Learning Objectives
After completion of the course you’ll be able to:
Chapter 3: The Prospect of Domestic Bioterrorism
Chapter 5: Epidemiology of Bioterrorism
Define indication of intentional release of biologic agent.
Describe the precautions laboratory personnel should take when collecting or handling clinical specimens.
Discuss the epidemiology of bioterrorism and differentiate between a natural outbreak an intentional attack.
List 10 clues that together may constitue proof of intentional use of biological agent.
Chapter 7: Anthrax
Describe the side effects of taking ciprofloxacin and doxycycline.
Describe recommendations made by the CDC for worker safety under engineering controls, administrative controls, housekeeping controls, and personal protective equipment.
Implement anthrax worker safety guidelines issued by the CDC.
Describe the epidemiology of naturally occurring anthrax.
Discuss the diagnosis of inhalational anthrax.
Discuss the therapeutic options of anthrax infection.
Discuss infection control and decontamination protocols for anthrax.
Describe the procedure for handling suspicious packages or envelopes.
Provide medication information to patients about ciprofloxacin, doxycycline, penicillin, and amoxicillin.
Discuss clinical issues in the prophylaxis, diagnosis, and treatment of anthrax.
Chapter 8: Smallpox
Describe various phases of the smallpox disease, symptoms, and degree of infectiousness.
Answer questions about the smallpox disease and the vaccine.
List the categories of people who should not get vaccine.
List the steps that one should take after vaccination to minimize the risk of spreading vaccinia.
Chapter 9: Botulism
Describe three main kinds of botulism and their mode of transmission.
Answer frequently asked questions about botulism.
List symptoms of botulism.
Describe infant botulism, its epidemiology, source of C. botulinum , and prevention and control.
Describe the clinical syndrome of botulism and provide a diagnosis of the disease.
Put the use of botulinum toxin as a bioweapon in historical perspective.
Describe the pathogenesis and clinical manifestations of botulism.
List typical symptoms and signs of foodborne botulism.
Identify features of an outbreak that would indicate a bioterrorist attack with botulinum toxin.
Describe the therapy, prophylaxis and decontamination for botulinum toxin.
Chapter 10: Plague
Answer frequently asked questions about pneumonic and bubonic plague, their signs and symptoms, and treatment.
Describe the role fleas play in the spread of plague to humans.
Explain the epidemiology of plague.
Describe clinical manifestations of bubonic, septicemic, pneumonic, and pharyngeal plague.
Discuss signs and symptoms and laboratory confirmation that can establish the diagnosis of plague.
Describe the treatment for plague.
Outline the strategies for the prevention of plague.
Chapter 11: Tularemia
Answer frequently asked questions about tularemia.
Describe the signs and symptoms of tularemia.
Identify epidemiological indicators that would suggest a bioterrorism act of inhalational tularemia.
Describe the pathogenesis and clinical manifestations of F. tularensis .
Provide a diagnosis of inhalational tularemia following its use as a biological weapon.
Describe the treatment of tularemia in adults and children.
Chapter 12: Viral Hemorrhagic Fevers
Answer frequently asked questions about the etiology and epidemiology of viral hemorrhagic fevers.
Describe various ways of preventing and controlling viral hemorrhagic fevers.
Describe the history and potential of HFVs as biological weapons.
Describe the clinical manifestations of diseases caused by hemorrhagic fever viruses.
Provide a diagnosis of viral hemorrhagic fevers and treatment options including drug therapy.
Chapter 13: Ricin
Chapter 14: Nerve Agents
Answer frequently asked questions about nerve agents, GA, GB, GD and VX.
Describe the signs and symptoms of nerve agents GA, GB, GD and VX, and their effects on health.
List the things people can do to protect themselves against VX and things they should do if they are exposed to VX.
Describe the health effects of nerve agents, GA, GB, GD, and VX.
Describe the prehospital management of victims of nerve agent attack.
Chapter 15: Blister Agents
Describe the health effects of sulfur mustard on various body systems.
Describe prehospital management of victims exposed to sulfur mustard.
List general principles of triage for chemical exposures.
Describe triage for mustard agent casualties.
Chapter 16: Foodborne Illness
Describe some of the most common foodborne diseases.
Identify instances when a doctor should be consulted for a diarrheal illness.
Describe how outbreaks of foodborne disease are detected and investigated.
Describe the ways food can become contaminated.
List foods that are most associated with foodborne illness.
State five simple precautions one can take to reduce the risk of foodborne diseases.
Identify persons who are at particularly high risk to contract a foodborne illness.
Chapter 17: Escherichia coli O157:H7
List various ways Escherichia coli O157:H7 is spread.
Describe the illness caused by Escherichia coli O157:H7.
Chapter 18: Salmonellosis
Answer frequently asked questions about salmonellosis, including how people can catch Salmonella, its health consequences and treatment.
List eight things one can do to prevent salmonellosis.
Chapter 19: Cholera
Chapter 20: Shigellosis
Answer frequently asked questions about shigellosis.
List eight tips for preventing the spread of shigellosis.
Chapter 21: Brucellosis
Chapter 22: Typhoid Fever
Answer frequently asked questions about typhoid fever.
List steps one can take to avoid typhoid fever.
Chapter 24: Injuries and Mass Trauma Events
Describe symptoms of posttraumatic stress disorder.
Identify the kind of injuries that occur in mass trauma events.
List the things health departments should do to prepare for and subsequent to mass trauma events.
Identify various steps one should plan to escape from home, workplace or hotel.
Describe 3 types of burns, their symptoms and early treatment.
List signs and symptoms after a mild traumatic brain injury (MTBI).
Describe the procedure for personal cleaning and disposal of contaminated clothing.
Describe the evacuation procedure in the event of a chemical accident or attack.
Describe how to prepare to shelter in place in case of a chemical accident or attack.
Allay general public’s concerns about the safety of drinking water.
Describe emergency room procedures in chemical hazard emergencies.
Chapter 25: Bioterrorism Readiness Plan: A Template for Healthcare Facilities
Develop and implement a bioterrorism readiness plan appropriate for a particular healthcare facility.
Identify 6 features that should alert healthcare providers to the possibility of a bioterrorism-related outbreak.
Describe clinical features of anthrax infection, infection control practices for patient management, and post-exposure management.
Describe clinical features of botulism infection, infection control practices for patient management and post-exposure management.
Describe clinical features of pneumonic plague, infection control practices for patient management, and post-exposure management.
Learning Objectives
To assess the effectiveness of the course material, we ask that you evaluate your achievement of each learning objective on a scale of A to D (A=excellent, B=good, C=fair, D=unsatisfactory). Please indicate your responses next to each learning objective and return it to us with your completed exam.
Contents
1. Bioterrorism as a Public Health Threat
References
Figure 1. Effects of a nuclear and biological weapons release.
2. The Threat of Biological Attack: Why Concern Now?
Figure 1. Effects of a nuclear and biological weapons release
Vulnerability to Biological Attack
Perpetrator Capability
Technical Capability
Institutional Capability
Intention to Use Biological Weapons
Nonintentional Pathogen Releases
Table 1. New and reemerging viruses
Conclusions
References
3. The Prospect of Domestic Bioterrorism
Motivational Factors
Getting Attention
Economic Terrorism
Millenarianism
Premillennial Tension
Exacting Revenge or Creating Chaos
Mimicking God
The Aura of Science
The Copycat Phenomenon
Technical Factors
Table. Anthrax incidents in the United States, 1992-1999
Organizational Factors
The Likeliest Perpetrators
Conclusions
Acknowledgments
4. Biologic Terrorism–Responding to the Threat
v Bioterrorism: How Prepared Are We?
5. Epidemiology of Bioterrorism
Differential Diagnosis
Epidemiologic Approach
Epidemic Curve
Epidemiologic Clues
Recommendations for Preparedness
References
6. Medical Aspects of Biological Terrorism
Health-Care Providers
Clinical Case
Clinical Questions
What is a biological weapon?
How does biological terrorism pertain to medicine?
Who should be contacted if biological terrorism is suspected?
When should a physician suspect biological terrorism?
What are the most serious biological weapons?
What are the clinical and epidemiological features of smallpox, inhalational anthrax, pneumonic plague?
Smallpox
Anthrax
Plague
Key Points
Clinical Laboratory Personnel
Infection-Control Professionals
State Health Departments
References
Bibliography
7. Anthrax
v Questions and Answers About Anthrax
What is anthrax?
What is the difference between exposure to anthrax and disease caused by anthrax?
Transmission
How is anthrax transmitted?
What are the types of anthrax infection?
What are the case fatality rates for the various forms of anthrax?
Symptoms
What are the symptoms for anthrax?
How can I know my cold or flu is not anthrax?
Testing
Can I get screened or tested to find out whether I have been exposed to anthrax?
Does CDC collect samples to test the bacteria?
When an area is tested for the presence of Bacillus anthracis, how long does it take to get the results?
Does CDC recommend the use of home test kits for anthrax?
Are health department laboratories capable of conducting testing?
How effective and reliable are anthrax tests?
What is subtyping?
Is subtyping different from polymerase chain reaction (PCR)?
What method does CDC use to subtype Bacillus anthracis?
How does MLVA (multi-locus variable-number of tandem [consecutive] repeat analysis) identify different strains of anthrax?
When is environmental sampling performed?
Why is environmental sampling performed?
What is the turnaround time for an anthrax test of an environmental sample?
Is the Mayo Clinic/Roche Rapid Anthrax Test a new test?
Is the Mayo Clinic assay the same as the assay available to Laboratory Response Network (LRN) laboratories?
What are the limitations of the Mayo Clinic test?
Is CDC going to validate this assay?
Are you aware of any sensitivity or specificity issues with the Mayo Clinic test? Should we expect a large number of false positive/negative results?
Are you furnishing CDC-tested equipment and reagents to laboratories?
If a laboratory asks your opinion on whether to use Mayo Clinic/Roche Rapid test, what is your answer?
Will CDC accept results from laboratories that use this assay?
Diagnosis
How is anthrax diagnosed?
What are the standard diagnostic tests used by the laboratories?
What is a nasal swab test?
When is a nasal swab indicated?
Why were nasal swabs used to screen individuals in the Florida investigation for anthrax?
Is there an X-ray for detecting anthrax?
Preventive/Vaccine
What is the therapy for preventing inhalational anthrax?
Is there a vaccination for anthrax?
Is the anthrax vaccine available to the public?
Who should be vaccinated against anthrax?
Treatment
What is the treatment for patients with inhalational and cutaneous anthrax?
If an anthrax event occurs, should people buy and store antibiotics?
What drugs are FDA-approved for postexposure prophylaxis (PEP) and treatment?
Who should receive antibiotics for 60 days?
If patients are suspected of being exposed to anthrax, should they be quarantined or should other family members be tested?
What if I develop side effects from the antibiotic?
Has CDC tested the anthrax isolates for sensitivity to different antibiotics?
What are the risks of using tetracyclines and fluoroquinolones in children? Are alternatives available?
Are there special instructions for taking ciprofloxacin or doxycycline?
After I have started taking ciprofloxacin to protect me from developing anthrax, what side effects could I get from taking this antibiotic?
After I have started taking doxycycline to protect me from developing anthrax, what side effects could I get from taking this antibiotic?
Why is CDC recommending doxycycline instead of ciprofloxacin for the treatment and prevention of anthrax?
Why are people who have been exposed to B. anthracis being given antibiotics for different amounts of time?
Are there different strains of B. anthracis? Do they all respond to antibiotics?
What is the FDA telling physicians and other health professionals about prescriptions for ciprofloxacin?
Can other fluoroquinolones be used instead of ciprofloxacin for postexposure prophylaxis (PEP)/treatment?
Why do I need 60 days of antibiotics?
What happens if I take ciprofloxacin, doxycycline, or amoxicillin for a few days, stop, and then restart the antibiotics?
The ciprofloxacin I am taking gives me headaches. Is there anything I can do to help this?
The ciprofloxacin, doxycycline, or amoxicillin I am taking makes me feel sick to my stomach. Is there anything I can do to help this?
The ciprofloxacin, doxycycline, or amoxicillin I am taking gives me diarrhea. Is there anything I can do to help this?
If taking one of the recommended antibiotics makes me feel terrible, can I switch to another of these antibiotics?
I am having terrible yeast infections while taking ciprofloxacin, doxycycline, or amoxicillin. Is there anything I can take for this?
I feel much better if I take only one pill of ciprofloxacin, doxycycline, or amoxicillin each day. Is that okay?
My prescription says to take one pill every 12 hours. If 15 hours have passed since my last dose, is it still okay to take the pill?
What side effects are serious enough that I should go to a doctor?
Can I drink alcohol if I am taking ciprofloxacin, doxycycline, or amoxicillin?
The ciprofloxacin, doxycycline, or amoxicillin I am taking makes me feel itchy all over. Is there anything I can do to help this?
The ciprofloxacin, doxycycline, or amoxicillin gave me an allergic reaction and I stopped taking it. What should I do? 1
Why can’t I take a shot, wear a patch, or take one large dose of the medicine instead of taking it for 60 days?
Ciprofloxacin and doxycycline look different and come in different doses. Is one better than the other?
Should all patients who have flu-like symptoms be treated with antibiotics?
Does a patient have immunity after recovering from anthrax infection?
How do doctors treat inhalational anthrax to reduce the risk of death in patients?
I was told that I had been exposed to Bacillus anthracis and prescribed antibiotics. I took the medicine for a couple weeks. Wouldn’t that weaken any anthrax that’s in my body?
Why was ciprofloxacin ever publicized as the best drug for anthrax? How can we know which antibiotic is best?
Besides anthrax, what else is ciprofloxacin prescribed for? Has there been resistance to ciprofloxacin when used in other instances (historically)?
Is there a generic form of ciprofloxacin?
Pregnancy
I’m taking medication to prevent anthrax, and I just found out that I’m pregnant. What should I do?
I’m pregnant. What medicine should I take to prevent anthrax?
I’ve heard that doctors don’t generally prescribe ciprofloxacin to pregnant women. Why is that? Why are they recommending it for anthrax prevention?
I was started on ciprofloxacin to prevent anthrax. I’ve heard that amoxicillin may be a safer drug for me to take during my pregnancy. How do I know if I can be switched to amoxicillin?
Doxycycline is being recommended for my coworkers who aren’t pregnant . Is doxycycline a better medicine against anthrax than ciprofloxacin?
I’m having a lot of heartburn during my pregnancy. Can I take ciprofloxacin at the same time as I take antacids?
I’ve been trying to get pregnant and have just started taking medication to prevent anthrax. Can I continue to try to get pregnant while taking this medication?
I just recently found out I’m pregnant, and I was exposed to anthrax at work. I want to take the best medication for my fetus and me, but I don’t yet want my employer to know that I’m pregnant. What should I do?
Risk
What is the risk for an individual if he or she is treated with antibiotics and is exposed to Bacillus anthracis again?
Can the spores that cause anthrax multiply outside of a human or animal host?
What are the odds of my getting anthrax? (What is the average risk of contracting anthrax in the United States?)
Can anthrax affect pregnancy? Should pregnant women exposed to anthrax take antibiotics?
Can anthrax be transmitted by handling money?
What is the risk for anthrax in employees of a facility with a positive environmental sample?
Anthrax and Influenza
Influenza (flu) and inhalation anthrax can have similar symptoms. Does CDC recommend that I get a flu shot to help diagnose anthrax?
Is there a way to distinguish between early inhalational anthrax and flu?
Is there a quick test that doctors can do to tell whether I have anthrax or an illness like the flu?
Safety Issues/Mail
How can mail get cross-contaminated with anthrax?
Can the presence of Bacillus anthracis spores be detected by a characteristic appearance, odor, or taste?
How long do anthrax spores live?
What is the importance of knowing the genetic information about anthrax?
Does the similarity in strains from Florida, New York, and Washington, D.C. mean that they came from the same source or are these just the most common strains?
When there is a known incident, how can I prevent anthrax exposure from cross- contaminated mail?
What kind of mail should be considered suspicious?
What should people do when they get a letter or package with powder?
What is the risk for getting anthrax from handling my own mail?
As a postal employee, am I at risk for getting anthrax from handling mail on the job when there is an anthrax cross-contaminated mail event?
When the possibility of cross-contamination of the mail exists, should I take antibiotics?
What should I do to protect my family and myself if a dangerous chemical agent were released in my community?
Should I purchase a gas mask as protection from any chemical agent release such as anthrax?
What kinds of anthrax worker safety guidelines have been issued?
Worker Safety
If these recommendations are followed does it mean workers will stop getting sick with anthrax?
Is CDC telling all mail handling operations to adopt these anthrax worker safety guidelines immediately?
What kinds of engineering controls should mail-handling/processing operations consider implementing for detecting anthrax spores?
What administrative controls should mail-handling/processing sites consider implementing to protect workers from exposure to B. anthracis spores?
What housekeeping controls in mail-handling/processing sites are recommended to protect workers from exposure to B. anthracis spores?
What personal protective equipment for workers in mail-handling/processing sites is recommended to protect workers from exposure to B. anthracis spores?
What are some examples of personal protective equipment and clothing that could be used to protect workers who handle mail from exposure to B. anthracis spores?
Are there some areas in the postal setting that present a greater risk to some workers than others for anthrax exposure?
How can I recognize suspicious packages that have anthrax?
What can the consumer buy to protect against germ or chemical warfare such as anthrax?
What should be done with clothing contaminated with anthrax? Is washing in a regular home washer and dryer ok? Does CDC recommend adding bleach to the wash?
Are other solutions used at hospitals for cleaning blood spills also effective against anthrax?
What actions need to be taken if a facility is found to have an environmental sample positive for anthrax?
Reporting
If tests confirm that I was potentially exposed to Bacillus anthracis or have anthrax, how will it be reported to the proper authorities?
How should healthcare workers respond to suspected exposure to a bioterrorist agent? Who should healthcare workers call first, second, third? CDC, FBI, local police, local health department?
v Anthrax as a Biological Weapon
Introduction
History of Current Threat
Epidemiology
Microbiology
Figure 1. Gram Stain of Bacillus anthracis
Pathogenesis and Clinical Manifestations
Inhalational Anthrax
Figure 2. Chest radiograph of a patient with inhalational anthrax.
Figure 3. Cutaneous Anthrax
Cutaneous Anthrax
Gastrointestinal Anthrax
Diagnosis 96
Table 1. Diagnosis of Inhalational Infection
Vaccination
Therapy
Table 2. Working Group Recommendations for Medical Therapy for Patients With Clinically Evident Inhalational Anthrax Infection in the Contained Casualty Setting
Table 3. Working Group Recommendations for Medical Therapy for Patients With Clinically Evident Anthrax Infection in the Mass Casualty Setting or for Postexposure Prophylaxis
Postexposure Prophylaxis
Management of Special Groups
Children
Pregnant Women
Immunosuppressed Persons
Infection Control
Decontamination
Figure 4. Day of Onset of Inhalation Anthrax Following Sverdlovsk Accident
Additional Research
Author Information
Acknowledgment
References
v Update: Investigation of Bioterrorism-Related Anthrax and Interim Guidelines for Exposure Management and Antimicrobial Therapy, October 2001
Florida
New York
New Jersey
District of Columbia
Susceptibility Testing of B. anthracis Isolates
Managing Threats
Box 1. Handling of Suspicious Packages or Envelopes
Managing Exposures
Antimicrobial Treatment
Table 1. Inhalational anthrax treatment protocol for cases associated with this bioterrorism attack
References
v Children and Anthrax: A Fact Sheet for Clinicians
Vaccination
Prophylaxis
Drug Recommendations For Pediatric Anthrax Cases
v Anthrax Technical Information
v Fact Sheet: Anthrax Information for Health Care Providers
v Drug Therapy
Patient Information: Ciprofloxacin 500 MG Oral Tablet
Patient Information: Doxycycline 100 MG Oral Tablet
Patient Information: Penicillin VK 500 MG Oral Tablet
Patient Information: Amoxicillin 250 MG – Oral Capsules Or Amoxicillin 250 MG/5 ML– Oral Suspension
v Clinical Issues in the Prophylaxis, Diagnosis, and Treatment of Anthrax
Prophylaxis
Clinical Recognition and Diagnosis
Inhalational Anthrax
Cutaneous Anthrax
Treatment
References
v Additional Options for Preventive Treatment For Those Exposed to Inhalational Anthrax
Background
Options
8. Smallpox
v Smallpox Overview
The Disease
Where Smallpox Comes From
Transmission
v Smallpox Disease
Rash distribution
v Smallpox Questions and Answers: The Disease and the Vaccine
In General
What should I know about smallpox?
How serious is the smallpox threat?
How dangerous is the smallpox threat?
If I am concerned about a smallpox attack, can I go to my doctor and get the smallpox vaccine?
The Disease
What are the symptoms of smallpox?
If someone comes in contact with smallpox, how long does it take to show symptoms?
Is smallpox fatal?
How is smallpox spread?
If smallpox is released in aerosol form, how long does the virus survive?
How many people would have to get smallpox before it is considered an outbreak?
Is smallpox contagious before the smallpox symptoms show?
Is there any treatment for smallpox?
The Vaccine
What is the smallpox vaccine, and is it still required?
Should I get vaccinated against smallpox?
How is the vaccine given?
Many vaccinations are required. Why don’t people have to get the smallpox vaccine?
If someone is exposed to smallpox, is it too late to get a vaccination?
How long does a smallpox vaccination last?
Are diluted doses of smallpox vaccine as effective?
Vaccinia
What is the smallpox vaccine made of?
Is it possible for people to get smallpox from the vaccination?
Is it possible to get vaccinia, the virus in the vaccine, from someone who has recently been vaccinated?
After Vaccination: What You Should Know
After Vaccination: Taking Care
Reactions After Vaccination
Vaccine Safety
How safe is the smallpox vaccine?
Who should NOT get the vaccine?
Should you get the smallpox vaccine if you have a weakened immune system (e.g., you are immunocompromised)?
Pregnant women are discouraged from getting the vaccine. Is there a danger to them (or to an unborn child) if broader vaccination occurs, increasing the