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Biological Weapons: Essential Information on Category B Agents

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Title: 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.

4
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.

5
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.

7
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.

8
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.

9
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.

10
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

11
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

12
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

13
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).

14
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.

15
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.

16
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.

17
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

18
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

19
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

20
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)

21
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.

22
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.

23
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.

24
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.

25
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.

26
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.

27
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.

28
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.

29
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.

30
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.

31
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.

32
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.

33
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.

34
Brucellosis-3
  • Infective dose
  • 10-100 organisms
  • Incubation period
  • 5 days to more than 6 months

35
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

36
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

37
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.

38
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.

39
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.

40
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.

41
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.

42
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.

43
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.

44
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.

45
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.

46
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.

47
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,

48
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,

49
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.

50
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

51
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.

52
e-Toxin-3
  • Treatment
  • Supportive care
  • Antibiotics not indicated
  • Nursing considerations
  • Standard precautions
  • Supportive care

53
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.

54
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.

55
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.

56
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.

57
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
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