mostly from California, Florida, Texas, and
  Virginia.
• B. abortus responsible for abortions in animals.
• Transmission by skin contact is considered an
  occupational hazard for vegetarians, farmers,
  butchers, workers, and animal handlers.

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Brucellosis-2

• Transmission
• Ingestion-especially of unpasteurized milk and
  milk products
• Direct skin contact when handling infected
  material, including animal material, tissue and
  fluids
• Aerosols
• No direct person-to-person transmission except
  rarely. Has been transmitted via banked sperm and
  sexual contact.
• Has occurred in lab worker as recently as 2006.

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Brucellosis-3

• Infective dose
• 10-100 organisms
• Incubation period
• 5 days to more than 6 months

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Brucellosis-4Clinical manifestations

• Acute (less than 8 weeks) are non-specific and
  flu-like and may begin insidiously
• Fever
• Profuse sweating (typically 101o F to 104o F),
  often with foul odor
• Malaise

• Headache
• Muscle pain
• Back pain
• Abdominal pain
• Generalized weakness
• Diarrhea or constipation
• Vomiting
• Leukocyte count may be lower or normal
• Splenomegaly

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Brucellosis-5Clinical manifestations

• Chronic can occur more than 1 year from onset
  symptoms may include
• Chronic fatigue syndrome
• Depression
• Arthritis

• Undulant form less than 1 year from onset
  symptoms may include
• Fever
• Arthritis
• Orchitis in males
• Neurological symptoms in up to 5

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Brucellosis-6

• Treatment
• In 2008 the most effective treatment was known to
  be doxycyline-aminoglycoside-rifampin with the
  aminoglycoside given for 7-14 days and
  doxycycline and rifampin given for 6-8
  weeks(Skalsky et al. 2008).
• Other therapies recommended are oral therapy with
  doxycycline and rifampin for 6 weeks but other
  combinations, such as doxycycline and gentamicin
  or doxycycline for 6 weeks with IM steptomycin
  for 2 weeks have been used.
• In cases of meningoencephalitis or endocarditis
  complications, then some recommend long term
  triple drug therapy with rafampin, a tetracycline
  and an aminoglycoside.
• Chemoprophylaxis may be recommended in a
  bioterrorism context or for high risk exposures,
  but is not usually recommended for possible
  exposure to endemic disease.

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Brucellosis-7

• Mortality
• Less than 5
• Nursing considerations
• Standard isolation precautions are recommended.
• Contact precautions may be needed for the
  draining lesions.
• General support and comfort measures depending on
  manifestations.
• Other notes
• Studied under biosafety level 3 conditions.

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Burkholderia mallei (Glanders)

• Etiology
• Burkholderia mallei, a gram-negative bacterium.
• Epidemiology
• Primarily infects horses, donkeys and mules but
  can also infect goats, dogs and cats.
• Until 2000, no human cases described in English
  medical literature since 1949.
• Sporadic cases occur in Asia, Africa, the Middle
  East and South America.

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Glanders-2

• Epidemiology cont.
• In 2000, a microbiologist at US Army Medical
  Research Institute for Infectious Diseases
  (USAMRIID), working on the microbiology of B.
  mallei acquired glanders.
• Glanders is considered to be a potential agent of
  biological warfare, and had been used by Germany
  during WWI.
• May be seen among those who work with equines,
  such as veterinarians, abbattoir workers, and
  caretakers of horses, donkeys and mules.

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Glanders-3

• Transmission
• Inhalation.
• Direct contact with infected animals through
  nasal, oral mucosa, conjunctiva or through open
  skin lesions.
• Human-to-human transmission has been reported in
  family caretakers and possibly through sexual
  transmission.
• Only a few organisms are needed to produce
  infections.
• The high attack rate leading to severe disease
  and high mortality make this a powerful potential
  bioterrorism agent.

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Glanders-4

• Incubation period
• Few days to several weeks.
• Clinical manifestations
• May be acute, subacute or chronic forms.
• Symptoms depend on the route of infection.
• In localized suppurative infection, a nodule can
  form with regional lymphadenopathy usually within
  1 to 5 days.
• Infection of the eyes, nose or respiratory tract
  can cause mucopurulent drainage with later
  lesions that may ulcerate.

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Glanders-6

• Clinical manifestations cont.
• In the case of aerosolized acquired infections,
  symptoms include pneumonia, pulmonary abscesses
  and may include pleural effusion.
• Cough and pleuritic pain occur.
• In the septicemic form either as a primary route
  or secondary to infection from another site,
  fever, myalgias, rigors, malaise, photophobia,
  lacrimation, sweating, diarrhea and pleuritic
  chest pain may occur along with cervical
  adenopathy and lesions on the face and limbs
  followed by generalized pustular lesions.

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Glanders-7

• Clinical manifestations cont.
• Suppurative disease can be seen in liver, spleen,
  lungs or subcutaneous tissues and high swinging
  features.
• The chronic form may include cutaneous abscesses
  as well as in muscles of arms and legs and in
  liver and spleen, and include regional
  lymphadenopathy, nasal discharge and ulceration.
• Diagnosis
• Isolation of organism in blood, lesions, or
  urine.
• Complement fixation tests.

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Glanders-8

• Mortality rates
• Mortality in the septicemic form is over 50 with
  treatment and 95 without treatment.
• Mortality can be 20 even in treated localized
  disease.
• Vaccination
• No vaccine is currently available.

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Glanders-9

• Treatment
• Information is limited.
• Imipenem and doxycycline were used to effectively
  treat the infected laboratory worker.
• In vitro tests indicate that ceftrazidime,
  gentamicin, ciprofloxacin, and a combination of
  sulfazine and trimethoprim would be effective.
• Need several weeks of intensive therapy and then
  eradication of the organism which can take as
  long as 3 to 6 months with oral antibiotics as
  indicated.

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Glanders-10

• Nursing and management considerations
• In hospital setting, standard precautions plus
  contact precautions may be observed, including
• Washing hands after patient contact,
• Wearing gloves when entering the room,
• Placing patient in private room if possible or
  cohort with patient with same pathogen,
• Wearing gown when entering room if contact with
  patient is anticipated or there is wound drainage
  without dressing,

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Glanders-11

• Nursing and management considerations cont.
• Use mask and eye protection during any procedures
  which may generate splashes or sprays of blood,
  body fluids, and/or secretions or excretions,
• Limit movement or transport of patient from the
  room,
• Handle used patient care equipment and linen in
  manner that prevents transfer of microorganisms
  to people or equipment,
• Use care when handling sharps,

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Glanders-12

• Nursing and management considerations cont.
• Use mouthpiece or other ventilation device as
  alternative to mouth-to-mouth resuscitation,
• Ensure that patient care items, bedside equipment
  and frequently touched surfaces receive daily
  cleaning,
• Dedicate use of patient care equipment such as
  stethoscopes to single patient or patients with
  same pathogen or be careful to ensure adequate
  disinfection between patients.
• These are described in module on infection
  control.

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Clostridium perfringens e-Toxin

• As a potential agent for bioterrorism,
  Clostridium perfringens e-toxin, is thought to
  have potential for dissemination by
  aerosolization.
• Etiology
• Produced by the bacteria Clostridium perfringens
  (a Gram positive spore forming rod) types B and
  D.
• Transmission
• Ingestion
• Inhalation

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e-Toxin-2

• Clinical manifestations
• Ingestion
• In animals who ingest this toxin, intestinal
  permeability is enhanced.
• Hyperemic kidneys, pulmonary edema and
  pericardial fluid accumulation may be seen.
• Can cause neurological dysfunction such as
  nervousness, seizures, or opisthotonos.
• There is a veterinary vaccine for animals for
  protection.
• Inhalation
• Inhalation could cause pulmonary edema, and
  renal, cardiac and central nervous system damage
  but information about human illness is sparse.

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e-Toxin-3

• Treatment
• Supportive care
• Antibiotics not indicated
• Nursing considerations
• Standard precautions
• Supportive care

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Coxiella burnetti (Q fever)

• Etiology
• Coxiella burnetti, a rickettsial bacterium.
• Has sometimes been called Query fever or 9-mile
  fever.
• Epidemiology
• Widespread in livestock worldwide.
• Is considered a zoonosis.
• Primary reservoirs are cattle, sheep and goats.
• Other affected animals include cats, dogs, wild
  rodents, and birds.

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Q fever-2

• Epidemiology cont.
• Ticks may also be affected.
• Infected animals shed organisms in birth products
  such as amniotic fluid and placenta as well as
  milk, urine, feces and other body tissue or
  fluid.
• The bacterium can survive for long periods in the
  environment.
• Certain occupational workers, such as abattoir
  workers, meat packers, farmers, veterinarians,
  and laboratory workers are at risk.

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Q fever-3

• Transmission
• Inhalation, for example, of contaminated dust,
• Direct contact with infected animals, or
• Contact with contaminated materials, such as
  bedding or hay.
• Transmission may also occur through blood
  transfusion or injection.

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Q fever-4

• Transmission cont.
• If used as a biological weapon might be used in
  aerosol form or through contaminated food or
  water.
• Rare cases have followed sexual contact and
  vertical transmission.
• Is highly infectious as just one organism can
  produce disease.

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Q fever-5

• Incubation period
• Variable.
• Most commonly 2 to 3 weeks after exposure.

58
Q fever-6

• Clinical manifestations
• In about 50 of those who are infected, no
  symptoms are seen.
• In others, flu-like symptoms may occur initially,
  including high fever, headache, malaise,
  sweating, chills, abodominal pain, possible
  photophobia, and myalgia.
• Cough may be present with x-ray evidence of
  pneumonia.
• Nausea and vomiting may occur.
• May see transient thrombocytopenia.
• Weight loss may be seen, and fever may last more
  than a week.
• Up to half of those with symptoms develop
  pneumonia.

59
Q fever-7

• Clinical manifestations cont.
• Hepatitis may occur, sometimes only detectable by
  abnormal lab tests.
• Some develop chronic Q fever either within a year
  or up to 20 years later.
• This consists of endocarditis, occurring in more
  than 7.
• Mortality is high if endocarditis develops.
• In addition, a syndrome similar to chronic
  fatigue syndrome with fatigue, myalgia,
  arthralgia, sweating and changes in mood and
  sleep may be seen.

60
Q fever-8

• Diagnosis
• Is typically serological by indirect
  immunofluorescence assay.
• DNA amplification by PCR may also be used.

61
Q fever-9

• Treatment
• Doxycycline 100 mg. po or iv every 12 hours for 2
  weeks for acute Q fever is treatment of choice.
• The acute form may be self-limited with recovery
  without treatment, especially if not seriously
  ill.
• Doxycycline may also be used in chronic Q fever,
  sometimes with hydroxychloroquine orally for as
  long as 18 months.
• In a mass casuality situation, doxycycline may be
  the drug of choice for 5 to 7 days.
• Doxycycline is contraindicated in pregnancy
• Special considerations and therapies are
  suggested for pregnant women, children and those
  with complications.

62
Q fever-10

• Nursing considerations
• Use of standard precautions that includes masks,
  gloves, and gowns unless aerosolized in the case
  of bioterrorism attack.
• Need to protect against droplet and direct
  contact.
• May be resistant against normal disinfectants.
• Prophylaxis not considered necessary for the
  general public but might be used for essential
  individuals.

63
Q fever-11

• Vaccination
• Vaccine is available.
• Used frequently in Australia.
• In case of terrorist attack, might use vaccine
  pre-exposure.

64
Q fever-12

• Other
• May have been used as biological weapon in WWII.
• May be used as a biological weapon because it is
• Widely available,
• Is easily transmitted by aerosol,
• Could be aerosolized easily,
• Is environmentally stable, and
• Could be produced in large quantities.
• Is believed that morbidity could be high with
  long convalescence and debilitation.

65
Ricin Toxin

• Etiology
• Is a cytotoxin derived from Ricin communis, the
  castor bean plant.
• Ricin is part of waste left over from castor bean
  processing.
• Ricin has potential medical uses.
• Its action is to inhibit protein synthesis in the
  cell.

66
Ricin Toxin-2

• Description
• Can be prepared in large quantities relatively
  easily without great technological capacity or
  expense.
• May appear as a white powder which can be
  dissolved.
• As a potential bioterror attack agent, is not as
  toxic as botulinum toxin or Staphlococcus
  Enterotoxin B but has reportedly been used in at
  least one instance.
• As a potential attack agent, could be used to
  contaminate food or water, be aerosolized for
  inhalation, or be injected.
• Is very stable.

67
Ricin Toxin-3

• Transmission
• Inhalation
• Injection (very rare)
• Ingestion
• Dermal and ocular exposures are not thought to
  cause systemic toxicity
• No person-to-person transmission

68
Ricin Toxin-4

• Epidemiology
• In October 2003, a threatening note in an
  envelope with a sealed container was processed at
  a mail facility in South Carolina. Ricin was
  found present in the container. No
  ricin-associated illness was identified among
  workers.
• Incubation period
• Ingestion within 6 hours
• Inhalation symptoms begin with a few hours
• In February, 2008, a 57 year old men contacted
  emergency personnel because of breathing
  difficulties. He was found to have ricin vials
  present in his room.

69
Ricin Toxin-5

• Clinical manifestations
• Vary with route of exposure.
• Severe allergic reactions may occur especially
  after inhalation.
• May be fatal.
• Ingestion of ricin toxin
• Symptoms occur within 1-4 hours of ingestion.
• Include nausea, vomiting, abdominal pain,
  cramping, diarrhea, gastrointestinal bleeding,
  low or absent urinary output, fever, thirst, sore
  throat, headache, vascular collapse, and shock.
• Can see necrosis of gastrointestinal epithelium,
  as well as hepatic, splenic and renal necrosis.

70
Ricin Toxin-6

• Clinical manifestations cont.
• Inhalation of ricin toxin (most symptoms may
  begin in 4 to 8 hours but be preceded by allergic
  reaction)
• Symptoms include fever, cough, wheezing, chest
  tightness, dyspnea, nausea, heavy sweating and
  arthralgias.
• Pulmonary edema, adult respiratory distress
  syndrome (ARDS), and respiratory failure,
  multisystem organ failure as well as death may
  occur within 36 to 72 hours.
• Eye and skin exposure to powder or mist may cause
  pain and redness of eyes.

71
Ricin Toxin-7

• Mortality
• Death often occurs within 36 to 72 hours after
  exposure.
• If death does not occur in 3-5 days, person often
  recovers.
• Diagnosis
• Detection of ricin in environmental samples with
  clinically compatible signs and symptoms.
• Methods are not available for ricin detection in
  biological fluids.

72
Ricin Toxin-8

• Treatment
• Varies as to route of exposure.
• Can adhere to skin or clothing, so need
  decontamination.
• If eyes or skin exposed, wash or shower with soap
  and water.
• Remove clothing if contaminated do not pull off
  head, cut off instead.
• Place clothing in plastic bag touching as little
  as possible preferably using stick or gloves and
  seal in bag. Double bag and dispose of properly.
• Remove contact lenses. Flush eyes if exposed do
  NOT reinsert. Eyeglasses can be thoroughly washed
  and put back on if needed.
• Discourage any hand-to-mouth or eye activities.

73
Ricin Toxin-9

• Treatment cont.
• Immediate care for exposure
• Ingestion
• Treatment may include lavage (controversial) and
  one dose of activated charcoal early if no
  vomiting.
• Aggressive IV fluid and electrolyte replacement.
• Treat any effects such as seizures.
• Supportive care which may include respiratory
  support and cardiac monitoring.
• Inhalation
• Provide fresh air, rest, half-upright position,
  and oxygen if necessary.
• Supportive care with management similar to
  pulmonary edema.

74
Ricin Toxin-10

• Nursing and management considerations
• Standard isolation precautions for patient care.
• Secondary aerosols not expected to be
  problematic.
• Be sure immediate exposure care has occurred.
• Supportive, precise care depends on clinical
  picture.

75
Ricin Toxin-11

• Other notes
• For inhalation situations, pressure demand,
  self-contained breathing apparatus and in other
  situations, powered air purifying respirator with
  HEPA filters are needed for workers at site.

76
Staphylococcal Enterotoxin B

• Etiology
• Is an exotoxin produced by various types of
  Staphylococcus aureus, a bacterium.
• Transmission
• Ingestion
• Inhalation
• Food poisoning by this toxin is considered one of
  the most common causes of outbreaks of food
  poisoning.
• The enterotoxins are usually preformed in the
  food, especially unfrigerated meats, dairy and
  bakery products.
• In a bioterror episode, could be used to
  contaminate water supplies or be put in food but
  inhalation is considered the greater possibility.

77
Staphylococcal Enterotoxin B-2

• Clinical manifestations
• Ingestion
• Symptoms can begin 1 to 8 hours after ingestion.
• Manifestations of staphylococcal enterotoxin
  ingestion include severe nausea, diarrhea,
  vomiting, abdominal cramps, and low grade fever.
• Prostration may occur.
• Usually resolves spontaneously within 20 hours
  but fluid and electrolyte management might be
  desirable.
• Fatalities are not usual, and may occur in those
  who are immunocompromised, in the elderly or in
  infants.
• Some cases are so mild they do not come to
  attention.

78
Staphylococcal Enterotoxin B-3

• Clinical manifestations cont.
• Inhalation
• Would likely begin with significant shortness of
  breath and chest pain after latent period of 3-12
  hours.
• Clinical manifestations of staphylococcal
  enterotoxin inhalation could result in
  respiratory disease leading to pulmonary edema.
• Symptoms could include fever, headache, mylagia,
  non-productive cough, chest pain (retrosternal),
  and dyspnea.
• Lung fields may be clear with no effusion or
  consolidation.

79
Staphylococcal Enterotoxin B-4

• Complications
• After inhalation exposure, cough could persist as
  long as a month.
• Mortality
• Rarely fatal with appropriate hydration.

80
Staphylococcal Enterotoxin B-5

• Treatment
• Supportive with appropriate fluid and electrolyte
  management.
• If ingested, most cases are self-limited
  resolving in under 24 hours.

81
Staphylococcal Enterotoxin B-6

• Nursing considerations
• Supportive as above.
• Standard isolation precautions.
• No secondary transmission from patients.

82
Staphylococcal Enterotoxin B-7

• Vaccination
• No human vaccine currently available.

83
Cryptosporidiosis

• Etiology
• A parasite, Cryptosporidium parvum, and other
  Cryptosporidium species.
• Are coccidian protozoa.
• Description
• A disease with largely gastrointestional and
  generalized symptoms resulting from
  Cryptosporidium ingestion.

84
Cryptosporidiosis-2

• Epidemiology
• Cryptosporidium are found in a variety of
  biological hosts including snakes, lizards, fish,
  amphibians, birds, rodents, cats, dogs, sheep,
  pigs, deer, and humans.
• Food sources implicated in outbreaks have
  included a variety of raw vegetables, basil,
  cilantro, unpasturized apple juice and cider,
  shellfish and chicken salad.
• The most well known outbreak occurred in
  Milwaukee in 1993 when about 430,000 people were
  affected from contamination in water treatment
  plants.

85
Cryptosporidiosis-3

• Transmission
• Generally through the fecal-oral route through
  oocyst contaminated drinking water, recreational
  water, food, or through close contact with
  infected humans or other hosts, such as animals
  in petting zoos as well as through contact with
  contaminated surfaces.
• The parasite may live in soil, water, food or
  surfaces contaminated with feces from infected
  humans or animals.

86
Cryptosporidiosis-4

• Incubation period
• 2 to 14 days with a median of 7 days.

87
Cryptosporidiosis-5

• Clinical manifestations
• The major manifestation is diarrhea that can last
  a median duration of 9 days with a median of 12
  stools per day accompanied by a copious loss of
  fluids, abdominal cramps, nausea, loss of
  appetite, fatigue, nausea, chills, sweating,
  myalgia, headache, and vomiting.
• Symptoms may cycle.
• Persons with weakened immune systems are at
  greater risk for severe disease.

88
Cryptosporidiosis-6

• Treatment
• In immunocompetent persons, is self-limited.
• Symptomatic treatment consists of oral
  rehydration and antimotility drugs.
• Nitazoxanide is a new broad spectrum
  antimicrobial agent being used for therapy
  especially in children.

89
Cryptosporidiosis-7

• Nursing considerations
• Supportive care.
• Observe for dehydration and treat appropriately.
• Standard isolation precautions with excellent
  handwashing and patient education on handwashing.
• Contact precautions may be necessary if patient
  is in diapers or incontinent.

90
Cryptosporidiosis-8

• Management
• Prevention consists of environmental controls,
  good personal hygiene, and the safety of water
  and food.
• The oocysts are resistant to many chemical
  disinfections, such as chlorine, iodine and
  lysol, and heat-sensitive medical equipment, such
  as endoscopes can be fomites for nosocomial
  transmission.

91
Cryptosporidiosis-9

• Management cont.
• Thus, the institution must determine which of the
  effective chemical disinfectants will be used for
  instrument and surfaces.
• Handwashing is of major importance, especially
  after exposure to feces, after diaper changes,
  and after using the toilet as well as before
  handling food or providing patient care.
• Vaccination
• None available

92
Escherichia coli O157H7

• Etiology
• E. coli are gram-negative, non-spore forming, rod
  shaped bacteria of the Enterobacteriaceae family
  that are capable of surviving in food and soil
  for long periods.
• They are part of the normal organisms in the
  intestine.
• There are various pathogenic strains and
  serotypes.
• E. coli O157H7 is a strain that produces Shiga
  toxin and adhere closely to mucosa.
• A few organisms can cause infection (10-100).

93
Escherichia coli O157H7-2

• Description
• Infection with E. coli O157H7 can result in
  hemolytic uremic syndrome (HUS) especially in
  those under 5 years of age or in the elderly.

94
Escherichia coli O157H7-3

• Epidemiology
• Animals, such as cattle, sheep, pigs, and deer,
  can carry E. coli O157H7 and discharge them in
  their feces to contaminate soil, food, or water.
• Food vehicles such as undercooked hamburger,
  unpasteurized apple cider, uncooked vegetables
  and sprouts have been the source of infection.
• Infection has occurred when visiting petting zoos
  or dairy farms or when swimming in contaminated
  water.
• Mainly reported in industrialized countries.

95
Escherichia coli O157H7-4

• Transmission
• Fecal-oral route.
• May be foodborne, waterborne or spread through
  animal-to-human or person-to-person contact.
• Nosocomial transmission has occurred.
• Household contacts may become infected, and
  person-to-person transmission is predominant in
  group settings, such as day care facilities or
  nursing homes.

96
Escherichia coli O157H7-5

• Incubation period
• Typically 1 to 14 days.
• Clinical manifestations
• Infection may be asymptomatic or symptomatic.
• Initial clinical signs include diarrhea, which
  may become blood-streaked or overtly bloody,
  vomiting (in about 50), and abdominal pain which
  is often cramping.

97
Escherichia coli O157H7-6

• Clinical manifestations cont.
• There is usually little or no fever.
• Most people recover in about a week, but HUS may
  occur, especially in children or the elderly.
• HUS usually occurs 4 to 13 days after initial
  diarrhea.
• It is believed that in children, HUS is one end
  of a gradient of coagulation abnormalities that
  occur after E. coli O157H7 associated colitis.

98
Escherichia coli O157H7-7

• Clinical manifestations cont.
• HUS manifestations may include thrombotic
  thrombocytopenic purpura, microangiopathic
  anemia, acute renal failure and CNS
  manifestations.
• Chronic renal failure, stroke, blindness,
  seizures and coma may be complications.
• Long-term sequelae in regard to renal disease,
  effects of colonic resection if needed to treat
  HUS or cognitive impairment may be seen.

99
Escherichia coli O157H7-8

• Diagnosis
• Stool culture usual in those with afebrile bloody
  diarrhea particularly.
• Treatment
• Antibiotics and antimotility agents are not
  recommended, and antibiotic treatment in children
  may be associated with HUS development.
• Generally supportive measures recommended
  including correcting and maintaining fluids and
  electrolytes, monitoring hemoglobin concentration
  and treating any anemia dialysis if renal
  complications occur with HUS.

100
Escherichia coli O157H7-9

• Nursing management
• Appropriate infection control including standard
  precautions and contact precautions when diarrhea
  present or for diapered or incontinent persons.
• Supportive care including observation for
  dehydration and fluid and electrolyte
  maintenance, and comfort measures.

101
Salmonella Species (spp)

• Description
• Various members (over 2,000) of the Salmonella
  spp. may cause illness and are considered
  Category B agents by CDC.
• Etiology
• Salmonella are enteric bacteria.
• Salmonella are gram-negative rod-shaped bacilli.
• Most well known for causing severe illness is S.
  serogroup Typhi (typhoid fever).
• S. Enteritidis and S. typhimurium are the two
  serotypes causing about 50 of salmonellosis in
  the US. S. Newport is a serotype increasing in
  incidence.

102
Salmonella-2

• Epidemiology
• For salmonellosis, infections are found worldwide
  with about 1.4 million cases per year in the US.
• About 400 cases of typhoid fever occur each year
  in the US, most acquired abroad.
• Worldwide about 17 million cases of typhoid fever
  occur each year.
• All age groups may be affected.

103
Salmonella-3

• Transmission
• Contaminated food or water through fecal-oral
  route.
• Salmonellosis may also be acquired through
  contact with infected animals, especially
  reptiles or exotic pets.
• In typhoid fever, a chronic carrier state may
  occur in about 5 of infected persons.

104
Salmonella-4

• Incubation period
• Typically 12 hours to 3 days.
• Clinical manifestations
• Typhoid fever
• Usually begins with fever reaching 103o to 104o
  F, chills, malaise, headache, loss of appetite,
  myalgia, abdominal pains, and possibly
  constipation.
• Diarrhea is not typical and if vomiting occurs it
  is not severe.

105
Salmonella-5

• Clinical manifestations cont.
• Typhoid fever cont.
• Some people get a flat, rose-colored rash.
• There is little to distinguish it from many other
  infectious diseases at first.
• In severe cases, intestinal perforation,
  confusion, delirium and even death may occur.
• Without treatment, duration of illness may be 3
  to 4 weeks.

106
Salmonella-6

• Clinical manifestations cont.
• Salmonellosis
• Fever, diarrhea and abdominal cramps.
• Most persons recover without treatment and
  symptoms usually resolve within a week.
• Mortality rates
• Typhoid fever may be 12 to 30.
• Salmonellosis - negligible

107
Salmonella-7

• Treatment
• In severe cases of either, appropriate hydration
  and supportive care is indicated.
• Typhoid fever
• Antibiotics such as ampicillin,
  trimethoprim-sulfamethoxazole, quinolones, and
  ciprofloxacin are usually given.
• Salmonellosis
• Antibiotics are not usually indicated unless
  illness is severe or there is extra-intestinal
  spread.
• Usually resolve in 5-7 days.
• If diarrhea is severe, rehydration may be needed.

108
Salmonella-8

• Nursing considerations
• Supportive care
• Observation for dehydration and appropriate fluid
  and electrolyte replacement.
• Good handwashing techniques are important, and
  should be taught to patients as well as pet
  handling precautions if secondary infected pet.
• Infection control Contact precautions if person
  is incontinent or in diapers, otherwise standard
  precautions. Contact precautions may also be used
  to control institutional oubreaks.
• Vaccination
• Typhoid vaccine available.

109
Salmonella-9

• Complications
• Typhoid fever -
• 2 of cases are complicated by chronic arthritis
  or Reiters syndrome.

110
Shigella dysenteriae

• Etiology
• Shigella dysenteriae are gram-negative bacteria.
• They can cause shigellosis.
• Epidemiology
• Shigellosis is most common in children,
  particularly 2 to 4 years of age, and the
  elderly.
• May be commonly seen in developing countries and
  in child care settings.

111
Shigella dysenteriae-2

• Transmission
• Fecal-oral route
• Person-to-person transmission.
• May be acquired from contaminated food or
  contaminated water which is drunk or used for
  bathing.
• Incubation period
• 24 to 48 hours is usual.

112
Shigella dysenteriae-3

• Clinical manifestations
• Some are asymptomatic.
• In others, one or two days after exposure,
  diarrhea (usually bloody), fever, malaise, and
  abdominal cramping occurs.
• The diarrhea may be severe enough to require
  hospitalization.
• However, usually resolution occurs in 5 to 7 days.

113
Shigella dysenteriae-4

• Treatment
• Antibiotic therapy shortens the illness and is
  used in severe cases.
• Preferred antibiotics include nalidixic acid or
  other quinolones.
• Some antibiotic-resistant strains have been
  noted.
• Usually antidiarrheal agents should be avoided.
• Supportive care.

114
Shigella dysenteriae-5

• Nursing and management considerations
• Infection control contact precautions if patient
  is incontinent or diapered to control an
  institutional outbreak otherwise standard
  precautions.
• Supportive care.
• In the bioterrorism context, prevention centers
  around appropriate handwashing and basic hygiene.

115
Cholera

• Etiology
• Vibrio cholerae, a gram-negative, curved,
  rod-shaped bacteria with many serogroups,
  including the well known El Tor and 01 and 0139
  pandemic strains.
• Epidemiology
• Is endemic in some areas such as India.
• Several pandemics have occurred.
• Is usually transmitted via contaminated water and
  food, especially contaminated undercooked or raw
  seafood.
• Poor sanitation, use of water from wells, using
  stored water which are contaminated by
  contaminated hands are all ways transmission
  occurs.

116
Cholera-2

• Transmission
• Generally food- and water-borne, usually
  transmitted through fecal-oral route.
• Person-to-person contact is rare because large
  doses of the organism are needed to cause
  illness.
• Incubation period
• 18 hours to 5 days usual.

117
Cholera-3

• Clinical manifestations
• Acute onset with vomiting which tends to be clear
  and watery, and watery diarrhea of great volumes
  ranging from 500 to 1000 mL that resembles rice
  water.
• Dehydration occurs rapidly with associated signs
  and symptoms such as poor skin turgor, deficient
  tears, and sunken eyes.
• Complications can include tachycardia,
  hypotension and vascular collapse.

118
Cholera-4

• Treatment
• Rehydration with rapid replacement of fluids.
• In severe dehydration, patients may require
  replacement intravenously but usually oral
  rehydration solutions are used especially for
  mild cases.
• Requires rapid replacement of fluids, correction
  of any electrolyte imbalances including metabolic
  acidosis and potassium imbalances, replacement of
  any continuing fluid losses and maintenance.

119
Cholera-5

• Treatment cont.
• Antibiotics are generally used after fluid
  replacement.
• Single dose Azithromycin appears to be effective
  for treatment in adults.
• In outbreaks, the antibiotic of choice will
  depend on antibiotic resistance patterns.
• Antibiotic treatment shortens symptoms and
  decreases the needs for fluid replacement and
  generally shortens care and the need for
  resources.

120
Cholera-6

• Mortality
• Without treatment can be as high as 50.
• With treatment, is often less than 1.
• Recovery with hydration and without antibiotics
  is typically 4 to 5 days and 2 to 3 days with
  antibiotics.

121
Cholera-7

• Nursing considerations
• Assess patient for hydration status, and assure
  appropriate replacement observe for additional
  symptoms.
• For isolation, standard precautions are
  recommended except for infants and young children
  or incontinent persons in which case contact
  precautions are recommended.
• In emergencies, the cholera cot has been used
  which consists of a bucket placed under a bed
  with a hole in the middle of the mattress which
  is protected by plastic with a sleeve draining
  from the hole into the bucket.
• Hand washing is important for staff, patients and
  visitors

122
Cholera-8

• Vaccination
• Oral vaccine avai