Bioterrorism - NurseCE · ©National Center of Continuing Education Bioterrorism Page 3 About the...

Bioterrorism

PREPAREDNESS FOR HEALTHCARE PROFESSIONALS

© National Center of Continuing Education Bioterrorism Page 1

Copyright © 2012W.S. Keefer All rights reserved Published by the National Center of Continuing Education, Inc., Lakeway, Texas. Printed in the United States of America.

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BIOTERRORISM: PREPAREDNESS FOR HEALTHCARE PROFESSIONALS

Course # 2028Contact Hours: 5 Hours

Author: Diana Harland, BS, CCRCEditor: Shelda L. K. Hudson, RN, BSN, PHN

Course Material valid through 07/2015

Bioterrorism © National Center of Continuing Education

About the Author/Editor ....................................... 3Purpose and Goals ................................................. 3Instructional Objectives ......................................... 3Introduction ............................................................ 3History .................................................................... 4Biological Agents and Terror ................................. 4

General Characteristics .................................... 4The US Terrorism Advisory System ................. 4

The Health Alert Network ................................. 4 The Biowatch Program ..................................... 4

The Strategic National Stockpile ...................... 4 Figure 1 ......................................................... 4The Ideal Bioweapon ......................................... 5Methods of Delivery for Bioweapons ................ 5

Personal Protective Equipment and Decontamination ......................................... 5Table 1 .................................................................... 5 Biosafety Levels ................................................. 6Table 2 .................................................................... 6Recognizing a Bioweapon Attack .......................... 7Reporting Suspected Cases or Exposure to a Bioterrorist Agent .................................................. 7Tables 3 and 4 ........................................................ 7&ODVVLÀFDWLRQ�RI�$JHQWV�RI�%LRWHUURULVP ............... 8

Category "A" Agents of Bioterrorism ................ 8Category "B" Agents of Bioterrorism ................ 8Category "C" Agents of Bioterrorism ................ 8

The Category "A" Agents ....................................... 8 Anthrax .............................................................. 8 Figures 2-4 .................................................... 9

Smallpox ........................................................... 11 Figures 5-6 .................................................. 11

Plague ............................................................... 13 Figure 7 ....................................................... 13 Tularemia ......................................................... 14 Botulinum Toxin .............................................. 14Table 5 .................................................................. 15The Viral Hemorrhagic Fevers ............................ 16Chemical and Nuclear Terrorism ........................ 17

Chemical Terrorism ........................................ 17Table 6 .................................................................. 17

Nuclear Terrorism and Radiation ................... 18 Figure 8 ....................................................... 18

Conclusion ............................................................ 19Suggested Reading and References .................... 19

© We Want You To Learn!

Table of Contents


About the Author/Editor

Diana Harland, BS, CCRC, re-

ceived her degree in Microbiology from the University of Texas at El Paso. She worked in pre-clinical research in retrovirology while in undergraduate school and again after graduation at Texas Biomedical Research Institute (formerly Southwest Foundation for Biomedical Research) in San Antonio, Texas. While at SWFBR, she worked in the department of Virology and Im-munology at biosafety level 3-4 (BSL-3/BSL-4). She has extensive training in NIH, OSHA, and CDC guidelines for sterility and asepsis in tissue culture and retrovirology. She holds a certificate in bioterrorism from Tulane University School of Public Health and Tropical Medicine and the University of Alabama at Birmingham School of Public Health. She is a member of the Austin Disaster Relief Network (infrastructure for the city of Austin, TX disaster response) and the Association for Clinical Research Professionals. (GLWLQJ� GRQH� E\� Shelda Hudson,

RN, BSN, PHN��'LUHFWRU� RI�+HDOWK-

FDUH� ,QIRUPDWLRQ��0V��+XGVRQ� LV� UH-

VSRQVLEOH� IRU� GLUHFWLQJ� WKH� DFWLYLWLHV�RI� WKLV�GHSDUWPHQW�� VHOHFWLQJ�TXDOLÀHG��FUHGHQWLDOHG� DXWKRUV� IRU� WKH� FRXUV-HV� RIIHUHG� E\� WKH� 1DWLRQDO� &HQWHU��DV�ZHOO� DV� DGYLVLQJ� VWDII� RI� UHTXLUHG�FRXUVH�GHVLJQ�DQG�FULWHULD��0V��+XGVRQ

KDV��\HDUV�RI�H[WHQVLYH�H[SHULHQFH�

Purpose and Goals�7KH�JRDO�RI� WKLV� FRXUVH� WR� UDLVH� WKH�

OHYHO�RI�SUHSDUHGQHVV�E\�HGXFDWLQJ�WKH�KHDOWKFDUH�SURIHVVLRQDO�LQ�WKH�DJHQWV�RI�ELRWHUURULVP��8QIRUWXQDWHO\��WHUURULVP�LV�QRW�OLPLWHG�WR�ELRORJLFDO�KD]DUGV��WKHUH�is also great concern regarding chemical

terrorism, as well as radiological, and

nuclear terrorism. This course will also

EULHÁ\�FRYHU�FKHPLFDO��UDGLRORJLFDO�DQG�nuclear terrorism so that, should a bio-

logical or other hazardous incident occur

(be it naturally occurring or intentionally

driven), the healthcare worker can be

instrumental in knowing how to handle,

UHSRUW�� DQG� HIIHFWLYHO\� GHDO�ZLWK� WKHVH�potentially deadly agents and situations.

16. ([SODLQ�WKH�PRVW�LPSRUWDQW�IDFWRUV�LQ� SURWHFWLRQ� IURP� UDGLDWLRQ� DQG�IDOORXW��UHFRJQL]H�WKH�EHVW�ORFDWLRQV�IRU�VKHOWHULQJ�LQ�SODFH��DQG�GHVFULEH�WKH� V\PSWRPV� RI� DFXWH� UDGLDWLRQ�syndrome.

IntroductionThere has been much public concern

RYHU�WKH�\HDUV�DERXW�WKH�WKUHDW�RI�ELRWHU-URULVP�� %LRWHUURULVP� LV�GHÀQHG�DV� WKH�XVH�RI�D�ELRORJLF�DJHQW�WR�LQWHQWLRQDOO\�cause disease against civilian popula-

WLRQV�IRU�WKH�SXUSRVH�RI�FUHDWLQJ�WHUURU��$�biological agent is a living organism or

RWKHU�LQIHFWLRXV�DJHQW�WKDW�LV�FDSDEOH�RI�replicating in a host victim’s body. The

U.S. military currently recognizes more

WKDQ� �� GLIIHUHQW� FRXQWULHV� �LQFOXGLQJ�5XVVLD�� ,UDQ�� 6\ULD�� ,VUDHO�� DQG�1RUWK�.RUHD��WKDW�DUH�VXVSHFWHG�RI�KDYLQJ�RI-IHQVLYH� ELRORJLFDO�ZHDSRQV� SURJUDPV�in place.

In past years, the United States also

SRVVHVVHG�LWV�RZQ�VWRFNSLOH�RI�ELRZHDS-

RQV��LQFOXGLQJ�DQWKUD[��XQWLO��ZKHQ�the Biological and Toxin Weapons &RQYHQWLRQ��%7:&� treaty was signed

E\�3UHVLGHQW�1L[RQ��8QGHU�WKLV�WUHDW\��QDWLRQV�DUH�SURKLELWHG�IURP�GHYHORSLQJ��producing, or retaining (stockpiling)

bioweapons or the equipment or means

RI�GHOLYHULQJ�WKHP��8QIRUWXQDWHO\��WKHUH�is no real way to monitor compliance,

DQG�HYLGHQFH�RI�ELRORJLFDO�ZHDSRQV�KDV�HYHQ�EHHQ�IRXQG�LQ�FHUWDLQ�FRXQWULHV�WKDW�have signed this treaty.

%HFDXVH� WKH� WKUHDW� RI� SXEOLF� KDUP�WKURXJK�WKH�XVH�RI�D�ELRORJLFDO�DJHQW�LV�D�very real possibility in today’s society, all

$PHULFDQV��HVSHFLDOO\�WKRVH�LQYROYHG�LQ�healthcare, must be particularly vigilant.

([SHUWV� RQ� ELRWHUURULVP� DQG� GLVDVWHU�preparedness now agree that there is

QR�ORQJHU�D�TXHVWLRQ�RI�´LIµ�DQ�LQFLGHQW�ZLOO�RFFXU�EXW�D�TXHVWLRQ�RI�´ZKHQµ�WKH�QH[W� LQFLGHQW�ZLOO� RFFXU�� +HDOWKFDUH�workers may be required to take on the

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important roles in saving lives.

Instructional Objectives8SRQ�FRPSOHWLRQ�RI� WKLV� FRXUVH�� WKH�

learner will be able to:

1. 'HÀQH�ELRWHUURULVP�DQG�WKH�UHDVRQV�ZK\� WKH� WKUHDW� RI� ELRWHUURULVP� LV�a very real possibility in today’s

society.

2. /LVW� WKH� JHQHUDO� FKDUDFWHULVWLFV� RI�biological agents that make them

HIIHFWLYH�LQ�FDXVLQJ�WHUURU�3. Relate how the CDC implements the

+HDOWK�$OHUW�1HWZRUN�LQ�WKH�8�6��4. 6WDWH�ZK\� WKH�+D]DUG�9XOQHUDELOLW\�$QDO\VLV�DQG�(PHUJHQF\�0DQDJHPHQW�3ODQ�DUH�YLWDO�LQ�KHDOWKFDUH�IDFLOLWLHV�

5. /LVW�33(�UHTXLUHG�E\�ÀUVW� UHFHLYHUV�DQG� VWDWH� WKH� FRUUHFW� SURFHGXUH� IRU�GHFRQWDPLQDWLRQ� RI� YLFWLPV�ZKHQ�YLFWLPV� RI�PDVV� FDVXDOW\� LQFLGHQWV�are brought to the hospital and the

substance released is an unknown

substance.

6. ,GHQWLI\� DQRPDOLHV� WKDW�PD\� VLJQDO�WKH�RFFXUUHQFH�RI�D�ELRZHDSRQ�DWWDFN�

7. 2XWOLQH�WKH�UHDVRQV�ZK\�FDWHJRU\�́ $µ�DJHQWV�RI�ELRWHUURULVP�DUH�JLYHQ�WKH�highest priority by the CDC.

8. ([SODLQ� ZK\�B. anthracis is so

KLJKO\� LQIHFWLRXV�� DQG� GHILQH� WKH�WKUHH�W\SHV�RI�DQWKUD[��LQFOXGLQJ�WKHLU�clinical presentation, diagnosis, and

treatment.

9. 'HVFULEH� FULWHULD� IRU� SUH�H[SRVXUH�YDFFLQH�IRU�SUHYHQWLRQ��SRVW�H[SRVXUH�WUHDWPHQW� DQG� GHFRQWDPLQDWLRQ� IRU�$QWKUD[�

10. Describe the variola virus and the

FOLQLFDO� SUHVHQWDWLRQ� RI� VPDOOSR[�as well as vaccination against the

disease.

11. Compare and contrast the symptoms

DQG�WUHDWPHQW�RI�SODJXH�DQG�WXODUHPLD�12. 5HFRJQL]H� WKH� W\SHV� RI� ERWXOLVP�DQG� WKHLU� FDXVHV�� DQG� H[SODLQ� KRZ�botulism is treated.

13. Outline the viral hemorrhagic

IHYHUV�� WKHLU� HSLGHPLRORJ\�� DQG� WKH�LVRODWLRQ� SUHFDXWLRQV� QHFHVVDU\� IRU�healthcare workers.

14. Recognize the symptoms associated

ZLWK � FKHPLFDO � H[SRVXUH � DQG�GHVFULEH� WKH� SURFHVV� RI� FKHPLFDO�GHFRQWDPLQDWLRQ� IRU� YLFWLPV� RI�chemical emergencies.

15. Compare chemical versus nuclear

H[SORVLRQV�


History 7KH�XVH�RI�ELRZHDSRQV�KDV�RFFXUUHG�

throughout history. Prior to 500 BC, the

$VV\ULDQV�SRLVRQHG�HQHP\�ZDWHU�ZHOOV�ZLWK�U\H�HUJRW��D�IXQJXV�WKDW�LQIHFWV�U\H�and other grains), causing many symp-

WRPV�RI�LOOQHVV�LQFOXGLQJ�KDOOXFLQDWLRQV��psychosis, and mania in those who drank

the water. In 1346, the Tartars cata-

SXOWHG�FRUSVHV�RI�SHUVRQV�ZKR�KDG�GLHG�RI� SODJXH�RYHU� WKH� FLW\�ZDOOV� RI�&DIID��WKH� FLW\� RI� )HRGRVL\D� LQ� WKH� SUHVHQW�day Ukraine), contributing to the Black

'HDWK�WKDW�WRRN�WKH�OLYHV�RI�PLOOLRQV�LQ�(XURSH�DQG�NLOOHG�DQ�HVWLPDWHG��WR��SHUFHQW�RI�WKH�SRSXODWLRQ��7KH�ÀUVW�XVH�RI�ELRZHDSRQV�LQ�$PHULFD�FDPH�GXULQJ�WKH�)UHQFK�DQG�,QGLDQ�:DU�ZKHQ�/RUG�-HIIUH\�$PKHUVW�JDYH�EODQNHWV�LQIHFWHG�ZLWK�VPDOOSR[�WR�WKH�,QGLDQ�DOOLHV�RI�WKH�)UHQFK�� FDXVLQJ� GHDGO\� VPDOOSR[� HSL-GHPLFV�LQ�WKH�QDWLYH�SRSXODWLRQ��0RUH�UHFHQWO\� LQ� �� DQWKUD[�ZDV� VHQW� LQ�envelopes through the mail to two U.S.

6HQDWRUV�DQG� WR� VHYHUDO�GLIIHUHQW�QHZV�PHGLD�� LQIHFWLQJ��SHRSOH�DQG�NLOOLQJ�ÀYH�RWKHUV�

Biological Agents and Terror

General Characteristics7KH�XVH�RI�ELRORJLFDO�DJHQWV�LV�HVSH-

cially good at causing terror in a popula-

tion primarily because they are invisible

to the human eye. These agents are also

generally odorless, tasteless, and unde-

WHFWDEOH�ZLWKRXW�WKH�PHDQV�RI�ODERUDWRU\�aids. They can be spread through air,

IRRG� VRXUFHV��ZDWHU�� VXUIDFHV�� fomites

(inanimate objects such as pens, toys,

or doorknobs that are contaminated with

DQ� LQIHFWLRXV� RUJDQLVP� DQG� FDQ� VHUYH�in their transmission), or direct contact

ZLWK�DQ�LQIHFWHG�LQGLYLGXDO��,W�PD\�WDNH�GD\V�IRU�DQ�LQIHFWHG�LQGLYLGXDO�WR�VKRZ�V\PSWRPV�RI�GLVHDVH��6RPH�DJHQWV��VXFK�DV� WKH�EDFWHULD� UHVSRQVLEOH� IRU� DQWKUD[�RU�WKH�EDFWHULD�UHVSRQVLEOH�IRU�ERWXOLVP�SRLVRQLQJ��FDQ�H[LVW�LQ�D�GRUPDQW�HQGR-

VSRUH�IRUP�WKDW�LV�UHVLVWDQW�WR�KHDW��FROG��UDGLDWLRQ��GU\LQJ��DQG�HYHQ�GLVLQIHFWDQWV�IRU�PDQ\�\HDUV�EHIRUH�FDXVLQJ�LQIHFWLRQ��)XUWKHUPRUH��ELRZHDSRQV�DUH�HDVLHU� WR�obtain and to use than nuclear weapons.

$OO� WKHVH� FKDUDFWHULVWLFV� FDXVH� D� JUHDW�

IHDU�RI�WKH�XQNQRZQ��OHDYLQJ�WKH�SXEOLF�IHHOLQJ� WKDW� WKH\� DUH� YXOQHUDEOH� DQG�RXW�RI�FRQWURO�� 3XEOLF�SDQLF� LV� IXUWKHU�IXHOHG�E\�PLVLQIRUPDWLRQ��UXPRUV��DQG�WKH�EHOLHI�WKDW�UHVRXUFHV�DUH�OLPLWHG�DQG�DYDLODEOH� WR� RQO\� D� VHOHFW� IHZ� RI� WKH�population.

7KH�8�6��7HUURULVP�$GYLVRU\�6\VWHP

In January 2011, the United States

'HSDUWPHQW� RI�+RPHODQG� 6HFXULW\��'+6��announced a new terrorism advi-

sory scale called the National Terrorism $GYLVRU\�6\VWHP��17$6�. Under this

new system, the public is to be alerted

ZLWK�ZKDWHYHU� LQIRUPDWLRQ�+RPHODQG�Security is able to give so that the pub-

OLF� FDQ� SURWHFW� LWVHOI� DW� WKH� LQGLYLGXDO��IDPLO\�� DQG� FRPPXQLW\� OHYHOV�� $OHUWV�DUH�WR�EH�LVVXHG�XQGHU�WKH�FDWHJRULHV�RI�either HOHYDWHG (credible terrorist threat

against the United States) or imminent �FUHGLEOH��VSHFLÀF��DQG�LPSHQGLQJ�WKUHDW�DJDLQVW�WKH�8QLWHG�6WDWHV��,QIRUPDWLRQ�on threat assessment and steps to take

in response to threats are to be given

WKURXJK�WKH�XVH�RI�QHZV�PHGLD�DQG�VRFLDO�PHGLD�QHWZRUNV��$�VXQVHW�SURYLVLRQ is

also included, which means individual

WKUHDW�DOHUWV�ZLOO�EH�LVVXHG�IRU�D�VSHFLÀF�WLPH�SHULRG�DQG�WKHQ�ZLOO�H[SLUH�XQOHVV�WKH� WKUHDW� HYROYHV� RU� QHZ� LQIRUPDWLRQ�becomes available.

The Health Alert 1HWZRUN

The +HDOWK�$OHUW�1HWZRUN� �+$1��sponsored by the Centers for Disease &RQWURO��&'&�, is a program that pro-

YLGHV� YLWDO� KHDOWK� LQIRUPDWLRQ� DQG� WKH�LQIUDVWUXFWXUH�WR�VXSSRUW�WKH�GLVVHPLQD-WLRQ�RI�WKDW�LQIRUPDWLRQ�DW�VWDWH�DQG�ORFDO�levels and beyond. Currently, all 50

VWDWHV�� WHUULWRULHV�� WKH�'LVWULFW�RI�&R-

lumbia, and several large city and county

health departments are all connected to

WKH�+$1��$FFRUGLQJ�WR�WKH�&'&��D�YDVW�PDMRULW\�RI�VWDWH�EDVHG�+$1�SURJUDPV�KDYH�RYHU��RI�WKHLU�SRSXODWLRQ�FRY-

HUHG�XQGHU�WKH�XPEUHOOD�RI�+$1�7KH�+$1�DOVR�HQVXUHV�WKDW�HDFK�FRP-

munity has:

�� rapid and timely access to emergent

KHDOWK�LQIRUPDWLRQ�� D�JURXS�RI�KLJKO\�WUDLQHG�SURIHVVLRQDO�

personnel

�� evidence-based practices and

SURFHGXUHV�IRU�HIIHFWLYH�SXEOLF�KHDOWK�preparedness, response, and service

on a 24/7 basis

7KH�+$1�0HVVDJLQJ�6\VWHP�GLUHFWO\�DQG�LQGLUHFWO\�WUDQVPLWV�YDULRXV�W\SHV�RI�PHVVDJHV�YLD�HPDLO�RU�566�IHHG�WR�RYHU�RQH�PLOOLRQ� UHFLSLHQWV�� 0HVVDJHV� DUH�FDWHJRUL]HG�EDVHG�RQ�OHYHO�RI�LPSRUWDQFH�DV�IROORZV�1. Health Alerts:� � +LJKHVW� OHYHO� RI�

importance that warrants immediate

attention.

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LQIRUPDWLRQ� IRU� D� VSHFLÀF� LQFLGHQW�or situation that may not require

immediate action.

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that is unlikely to require immediate

action.

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DGGUHVV��LQIRUPDWLRQ�SUHIHUHQFHV��VWDWH��and zip code.

7KH�%LRZDWFK�3URJUDP7KH�%LRZDWFK�SURJUDP�EHJDQ�DIWHU�WKH�

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Source: OSHA Best Practices for Hospital-based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances

The 6WUDWHJLF�1DWLRQDO�6WRFNSLOH��616� is managed by both the Department of +HDOWK� DQG�+XPDQ�6HUYLFHV� �++6� and the Department of Homeland Se-FXULW\��'+6��,Q�WKH�HYHQW�RI�DQ�HPHU-JHQF\��WKH�8�6��KROGV�D�UHVHUYH�VXSSO\�RI�vaccines, antibiotics, chemical antidotes,

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in armed, guarded, unmarked, and clas-

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occur, needed supplies can be deployed

wherever necessary. In the early hours

RI�DQ�HYHQW��Push Packages FRQVLVWLQJ�RI�pharmaceuticals, medical supplies, and

antidotes can be delivered where neces-

VDU\�ZLWKLQ��KRXUV�RI�IHGHUDO�UHTXHVW�(see Figure 1��,I�PRUH�SKDUPDFHXWLFDOV�or supplies are needed, Vendor Man-DJHG�,QYHQWRU\��90,� is structured to

have additional supplies arrive within

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7KH�,GHDO�%LRZHDSRQ�$V� D� UXOH�� ELRZHDSRQV� DUH� XQUHOL-

able, and when used they carry a high

OHYHO� RI� XQFHUWDLQW\� DV� WR� WKH�RXWFRPH�RI�D�EDWWOH��7KHUH�LV�DOVR�KLJK�FROODWHUDO�damage associated with their use. To be

DQ�LGHDO�ELRZHDSRQ��WKH�DJHQW�RI�FKRLFH�

ZRXOG�QHHG�WR�EH�ERWK�KLJKO\�LQIHFWLYH�and highly virulent, with no available

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LQKDODWLRQ�RI�WKH�DJHQW�ZRXOG�FDXVH�LW�WR�go into the lung alveoli. Once there, it

could be quickly ingested by phagocy-

WRVLV�RI�DOYHRODU�PDFURSKDJHV��PDNLQJ�LW�GLIÀFXOW�IRU� WKH�ERG\�WR�HOLPLQDWH�LW��$JHQWV�WKDW�KDYH�D�SDUWLFOH�VL]H�RI��RU�PRUH�DUH�WDNHQ�XS�E\�PXFRXV�ÁRZ�DQG�transported to the digestive tract where

elimination by the body is much easier.

Methods of Delivery for %LRZHDSRQV�

7KH�JRDO�RU�FKDOOHQJH�RI�ELRZHDSRQ�GHOLYHU\�LV�WR�GHOLYHU�WKH�DJHQW�LQ�D�VZLIW�manner and with the greatest strategic

HIIHFW�� %LRZHDSRQV� FDQ� EH� GHOLYHUHG�through aerosolization, through animals,

WKURXJK�IRRG�DQG�ZDWHU�FRQWDPLQDWLRQ��through the postal system (as in the 2001

DQWKUD[�VSRUHV�PDLOHG�WKURXJK�WKH�8�6��postal system), and through person to

SHUVRQ� FRQWDFW�� 7KH�PRVW� IDYRUHG� RI�these methods is aerosolization.

Personal Protective (TXLSPHQW�DQG�'HFRQWDPLQDWLRQ

(DFK�KHDOWKFDUH�IDFLOLW\�VKRXOG�KDYH�LQ�place a +D]DUG�9XOQHUDELOLW\�$QDO\VLV��+9$��[required by the Joint Commis-sions on Accreditations of Healthcare 2UJDQL]DWLRQV� �-&$+2�� IRU� DFFUHGL-WDWLRQ� RI� KHDOWKFDUH� IDFLOLWLHV@�� DQG� DQ�(PHUJHQF\�0DQDJHPHQW�3ODQ��(03��These must both be conducted/devel-

oped and updated within the last year

DQG�WDLORUHG�WR�HDFK�LQGLYLGXDO�IDFLOLW\��%HFDXVH�KHDOWKFDUH�IDFLOLWLHV�PD\�KDYH�OLPLWHG� LQIRUPDWLRQ� RQ� DQ� DJHQW� WKDW�KDV�EHHQ�UHOHDVHG��WKHVH�IDFLOLWLHV�PXVW�conduct research on hazard assessments

IRU�WKH�EDVLV�RI�SURSHU�Personal Protec-WLYH�(TXLSPHQW��33(��VHOHFWLRQ��33(�VHOHFWLRQ�PXVW� EH� IRU� D�ZLGH� UDQJH�RI�substances since no material will protect

against all possible hazards.

Table 1�VKRZV�WKH�PLQLPXP�33(�UHF-RPPHQGHG�E\�26+$�IRU�ÀUVW�UHFHLYHUV�when the area covered is not the release

VLWH�RI�WKH�DJHQW��WKH�KD]DUGRXV�VXEVWDQFH�is unknown, and other eligibility condi-

WLRQV�KDYH�EHHQ�PHW��IRU�FRQGLWLRQV�VHH�WKH�26+$�ZHEVLWH�DW�KWWS��ZZZ�RVKD�gov/dts/osta/bestpractices/html/hospi-

WDOBÀUVWUHFHLYHUV�KWPO�W�� +RVSLWDOV�

ZONE MINIMUM PPE

Hospital Decontamination Zone

1. All employees in this zone

(Includes, but not limited to, any of the following employees: decontamination team members, clinicians, set-up crew, cleanup crew, security staff, and patient

tracking clerks.)

1. Powered air-purifying respirator (PAPR) that provides a protection factor of 1,000. The respirator must be NIOSH-approved.

2. Combination 99.97% high-efficiency particulate air (HEPA)/organic vapor/acid gas respirator cartridges (also NIOSH-approved).

3. Double layer protective gloves. 4. Chemical resistant suit. 5. Head covering and eye/face protection (if not

part of the respirator). 6. Chemical-protective boots. 7. Suit openings sealed with tape.

Hospital Post-decontamination Zone

1. All employees in this zone

1. Normal work clothes and PPE, as necessary, for infection control purposes (e.g., gloves, gown, and appropriate respirator).

��

Table 1: Minimum Personal Protective Equipment Required for Hospital-based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Unknown Hazardous Substances


must use National Institute of Occu-SDWLRQDO�6DIHW\�DQG�+HDOWK (a division

RI�WKH�&'&��NIOSH-approved CBRN

(chemical, biological, radiological,

DQG�QXFOHDU��UHVSLUDWRUV�ZKHQ�WKH�+9$�UHYHDOV�D�SRWHQWLDO�ZHDSRQ�RI�PDVV�GH-VWUXFWLRQ� WKUHDW��1R�KHDOWKFDUH�ZRUNHU�VKRXOG�ZHDU�RU�XVH�VSHFLDOL]HG�33(�RU�respiratory protective equipment without

SURSHU�WUDLQLQJ�DQG�ÀW�WHVWLQJ��The 2FFXSDWLRQDO�6DIHW\�DQG�+HDOWK�

$GPLQLVWUDWLRQ� �26+$� has identi-

ÀHG�KHDOWKFDUH�ZRUNHUV�DW�D�KRVSLWDO�RU�KHDOWKFDUH�IDFLOLW\�ZKR�UHFHLYH�YLFWLPV�contaminated during a mass casualty

LQFLGHQW� IRU� WUHDWPHQW� DV�ÀUVW� UHFHLY-ers��7KLV�GLVWLQJXLVKHV�WKHP�IURP�ÀUVW�responders WKDW�LQFOXGH�ÀUHÀJKWHUV��ODZ�HQIRUFHPHQW�� DQG� HPHUJHQF\�PHGLFDO�SHUVRQQHO�� 26+$�KDV� SXEOLVKHG� EHVW�practice guidelines that help healthcare

IDFLOLWLHV�VHOHFW� WKH�PLQLPXP�33(�WKDW�26+$� DQWLFLSDWHV� JHQHUDOO\� ZLOO� EH�QHHGHG� WR� SURWHFW� ÀUVW� UHFHLYHUV� IDFHG�ZLWK�D�ZLGH�UDQJH�RI�XQNQRZQ�KD]DUGV��7KH� JXLGHOLQHV� FRYHU� SURWHFWLRQ� IRU�ÀUVW� UHFHLYHUV� GXULQJ�RYHUW� UHOHDVHV� RI�biological agents, as well as releases

RI�FKHPLFDOV�DQG�UDGLRORJLFDO�SDUWLFOHV�that may produce victims who may need

decontamination prior to administra-

WLRQ�RI�PHGLFDO�FDUH��7KH�JXLGHOLQHV�DUH�LQWHQGHG�IRU�PDVV�FDVXDOW\�LQFLGHQWV�DV�WKH\� DIIHFW� ÀUVW� UHFHLYHUV� DW� KRVSLWDOV��but concepts can also apply to mobile

FDVXDOW\� FDUH� IDFLOLWLHV� DQG� WHPSRUDU\�

shelters should a catastrophic incident

RFFXU�WKDW�LQYROYHV�WKRXVDQGV�RI�YLFWLPV��$VVXPSWLRQV�DUH�PDGH�E\�26+$�WKDW�WKH�KRVSLWDO�RU�KHDOWKFDUH�IDFLOLW\�LV�QRW�WKH�SULPDU\�LQFLGHQW�VLWH�DQG�WKDW�H[SRVXUH�FRPHV�IURP�YLFWLPV��WKHLU�FORWKLQJ��DQG�their personal belongings, rather than the

location where the hazardous substance

was released.

2QH�RI�WKH�PRVW�LPSRUWDQW�IDFWRUV�LQ�FRQVLGHUDWLRQ�RI�33(�IRU�WKH�KHDOWKFDUH�ZRUNHU� LV� WR� OLPLW� WKH� DPRXQW�RI� WR[LF�DJHQW�WR�ZKLFK�KH�VKH�LV�H[SRVHG��:KHQ�YLFWLPV�KDYH�EHHQ�H[SRVHG�WR�D�KD]DUG-

RXV�VXEVWDQFH��26+$�UHFRPPHQGV�WKH�ÀUVW�VWHS�LQ�WKH�GHFRQWDPLQDWLRQ�SURFHVV�WR�EH�UHPRYDO�RI�WKH�YLFWLP·V�FORWKLQJ�E\�cutting it away with blunt-nose shears to

DYRLG�DQ\�IXUWKHU�XQQHFHVVDU\�H[SRVXUH�to the victim or the worker. Clothing

removal is estimated to remove 75-

��RI�WKH�FRQWDPLQDQW�RQ�WKH�YLFWLP��Contaminated clothing and possessions

should then be placed in an approved

hazardous waste container that is isolated

outdoors. The second step is shower-

LQJ�RI� WKH�YLFWLP�ZLWK� WHSLG�ZDWHU�DQG�D� OLTXLG� VRDS� WKDW� KDV� JRRG� VXUIDFWDQW�properties but is not harsh on skin (good

H[DPSOHV�DUH�KDQG�RU�GLVKZDVKLQJ�VRDSV�such as Joy, Dawn, Ivory, and various

VKDPSRRV��IRU�D�minimum of 5 minutes

under running water. Scrubbing should

SURFHHG�GRZQZDUG�IURP�KHDG�WR�WRHV�WR�UHPRYH� WKH� FRQWDPLQDQW� IURP� WKH�KDLU�and skin. This step is also promoted by

WKH�8�6��$UP\�IRU�UHPRYDO�RI�ELRORJLFDO�agents as well as chemical agents and

UDGLRORJLFDO�SDUWLFOHV��/DVWO\��WR�IXUWKHU�PLQLPL]H�H[SRVXUH��ÀUVW�UHFHLYHUV�VKRXOG�UHPRYH�DOO�33(��see Table 2) and shower

WKHPVHOYHV��33(�DQG�VKRZHUV�PXVW�DOVR�be decontaminated.

Table 2 shows the recommended

SURFHGXUH�IRU�UHPRYDO�RI�33(�DQG�GH-contamination as outlined by the U.S.

'HSDUWPHQW�RI�+HDOWK�DQG�+XPDQ�6HU-vices $JHQF\�IRU�7R[LF�6XEVWDQFHV�DQG�'LVHDVH�5HJLVWU\��$67'5�.'HWDLOHG� RXWOLQHV� RI� SURFHGXUHV� IRU�

PRQLWRULQJ�RI�PHGLFDO�VWDII��GRQQLQJ�RI�33(��SDWLHQW�GHFRQWDPLQDWLRQ�� DQG�GH-FRQWDPLQDWLRQ�RI�ZRUNHUV�DQG�WKHLU�33(�DUH�DYDLODEOH�LQ�WKH�26+$�%HVW�3UDFWLFHV�IRU�+RVSLWDO�%DVHG�)LUVW�5HFHLYHUV� RI�9LFWLPV�)URP�0DVV�&DVXDOW\�,QFLGHQWV�,QYROYLQJ� WKH� 5HOHDVH� RI�+D]DUGRXV�6XEVWDQFHV�� DYDLODEOH� RQ� WKH� 26+$�website at http://www.osha.gov/dts/

RVWD�EHVWSUDFWLFHV�KWPO�KRVSLWDOBÀUVWUH-FHLYHUV�KWPO�W��

Biosafety LevelsThe CDC and the National Institute

RI�+HDOWK��1,+��KDYH�VSHFLÀHG�FHUWDLQ�biocontainment or lab ELRVDIHW\�OHYHOV��OHYHOV�RI�SUHFDXWLRQ�WKDW�SUHYHQW�ZRUN-

HUV�IURP�LQIHFWLRQ��QHFHVVDU\�WR�LGHQWLI\�and research various pathogenic agents.

$�VXPPDU\�RI�WKH�ELRVDIHW\�OHYHOV�BSL-1 through BSL-4 is shown in Table 3.

7DEOH��7HFKQLFDO�'HFRQWDPLQDWLRQ�3URFHVV�IRU�(06�3HUVRQQHO

3HUVRQQHO�VKRXOG�UHPRYH�SURWHFWLYH�FORWKLQJ�LQ�WKH�IROORZLQJ�VHTXHQFH�1. 5HPRYH�WDSH��LI�XVHG��VHFXULQJ�JORYHV�DQG�ERRWV�WR�VXLW�2. Remove outer gloves, turning them inside out as they are removed.

3. 5HPRYH�VXLW��WXUQLQJ�LW�LQVLGH�RXW�DQG�IROGLQJ�LW�GRZQZDUG��$YRLG�VKDNLQJ�4. 5HPRYH�ERRW�VKRH�FRYHU�IURP�RQH�IRRW�DQG�VWHS�RYHU�WKH�FOHDQ�OLQH��5HPRYH�RWKHU�ERRW�VKRH�FRYHU�DQG�SXW�WKDW�IRRW�RYHU�

the clean line.

5. 5HPRYH�PDVN��7KH�ODVW�SHUVRQ�UHPRYLQJ�KLV�KHU�PDVN�PD\�ZDQW�WR�ZDVK�DOO�PDVNV�ZLWK�VRDS\�ZDWHU�EHIRUH�UHPRYLQJ�KLV�KHU�VXLW�DQG�JORYHV��3ODFH�WKH�PDVNV�LQ�D�SODVWLF�EDJ�DQG�KDQG�WKH�EDJ�RYHU�WKH�FOHDQ�OLQH�IRU�SODFHPHQW�LQ�D�VHFRQG�EDJ�KHOG�E\�DQRWKHU�VWDII�PHPEHU��6HQG�EDJ�IRU�GHFRQWDPLQDWLRQ�

6. Remove inner gloves and discard them in a drum inside the dirty area.

7. 6HFXUH�WKH�GLUW\�DUHD�XQWLO�WKH�OHYHO�RI�FRQWDPLQDWLRQ�LV�HVWDEOLVKHG�DQG�WKH�DUHD�LV�SURSHUO\�FOHDQHG�8. Personnel should then move to a shower area, remove undergarments and place them in a plastic bag.

9. Double-bag all clothing and label bags appropriately.

10. 3HUVRQQHO�VKRXOG�VKRZHU�DQG�UHGUHVV�LQ�QRUPDO�ZRUNLQJ�DWWLUH�DQG�WKHQ�UHSRUW�IRU�PHGLFDO�VXUYHLOODQFH�

7DEOH�WDNHQ�IURP�$JHQF\�IRU�7R[LF�6XEVWDQFHV�DQG�'LVHDVH�5HJLVWU\�0DQDJLQJ�+D]DUGRXV�0DWHULDOV�,QFLGHQWV�9RO�,,�²�+RVSLWDO�(PHUJHQF\�'HSDUWPHQWV��$�3ODQQLQJ�*XLGH�IRU�WKH�0DQDJHPHQW�RI�&RQWDPLQDWHG�3DWLHQWV��$YDLO�DW��KWWS��ZZZ�DWVGU�FGF�JRY�0+0,�PKPL�Y��SGI


Recognizing a %LRZHDSRQ�$WWDFN�:LWK�WKH�H[FHSWLRQ�RI�VPDOOSR[��DOO�RI�

WKH�SRWHQWLDO�FDWHJRU\�$�DJHQWV��VHH�WKH�VHFWLRQ�HQWLWOHG�&DWHJRU\�´$µ�$JHQWV�RI�%LRWHUURULVP��DUH�RULJLQDOO\�GLVHDVHV�RI�animals. Should a bioweapon attack oc-

cur, it is very likely that animal popula-

WLRQV�ZLOO�EHFRPH�LOO�HLWKHU�EHIRUH�LOOQHVV�is seen in humans or simultaneously as

KXPDQV� EHFRPH� LOO�� $�ELRZHDSRQ� DW-tack may have unusual circumstances

or characteristics that are not normally

seen with a particular disease. Because

RI�SRWHQWLDOO\� ORQJ� LQFXEDWLRQ�SHULRGV��persons who become ill may not seek

FDUH� IRU� GD\V� RU�ZHHNV�� +HDOWKFDUH�ZRUNHUV�PD\�EH�RQH�RI�WKH�ÀUVW�JURXSV�to observe such anomalies and should be

DZDUH�RI�DQ\WKLQJ�XQXVXDO��Table 4 lists

anomalies that may signal the occurrence

RI�D�ELRZHDSRQ�DWWDFN�

5HSRUWLQJ�6XVSHFWHG�Cases or Exposure to a Bioterrorist Agent(DFK�IDFLOLW\�VKRXOG�KDYH�LQ�SODFH�SUR-

FHGXUHV�IRU� UHSRUWLQJ�RI�DQ\�VXVSHFWHG�RU�FRQÀUPHG�FDVHV�RU�DQ\�H[SRVXUH�RI�SDWLHQWV�RU�VWDII�WR�D�ELRWHUURULVW�DJHQW��,PPHGLDWH�QRWLÀFDWLRQ�WR�ORFDO�DQG�VWDWH�SXEOLF�KHDOWK�DJHQFLHV�LV�UHTXLUHG��$�OLVW�

7DEOH��$QRPDOLHV�7KDW�0D\�6LJQDO�WKH�2FFXUUHQFH�RI�D�%LRZHDSRQ�$WWDFN

1. 'HDG�DQLPDOV��HVSHFLDOO\�LI�WKHUH�DUH�PXOWLSOH�DQLPDO�VSHFLHV�LQYROYHG�2. $�GLVHDVH�ZLWK�QR�QDWXUDO�YHFWRU�SUHVHQW��IRU�H[DPSOH��SODJXH�LQ�WKH�DEVHQFH�RI�UDWV�RU�ÁHDV�

3. Unusual illnesses in certain populations or certain age groups.

4. *URXSV�RI�SHRSOH�ZLWK�WKH�VDPH�GLVHDVH�LQ�JHRJUDSKLFDO�DUHDV�WKDW�DUH�QRW�DGMDFHQW�or near to each other.

5. *URXSV�RI�SHRSOH�ZKR�ZHUH�LQGRRUV�DQG�DUH�LOO�RU�VKRZ�KLJKHU�PRUELGLW\�WKDQ�WKRVH�SHRSOH�ZKR�ZHUH�RXWGRRUV��LQGLFDWLQJ�DQ�LQGRRU�DWWDFN��&RQYHUVHO\��JURXSV�RI�SHRSOH�who were outdoors who are ill or show higher morbidity than those people who were

indoors, indicating an outdoor attack.

6. $�GLVHDVH�WKDW�RFFXUV�LQ�DQ�XQXVXDO�JHRJUDSKLF�DUHD�7. $�ODUJH�QXPEHU�RI�SHUVRQV�ZLWK�WKH�VDPH�GLVHDVH�8. $�GLVHDVH� LQ�D�SRSXODWLRQ�DW�DQ�XQXVXDO� WLPH�RI� WKH�\HDU�� IRU�H[DPSOH��ÁX� LQ� WKH�

summer months.

9. $�GLVHDVH�ZLWK�D�VKRUWHU�LQFXEDWLRQ�WKDQ�LV�QRUPDOO\�H[SHFWHG��LQGLFDWLQJ�WKDW�SHUVRQV�KDYH�EHHQ�H[SRVHG�WR�KLJKHU�DPRXQWV�RI�DQ�DJHQW�WKDQ�LQ�D�QDWXUDO�RFFXUUHQFH��

10. $�GLVHDVH� WKDW� LV� QRW� QRUPDOO\� DQWLELRWLF� UHVLVWDQW� DQG� QRZ� VKRZV� DQWLELRWLF�resistance.

11. $�GLVHDVH�WKDW�VKRZV�IDLOXUH�WR�UHVSRQG�WR�XVXDO�WKHUDS\�12. $�GLVHDVH�FDXVHG�E\�DQ�XQXVXDO�RU�GLIIHUHQW�VWUDLQ�RI�DQ�RUJDQLVP�WKDQ�ZKDW� LV�

normally seen.

13. $�GLVHDVH�FDXVHG�E\�DQ�XQNQRZQ�RUJDQLVP�14. $�GLVHDVH�WKDW�KDV�EHHQ�WUDQVPLWWHG�LQ�DQ�XQXVXDO�ZD\��HVSHFLDOO\�LI�WKH�WUDQVPLVVLRQ�URXWH�LQYROYHV�IRRG�RU�ZDWHU�

15. $�GLVHDVH�WKDW�LV�FRPPRQ�EXW�QRZ�VKRZV�D�KLJKHU�PRUELGLW\�WKDQ�XVXDO�RU�PRUWDOLW\�ZKHUH�LW�LV�QRW�H[SHFWHG�

16. $�KLJK�LQFLGHQFH�RI�D�FHUWDLQ�GLVHDVH�17. $�VLQJOH�FDVH�RI�DQ�XQFRPPRQ�GLVHDVH�VXFK�DV�VPDOOSR[�RU�LQKDODWLRQDO�DQWKUD[�18. $Q\�XQH[SODLQHG�GLVHDVHV�RU�GHDWKV�

Table 3: Summary of Recommended Biosafety Levels for Infectious Agents

7DEOH�WDNHQ�IURP�8�6��'HSDUWPHQW�RI�+HDOWK�DQG�+XPDQ�6HUYLFHV��&'&�DQG�1,+�%LRVDIHW\�LQ�0LFURELRORJLFDO�DQG�%LRPHGLFDO�/DERUDWRULHV��WK�HG��


RI�VWDWH�KHDOWK�GHSDUWPHQWV�FDQ�EH�IRXQG�through the CDC website at http://www.

cdc.gov/mmwr/international/relres.html.

The CDC 'LYLVLRQ� RI� %LRWHUURULVP�Preparedness and Response can be

reached at 404-639-0385.The CDC also maintains a 24/7 Emer-

JHQF\�2SHUDWLRQV�&HQWHU� telephone

number 770-488-7100,� IRU� KHDOWKFDUH�SURIHVVLRQDOV�DQG�JRYHUQPHQW�RIÀFLDOV��ORFDO��VWDWH��DQG�IHGHUDO�DJHQFLHV��WR�DV-sist with questions on emergency patient

FDUH��,W�LV�QRW�IRU�WKH�JHQHUDO�SXEOLF��ZKR�are instead advised to call 911 in the

HYHQW�RI�DQ�HPHUJHQF\�

&ODVVLÀFDWLRQ�of Agents of %LRWHUURULVP

Category “A” Agents of %LRWHUURULVP

7KHUH� DUH� OLWHUDOO\� WKRXVDQGV� RI�PL-crobes that could potentially be used in

DQ�DWWDFN�RI�ELRWHUURULVP��2I�SDUWLFXODU�concern, as established by the CDC, are

WKH�DJHQWV�FODVVLÀHG�DV�&DWHJRU\�´$µ�agents of bioterrorism. These microbes

are given the highest priority because:

1. 7KH\� DUH� HDVLO\� WUDQVPLWWHG� IURP�person to person or are easily

dispersed.

2. They result in high morbidity and

high mortality rates.

3. They have the potential to cause

widespread panic and socia l

GLVUXSWLRQ�RI�WKH�SXEOLF�4. They require special preparedness to

deal with should an outbreak occur.

&DWHJRU\�$� DJHQWV� RI�%LRWHUURULVP�include:

1. %DFLOOXV�DQWKUDFLV��$QWKUD[2. 9DULROD� PDMRU�� 9DULROD� PLQRU��6PDOOSR[

3. Yersinia pestis---Plague

4. )UDQFLVHOOD�WXODUHQVLV��WXODUHPLD�5. Clostridium botulinum---Botulism

6. 7KH�9LUDO�+HPRUUKDJLF�)HYHUV�a. ) L O R Y L U X V H V � � � ( E R O D�KHPRUUKDJLF� IHYHU��0DUEXUJ�IHYHU

b. $UHQDYLUXVHV��/DVVD� IHYHU��$UJHQWLQH� KHPRUUKDJLF� IHYHU��%ROLYLDQ� KHPRUUKDJLF� IHYHU��9HQH]XHODQ�KHPRUUKDJLF�IHYHU��%UD]LOLDQ� KHPRUUKDJLF� IHYHU��etc.

Because the CDC considers these

PLFUREHV� WR� EH� RI� WKH� KLJKHVW� SULRULW\��WKLV�FRXUVH�ZLOO� IRFXV�RQ� WKH�&DWHJRU\�´$µ�DJHQWV��ZLWK�SDUWLFXODU�DWWHQWLRQ�WR�DQWKUD[�DQG�VPDOOSR[�

Category “B” Agents of %LRWHUURULVP

$JHQWV�ZLWK�D�FDWHJRUL]DWLRQ�RI�VHFRQG�KLJKHVW�SULRULW\�DUH�FODVVLÀHG�DV�Catego-U\�´%µ�DJHQWV�RI�ELRWHUURULVP� These

agents are moderately easy to disperse,

WKHLU� LQIHFWLRQ� UHVXOWV� LQ� D�PRGHUDWH�GHJUHH�RI�PRUELGLW\�ZLWK�ORZ�PRUWDOLW\��and their outbreak will cause the CDC to

enhance its diagnostic capacity and dis-

ease surveillance. These agents include:

1. Brucellosis spp.—Brucellosis

2. Clostridium perfringens³(SVLORQ�WR[LQ

3. Salmonella� VSS�� (VFKHULFKLD� FROL��Shigella� VSS�³)RRGERUQH� LOOQHVV�VDIHW\�WKUHDWV

4. Burkholderi mallei—Glanders

5. Burkho lde r i p seudomal l e i—

0HOLRGRVLV6. Chlamydia psittaci—Psittacosis

7. Coxiella burnetti³4�IHYHU8. Ricinus communis³5LFLQ�WR[LQ9. Staphylococcal enterotoxin B—

produces a multi-symptom disease

UHVHPEOLQJ�VHSVLV��H�J��7R[LF�VKRFN�syndrome)

10. Rickettsia prowazekii—Typhus

IHYHU11. $OSKDYLUXVHV³9LUDO�HQFHSKDOLWLV12. Vibrio cholera; Cryptosporidium

parvum³:DWHUERUQH� LOOQHVV� VDIHW\�threats

Category “C” Agents of %LRWHUURULVP

The third highest priority agents are

FODVVLILHG� DV�&DWHJRU\� ´&µ� DJHQWV� RI�bioterrorism. These microbes have

WKH�SRWHQWLDO�WR�EH�HQJLQHHUHG�IRU�ODUJH�scale use because they are readily avail-

able and can be easily produced and

GLVVHPLQDWHG�� $Q� DWWDFN�ZLWK� DJHQWV�IURP�WKLV�FDWHJRU\�ZRXOG�SURGXFH�KLJK�PRUELGLW\�DQG�PRUWDOLW\��$JHQWV�LQFOXGH�HPHUJLQJ�PLFUREHV�VXFK�DV�1LSDK�YLUXV�DQG�+DQWDYLUXV�

The Category “A” Agents

Anthrax

(WLRORJ\$QWKUD[�LV�D�]RRQRWLF�GLVHDVH�SULPDU-

LO\� IRXQG� LQ� FDWWOH�� VKHHS�� KRUVHV�� DQG�JRDWV��7KH�QDPH�DQWKUD[�PHDQV�´FRDOµ�LQ�*UHHN� DQG�ZDV� QDPHG� IRU� WKH� FRDO�EODFN��FRORUHG�OHVLRQV�WKDW�DUH�FODVVLF�RI�WKH�FXWDQHRXV�IRUP�RI�WKH�GLVHDVH��$Q-

WKUD[�LV�FDXVHG�E\�WKH�EDFWHULXP�Bacillus

anthracis, a Gram-positive, non-motile,

VSRUH�IRUPLQJ�URG�WKDW�LV�W\SLFDOO\�VHHQ�LQ�ER[FDU�IRUPDWLRQ��$QWKUD[�LV�D�WR[LQ�PHGLDWHG�GLVHDVH��PHDQLQJ�LW�LV�WKH�WR[LQ�produced by the bacteria, not the bacteria

LWVHOI�� WKDW� FDXVHV� LQMXU\�� B. anthracis

produces a capsule that prevents leu-

NRF\WHV�IURP�EHLQJ�DEOH�WR�SKDJRF\WL]H�or lyse it, and it also produces three

proteins known as SURWHFWLYH� DQWLJHQ��3$�� OHWKDO� IDFWRU� �/)�� DQG� HGHPD�IDFWRU��()�� $ORQH��WKH�WKUHH�SURWHLQV�DUH�QRW�WR[LF��EXW�LQ�FRPELQDWLRQ�LQ�WKH�ERG\� WKH\� DUH� UHVSRQVLEOH� IRU�PDVVLYH�bleeding, edema, tissue destruction, and

XOWLPDWH� GHDWK� RI� WKH� LQIHFWHG� SHUVRQ��$OO�WKHVH�FKDUDFWHULVWLFV�WRJHWKHU�H[SODLQ�why these bacteria can produce such a

UDSLG��VHYHUH��DQG�SRWHQWLDOO\�IDWDO�GLV-HDVH�DQG�ZK\�ERG\�GHIHQVHV�DUH�XQDEOH�to overcome them.

(SLGHPLRORJ\$QWKUD[�LV�VSUHDG�E\�VSRUHV��LW�LV�QRW�

known to be spread by human- to- human

FRQWDFW�� +XPDQV�FDQ�FRQWUDFW�DQWKUD[�WKURXJK�WKH�KDQGOLQJ�RI�SURGXFWV�IURP�LQIHFWHG� DQLPDOV� �VXFK� DV� ZRRO� DQG�hides) when spores invade the skin via

VFUDWFKHV�DQG�ZRXQGV��$QWKUD[�FDQ�DOVR�be contracted through the consumption

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FDQ�OLYH�LQ�WKH�VRLO�IRU�GHFDGHV�DQG�VWLOO�return to their vegetative (active and

WKHUHIRUH�LQIHFWLRXV��VWDWH��)RU�KXPDQV��WKH�JUHDWHVW�ULVN�IRU�FRQWUDFWLQJ�DQWKUD[�LV�WKURXJK�DHURVROL]DWLRQ�RI�VSRUHV�7KHUH�DUH��WR��FDVHV�RI�

DQWKUD[�ZRUOGZLGH�SHU�\HDU�� RFFXUULQJ�primarily in the developing countries.

$QWKUD[�LV�UDUH�LQ�WKH�8�6��EHFDXVH�YHU\�IHZ�DQLPDOV�DUH�LQIHFWHG�GXH�WR�URXWLQH�


LQVSHFWLRQ� RI� DQLPDOV� DQG� VODXJKWHU-houses.

Clinical Presentation, Diagnosis, and TreatmentA. Cutaneous Anthrax 7KLV� IRUP�RI� LQIHFWLRQ� DFFRXQWV� IRU�

��RI�FDVHV��,WFKLQJ�RI�WKH�DIIHFWHG�DUHD�RFFXUV�D�IHZ�KRXUV�DIWHU�LQLWLDO�LQRFXOD-WLRQ��$�SDLQOHVV�KHPRUUKDJLF�SDSXOH�WKHQ�GHYHORSV�DIWHU��GD\V��DYHUDJH�RI��GD\V��IROORZHG�E\�DQ�XOFHU��$V�WKH�XOFHU�GULHV��D�EODFN�VFDU�RU�HVFKDU�IRUPV��DQG�WKLV�ZLOO�IDOO�RII�LQ��ZHHNV�DQG�KHDO�with possible scarring (see Figures 2-4).

Diagnosis is made in part based on

WKH�SUHVHQFH�RI�D�SDLQOHVV�XOFHU��6SLGHU�ELWHV�FDQ�EH�GLIIHUHQWLDWHG�EHFDXVH�WKHVH�OHVLRQV�DUH�W\SLFDOO\�SDLQIXO��*UDP�VWDLQV�DQG�EDFWHULDO�FXOWXUHV�RI�WKH�OHVLRQ�PD\�EH�REWDLQHG��$�EORRG�FXOWXUH�VKRXOG�EH�collected in all patients.

7UHDWPHQW� RI� ELRWHUURULVP�UHODWHG�FXWDQHRXV�DQWKUD[�FRQVLVWV�RI�D��GD\�FRXUVH�RI�ÀUVW�OLQH�WKHUDS\�RUDO�DQWLELRW-LFV�FLSURÁR[DFLQ�RU�GR[\F\FOLQH�� ,W� LV�important that lesions be kept clean and

covered and that all contaminated dress-

ings are properly handled and disposed.

Isolation precautions are standard with

DGGHG� FRQWDFW� SUHFDXWLRQV� LI� ZRXQG�GUDLQDJH�LV�H[FHVVLYH��,I�WKHUH�DUH�VLJQV�RI� V\VWHPLF� LQYROYHPHQW�� H[WHQVLYH�HGHPD��RU� LI� OHVLRQV�DUH�SUHVHQW�RQ�WKH�head or neck, treatment is intravenous

therapy with a multidrug regimen that

LQFOXGHV�FLSURÁR[DFLQ��IROORZHG�E\�RUDO�WKHUDS\�� 1DWXUDOO\�DFTXLUHG�FXWDQHRXV�DQWKUD[�FDQ�EH�WUHDWHG�ZLWK�RUDO�FLSUR-

ÁR[DFLQ�RU�GR[\F\FOLQH�IRU��GD\V�LQ�uncomplicated cases. There is less than

1% mortality in treated cases.

B. Gastrointestinal Anthrax7KLV� IRUP� RI� DQWKUD[� LV� UDUH�� DF-

FRXQWLQJ�IRU�OHVV�WKDQ��RI�DOO�DQWKUD[�FDVHV��DQG�UHVXOWV�IURP�FRQVXPSWLRQ�RI�WKH�PHDW�RI�LQIHFWHG�DQLPDOV��,QIHFWLRQ�may involve the intestines (intestinal anthrax) or the mouth or throat (oro-

SKDU\QJHDO�DQWKUD[). The incubation

period is 1 to 6 days.

6\PSWRPV�RI�LQWHVWLQDO�DQWKUD[�EHJLQ�with nausea, vomiting, abdominal pain,

DQG� IHYHU�� $V� WLPH� SURJUHVVHV�� WKHUH�LV�DQ� LQFUHDVH�RI�ZDWHU\�GLDUUKHD�� WKHQ�PDVVLYH�DPRXQWV�RI�EORRG\�GLDUUKHD��DQG�H[WUHPH�H[KDXVWLRQ��(GHPD�LV�SUHVHQW�LQ�WKH�ORZHU�WUXQN��7KLV�W\SH�RI�DQWKUD[�LV�YHU\�GLIÀFXOW�WR�GLDJQRVH��&DVHV�FDQ�VWLOO�EH�WUHDWHG�DW�WKH�SRLQW�RI�EORRG\�GLDUUKHD�LI�WKH�WUHDWPHQW�LV�H[WUHPHO\�DJJUHVVLYH��Without treatment, there is cyanosis and

death. The mortality rate is 20-60%.

6\PSWRPV�RI�RURSKDU\QJHDO�DQWKUD[�LQFOXGH� H[WUHPH� WKURDW� SDLQ�� HQODUJHG�FHUYLFDO� O\PSK� QRGHV�� DQG� GLIILFXOW\�swallowing. Ulcers may be seen in the

WKURDW� RU�PRXWK�� $Q� DLUZD\�PXVW� EH�placed in the patient at the point where

WKHUH�LV�GLIÀFXOW\�LQ�VZDOORZLQJ�EHFDXVH��DV�WKH�LQIHFWLRQ�SURJUHVVHV��WKHUH�LV�JUHDW�HGHPD�RI� WKH�QHFN�DQG� VXEPDQGLEXODU�areas.

7UHDWPHQW� RI�*,� DQWKUD[� LV� QRW�ZHOO�GRFXPHQWHG� EXW� VKRXOG� FRQVLVW� RI� DQ�aggressive intravenous multi-drug an-

WLELRWLF� WKHUDS\�ZLWK� FLSURÁR[DFLQ� DV�the primary antibiotic, and one to two

DGGLWLRQDO�DQWLPLFURELDOV�IROORZHG�E\�DW�OHDVW��GD\V�RI�RUDO�WKHUDS\��,VRODWLRQ�precautions are standard.

C. Inhalation Anthrax,QKDODWLRQ� DQWKUD[� KDV� WZR� SKDVHV��

Phase one�EHJLQV�ZLWK�D�ÁX�OLNH�XSSHU�respiratory illness. Symptoms include

PLOG� IHYHU�� IDWLJXH�� D� QRQ�SURGXFWLYH�cough, and malaise. Substernal chest

GLVFRPIRUW�DQG�VKRUWQHVV�RI�EUHDWK��G\V-SQHD��PD\�EH�SUHVHQW��$IWHU�D�IHZ�GD\V��there is slight improvement. Phase two progresses rapidly and results in death

within 24 hours. Symptoms include nau-

sea, vomiting, severe respiratory distress,

F\DQRVLV��HGHPD�RI�WKH�FKHVW�DQG�QHFN��and cardiovascular collapse. The lungs

and alveoli are destroyed. Death results

IURP�VXIIRFDWLRQ�DQG�HIIHFWV�RI�WKH�WR[LQ�

'LDJQRVLV�DW�WKH�RQVHW�RI�GLVHDVH�LV�GLI-ÀFXOW�EHFDXVH�RI�LWV�QRQ�VSHFLÀF�ÁX�OLNH�SUHVHQWDWLRQ��$�WKRURXJK�SDWLHQW�KLVWRU\�LV�HVVHQWLDO�WR�GHWHUPLQH�LI�H[SRVXUH�WR�VSRUHV�PD\�KDYH�RFFXUUHG��$�NH\�V\PS-

WRP�RI�SKDVH�RQH�LV�G\VSQHD (shortness

RI�EUHDWK��ZKLFK�LV�SUHVHQW�LQ�RQO\��RI�LQÁXHQ]D�FDVHV��,QKDODWLRQ�DQWKUD[�IURP�the 2001 U.S. postal cases showed an

��LQFLGHQFH�RI�G\VSQHD��6XEVWHUQDO�FKHVW�GLVFRPIRUW�LV�DOVR�PRUH�FRPPRQ�LQ� LQKDODWLRQ� DQWKUD[� WKDQ� LQ� FDVHV� RI�LQÁXHQ]D��7KH�FODVVLF�FKHVW�UDGLRJUDSK�will show mediastinal widening that is

due to hemorrhage and massive edema.

7KLV�UHVXOWV�IURP�WKH�H[RWR[LQ�UHOHDVHG�E\�LQFUHDVLQJ�FRQFHQWUDWLRQV�RI�DQWKUD[�bacilli in the regional lymph nodes that

drain pulmonary alveoli. This is an im-

SRUWDQW�LQGLFDWLRQ�RI�LQKDODWLRQ�DQWKUD[��,I�D�&7�VFDQ�LV�GRQH��LW�ZLOO�VKRZ�KHPRU-UKDJLF�PHGLDVWLQLWLV��LQÁDPPDWLRQ�RI�WKH�WLVVXHV�RI�WKH�PHGLDVWLQXP��DQG�WKLV�LV�GLDJQRVWLF�RI�LQKDODWLRQ�DQWKUD[��$�EORRG�culture should always be taken because

B. anthracis is present in blood cultures

HYHQ�LQ�WKH�HDUO\�VWDJH�RI�WKH�GLVHDVH�7UHDWPHQW� RI� LQKDODWLRQ� DQWKUD[� LV�

also an intravenous multidrug therapy

ZLWK�FLSURÁR[DFLQ��UHFRPPHQGHG�RYHU�GR[\F\FOLQH��DV�WKH�SULPDU\�DQWLELRWLF��and one to two additional antimicrobials

ZLWK�JRRG�&16�SHQHWUDWLRQ��IROORZHG�E\�DW�OHDVW��GD\V�RI�RUDO�WKHUDS\��,VRODWLRQ�precautions are standard. Without treat-

ment, mortality is nearly 100%, and with

treatment mortality is 75%.

D. Complications of Anthrax InfectionSepticemic anthrax is due to inva-

VLRQ� RI� WKH� DQWKUD[� EDFLOOL� LQWR� WKH�bloodstream and may be secondary to

LQIHFWLRQ�RI� DQ\�RI� WKH� DERYH� W\SHV�RI�DQWKUD[� EXW�PRUH� IUHTXHQWO\� IROORZV�LQKDODWLRQ� RU� JDVWURLQWHVWLQDO� DQWKUD[��8QWUHDWHG� FDVHV� RI� FXWDQHRXV� DQWKUD[�ZLOO� SURJUHVV� WR� VHSWLFHPLF� DQWKUD[� LQ��LQ��RU��RI�FDVHV��6\PSWRPV�LQ-

FOXGH�HGHPD�RI�WKH�KHDG�DQG�QHFN�WKDW�LQWHUIHUHV�ZLWK� EUHDWKLQJ�� VZDOORZLQJ��

Figure 3- Day 6 postinfection Figure 4- Day 10 postinfectionFigure 2- Eschar formation

Photos taken from the CDC


DQG� YLVLRQ�� ,QIHFWLRQ� LV� VSUHDG� DORQJ�O\PSKDWLF�FKDQQHOV��7KH�WUHDWPHQW�IRU�VHSWLFHPLF�DQWKUD[�LV�D�YHU\�DJJUHVVLYH�FRXUVH�RI�LQWUDYHQRXV�DQWLELRWLF�WKHUDS\�with a multidrug regimen that includes

FLSURÁR[DFLQ� �XQOHVV� FRQWUDLQGLFDWHG��IROORZHG�E\�RUDO�WKHUDS\��

Anthrax meningitis may also result

IURP� DQ\� IRUP� RI� DQWKUD[� DV� EDFLOOL�spread to the central nervous system.

&16� WLVVXHV� EHFRPH�KHPRUUKDJLF� DQG�ÀOOHG�ZLWK� HGHPD�� 6\PSWRPV� LQFOXGH�IHYHU��GHWHULRUDWLQJ�PHQWDO�IXQFWLRQ��DQG�VHL]XUHV��'HDWK�FDQ�UHVXOW�LQ�DV�IHZ�DV��GD\V��0RUWDOLW\�LV�DERXW��E. Important Notes about Anthrax

MedicationsOriginally, penicillin was considered

WR�EH�D�ÀUVW�OLQH�DQWLELRWLF�IRU�WUHDWPHQW�RI�DQWKUD[��$IWHU�WKH��SRVWDO�DQWKUD[�DWWDFNV��KRZHYHU��WKLV�KDV�FKDQJHG��1DW-XUDOO\�RFFXUULQJ�LVRODWHV�RI�B. anthracis

KDYH�EHHQ�VKRZQ�WR�SURGXFH�WKH�FODVV�RI�enzymes known as beta-lactamases that

inactivate penicillins, cephlasporins, and

VLPLODU�DQWLPLFURELDO�GUXJV��,VRODWHV�RI�B. anthracis have also been shown to

FRQWDLQ�WKH�SUHVHQFH�RI�FHSKODVSRULQDVH�DQG�SHQLFLOOLQDVH��7KHUHIRUH��HVSHFLDOO\�LQ� WKH� FDVH� RI� ELRWHUURULVP�� SHQLFLOOLQ�DORQH� LV� QRW� UHFRPPHQGHG�EHFDXVH� RI�WKH� SRWHQWLDO� IRU� JHQHWLFDOO\� DOWHUHG�B. anthracis. The CDC recommends

FLSURÁR[DFLQ� DQG� GR[\F\FOLQH� DV� ÀUVW�OLQH� DQWLELRWLFV�� ZLWK� SUHIHUHQFH� IRU�FLSURÁR[DFLQ� LQ� DQ\� VHYHUH� FDVHV�� ,Q�FDVHV� RI�PHQLQJLWLV� RU�&16� LQYROYH-

PHQW�� GR[\F\FOLQH� VKRXOG� QRW� EH� XVHG�EHFDXVH� LW� KDV� SRRU� SHQHWUDWLRQ� RI� WKH�&16�� &RQVXOWDWLRQ� ZLWK� LQIHFWLRXV�disease specialists at the CDC is highly

UHFRPPHQGHG�IRU�WUHDWPHQW�RI�DQ\�FDVHV�LQYROYLQJ�DQWKUD[��F. 3UH�H[SRVXUH�3URSK\OD[LV�$Q�)'$�OLFHQVHG�DQWKUD[� YDFFLQH��

$QWKUD[�9DFFLQH�$GVRUEHG��$9$�, is

DYDLODEOH� LQ� WKH�8�6�� IRU� SUH�H[SRVXUH�human use in individuals between 18

DQG�� \HDUV� RI� DJH� DQG� LV� NQRZQ�E\�the trade name BioThrax. It is not li-

FHQVHG�IRU�SRVWH[SRVXUH�XVH��7KH�8�6��'HSDUWPHQW�RI�'HIHQVH�UHFRPPHQGV�DOO�military personnel be vaccinated against

DQWKUD[�� 7KH�$GYLVRU\�&RPPLWWHH�IRU� ,PPXQL]DWLRQ�3UDFWLFHV� �$&,3�, D�SDQHO�RI�H[SHUWV�VHOHFWHG�E\�WKH�6HF-UHWDU\�RI�WKH�++6�WR�SURYLGH�DGYLFH�WR�the CDC, also recommends the vaccine

IRU� DQ\RQH� LQ� WKH�ZRUNSODFH�ZKR� KDV�

FRQWDFW�ZLWK�LPSRUWHG�DQLPDO�KLGHV��IXUV��wool, bone meal, bristles, and animal

hair (especially goat hair), as well as

all persons who engage in diagnostic

or investigational activities involving

DQWKUD[�VSRUHV��3UHJQDQW�ZRPHQ�VKRXOG�QRW�EH�YDFFLQDWHG�EHFDXVH�HIIHFWV�RQ�WKH�IHWXV�DUH�QRW�NQRZQ��7KH�YDFFLQH�FRXUVH�FRQVLVWV�RI�WZR�LQWUDPXVFXODU�LQMHFWLRQV��given at 0 and 4 weeks, then three ad-

ditional injections given at 6, 12, and 18

months. To maintain immunity, annual

booster injections are also needed.

Currently, the U.S. holds a reserve

RI�%LR7KUD[� YDFFLQH� LQ� WKH� 6WUDWHJLF�1DWLRQDO�6WRFNSLOH��7KHUH�DUH�QR�FRP-

PHUFLDOO\� DYDLODEOH� GRVHV� RI� DQWKUD[�YDFFLQH�� DOO� DQWKUD[� YDFFLQH� LV� RZQHG�DQG�PDQDJHG�E\�WKH�86�'HSDUWPHQW�RI�'HIHQVH��7KH�VKHOI�OLIH�IRU�%LR7KUD[�LV�three years.

$W�WKH�SUHVHQW�WLPH��QR�DQWLELRWLFV�DUH�DSSURYHG�IRU�SUH�H[SRVXUH�SURSK\OD[LV�WR�DQWKUD[�VSRUHV�$QWLWR[LQ�NQRZQ�DV�Anthrax Immune

*ORELQ��$,*��PDGH�IURP�SODVPD�WKDW�LV�WDNHQ�IURP�LQGLYLGXDOV�ZKR�ZHUH�SUHYL-RXVO\�LPPXQL]HG�ZLWK�DQWKUD[�YDFFLQH��LV�DYDLODEOH�LQ�WKH�616��,W�FDQ�EH�XVHG�in addition to antibiotic therapy to treat

SHUVRQV�VKRZLQJ�DQWKUD[�V\PSWRPV��$�PRQRFORQDO�DQWLERG\�FDOOHG�5D[LEDFXP-

ab (under the trade name $%WKUD[� that

WDUJHWV�DQWKUD[�WR[LQ�DW�WKH�SRLQW�ZKHQ�DQWLELRWLFV�PD\�QR�ORQJHU�EH�HIIHFWLYH�LV�DOVR�DYDLODEOH�LQ�WKH�616��,W�LV�UHSRUWHG�to improve survival rates by 64% in

animal studies.

G. 3RVWH[SRVXUH�3URSK\OD[LV)RU�SRVWH[SRVXUH�SURSK\OD[LV��3(3��

RI� SRWHQWLDO� LQKDODWLRQDO� H[SRVXUH�� WKH�CDC recommends decontamination

LI� QHFHVVDU\�� IROORZHG� E\� YDFFLQDWLRQ�(although the vaccine is not licensed

IRU�3(3��DQG�DQWLELRWLF�WUHDWPHQW��9DF-FLQDWLRQ��ZKLFK�LQ�FDVHV�RI�ELRWHUURULVP�would be available under an ,QYHVWL-JDWLRQDO�1HZ�'UXJ� �,1'� protocol,

FRQVLVWV� RI� WKUHH� GRVHV� RI� %LR7KUD[�given at week 0, week 2, and week 4.

In asymptomatic individuals, a 60 day

FRXUVH�RI�FLSURÁR[DFLQ�ZLWK�GR[\F\FOLQH�(or other tetracycline) or penicillin is

UHFRPPHQGHG��7KH��GD\V�RI�WKHUDS\�has been considered critical and should

QHYHU�EH�UHGXFHG�EHFDXVH�RI�WKH�SRWHQWLDO�VSRUH�IRUPDWLRQ�RI�B. anthracis.��$QWKUD[�LV� NQRZQ� WR� UHFXU� XS� WR� ��GD\V� DIWHU�LQLWLDO�LQIHFWLRQ�LQ�VLPLODU�VWXGLHV�

Research by the 8�6��$UP\�0HGLFDO�Research Institute of Infectious Dis-HDVHV� �86$05,,'� and the National ,QVWLWXWH� RI�$OOHUJ\� DQG� ,QIHFWLRXV�'LVHDVHV� �1,$,'�� has shown that

ZKHQ� DQWKUD[� YDFFLQH� LV� DGPLQLVWHUHG�with a short-term 14 day combination

RI� DQWLELRWLFV� EHJLQQLQJ� RQH� WR� WZR�KRXUV� SRVWH[SRVXUH�� QRQ�KXPDQ� SUL-PDWHV�ZHUH�FRPSOHWHO\�SURWHFWHG�IURP�LQKDODWLRQ� DQWKUD[�� 0RUH� LQIRUPDWLRQ�FDQ� EH� IRXQG� DW� KWWS��ZZZ�SQDV�RUJ�FRQWHQW��IXOO�� 5HJDUGOHVV�RI�WKH�FRXUVH�GXUDWLRQ�RI�DQWLELRWLFV��LP-

PHGLDWH�SURSK\OD[LV�RI�FDVHV�RI�SRWHQWLDO�H[SRVXUH�ZLOO�EH�RI�XWPRVW�LPSRUWDQFH�H. Decontamination of Anthrax+DQGZDVKLQJ�ZLWK� VRDS� DQG�ZDWHU��

IROORZHG�E\� VKRZHULQJ�ZLWK� VRDS� DQG�ZDWHU��LV�WKH�UHFRPPHQGHG�PHWKRG�IRU�GHFRQWDPLQDWLRQ� RI� DQ\� SHUVRQV�ZKR�KDYH�FRPH�LQWR�FRQWDFW�ZLWK�VRXUFHV�RI�potential B. anthracis spores. The use

RI� EOHDFK� KDV� QRW� VKRZQ� DQ\� DGYDQ-

WDJHV� RYHU� VRDS� DQG�ZDWHU��6RXUFHV� RI�spores such as clothing, shoes, and so

RQ�� VKRXOG� EH� LGHQWLÀHG�� &ORWKLQJ� RU�other potentially contaminated materials

should be triple bagged in plastic bags

EHIRUH�WUDQVSRUWLQJ��WKHQ�LQFLQHUDWHG�RU�autoclaved.

The CDC recommends a 1:10 bleach solution (one part household bleach

containing 5.25% sodium hypochlorite

WR�QLQH�SDUWV�ZDWHU��DV�DQ�HIIHFWLYH�VSR-

ricidal solution to decontaminate any

ZRUN�VXUIDFHV��RU�VXUIDFHV�FRQÀUPHG�WR�have contamination. Other approved

sporicidal agents may also be used.

1RQ�VWHULOL]DEOH� HTXLSPHQW� VKRXOG� EH�routinely cleaned with a sporicidal agent.

,WHPV�WKDW�FDQ�EH�DXWRFODYHG�VKRXOG�ÀUVW�be soaked in a sporicidal solution, then

autoclaved.

,I�WKHUH�LV�DQ�DFFLGHQWDO�FRQWDPLQDWLRQ�IURP� IUHVK� FOLQLFDO� VDPSOHV�� WKH� DUHD�VKRXOG�EH�ÁRRGHG�ZLWK�VSRULFLGDO�VROX-

WLRQ��VRDNHG�IRU�DW�OHDVW��PLQXWHV��DQG�WKHQ�FOHDQHG��$UHDV�LQYROYHG�LQ�DFFLGHQ-

WDO�FRQWDPLQDWLRQ�RI�VDPSOHV�ZLWK�ODUJH�FRQFHQWUDWLRQV� RI� VSRUHV�� VXFK� DV� ODE�specimens (e.g., blood cultures or culture

plates), areas with accidents that involve

organic matter, or areas with contamina-

tion where there is a temperature, lower

than room temperature should be gently

FRYHUHG�WR�DYRLG�DHURVROL]DWLRQ��$�VSR-

ricidal solution should then be liberally

DSSOLHG�WR�WKH�DUHD�DQG�OHIW�WR�VRDN�IRU�


��KRXU�EHIRUH�FOHDQLQJ��6RLOHG�FOHDQLQJ�PDWHULDOV� VKRXOG� EH� DXWRFODYHG�� $OO�FXOWXUHV�� LQIHFWHG�PDWHULDO�� RU� VXVSHFW�material should be incinerated or auto-

claved. It should be noted that boiling

at 100ºC does NOT�NLOO�HQGRVSRUHV��WKH\�DUH�NQRZQ�WR�VXUYLYH�IRU�KRXUV�DW�ERLOLQJ�temperatures.

I. Reporting of Anthrax Cases3XEOLF� KHDOWK� DQG� ODZ� HQIRUFHPHQW�

RIÀFLDOV�VKRXOG�EH�QRWLÀHG�LPPHGLDWHO\�LI�D�FDVH�RI�DQWKUD[�LV�GLDJQRVHG�RU�VXV-pected. It is essential that any lab that

ZLOO�EH�KDQGOLQJ�VSHFLPHQV�VXVSHFWHG�RI�FRQWDLQLQJ�DQWKUD[�EH�QRWLÀHG�EHFDXVH�clinical specimens must be handled at

ELRVDIHW\�OHYHO��%6/��RU�DW�ELRVDIH-W\�OHYHO��%6/��LI�KLJKHU�FRQFHQWUD-WLRQV�DUH�KDQGOHG�RU�LI�VFUHHQLQJ�LQYROYHV�environmental samples (especially

SRZGHUV�� IURP� DQWKUD[� FRQWDPLQDWHG�locations. It is also important to alert

the diagnostic lab so that the suspect

DJHQW�FDQ�EH�SURSHUO\�LGHQWLÀHG�EHFDXVH�Bacillus is generally considered to be a

contaminant and is normally not tested.

6PDOOSR[

(WLRORJ\�6PDOOSR[� LV� FDXVHG� E\� HLWKHU� RI� WKH�

GRXEOH� VWUDQGHG�'1$�� EULFN�VKDSHG�viruses Variola major or Variola minor,

PHPEHUV� RI� WKH� RUWKRSR[YLUXV� IDPLO\��Variola major causes a more severe

IRUP�RI�WKH�GLVHDVH�ZLWK�D�PRUH�VHYHUH�UDVK��KLJKHU�IHYHU��DQG�XS�WR��PRU-tality. V. major�DFFRXQWV�IRU�IRXU�W\SHV�RI�LQIHFWLRQ�

1. 2UGLQDU\�� PRVW� IUHTXHQW�� DFFRXQWV�IRU��RI�FDVHV

2. 0RGLILHG�� PLOG� DQG� RFFXUULQJ� LQ�previously vaccinated persons

3. )ODW�� OHVLRQV� GR� QRW� SURMHFW� DERYH�

WKH� VNLQ� VXUIDFH�� UDUH�� VHYHUH�� DQG�XVXDOO\�IDWDO

4. +HPRUUKDJLF�� KHPRUUKDJHV� RFFXU�LQ�WKH�VNLQ�DQG�PXFRXV�PHPEUDQHV��UDUH��VHYHUH��DQG�XVXDOO\�IDWDO

Variola minor causes a less severe

IRUP�RI� WKH�GLVHDVH�ZLWK� OHVV� WKDQ��PRUWDOLW\�� 6PDOOSR[�YLUXV�LQIHFWV�RQO\�humans and has no animal reservoir.

(SLGHPLRORJ\&DVHV� RI� VPDOOSR[� KDYH� EHHQ� GRFX-

mented throughout history, and this

GLVHDVH� LV� RQH�RI� WKH�PRVW� GHYDVWDWLQJ�diseases known to mankind. It is be-

OLHYHG� WKDW� WKH�PXPPLÀHG� UHPDLQV� RI�5DPVHV�9�RI�(J\SW��UHLJQHG�IURP��%&��VKRZ�WKDW�KH�GLHG�RI�VPDOOSR[�LQIHFWLRQ��PDNLQJ�WKLV�SKDUDRK�WKH�ROGHVW�known victim with actual visible signs

RI�WKH�SR[�SXVWXOHV��6PDOOSR[�KDV�VKRZQ�great morbidity and mortality throughout

the ages and has even destroyed entire

FLYLOL]DWLRQV�LQFOXGLQJ�WKH�,QFDV��WKH�$]-WHFV��DQG�PDQ\�1DWLYH�$PHULFDQ�WULEHV��In survivors, blindness, osteomyelitis,

DUWKULWLV��DQG�GLVÀJXULQJ�VFDUV�ZHUH�FRP-

PRQ��%HFDXVH�WKHUH�LV�QR�WUHDWPHQW�IRU�VPDOOSR[�� YDFFLQDWLRQ� LV� WKH� RQO\�ZD\�WR� SUHYHQW� WKH� GLVHDVH��$IWHU� JUHDW� HI-IRUWV�WKURXJK�YDFFLQDWLRQ�SURJUDPV��WKH�:RUOG�+HDOWK�2UJDQL]DWLRQ� �:+2��GHFODUHG� VPDOOSR[� WR� EH� HUDGLFDWHG� LQ�1979. There is now no variola virus

LQ�WKH�ZRUOG�H[FHSW�IRU�WKH�YLUXV�VWRUHG�in laboratory stockpiles. The only two

:+2�DXWKRUL]HG�UHIHUHQFH�VLWHV�DUH�WKH�&'&�LQ�$WODQWD��*$��DQG�WKH�9(&725�LQVWLWXWH�LQ�.ROWVRYR��5XVVLD�6PDOOSR[�LV�VSUHDG�WKURXJK�ÁXLGV�DQG�

VFDEV�IURP�WKH�SXVWXOHV�FKDUDFWHULVWLF�RI�the disease (see Figure 5), and requires

SURORQJHG�IDFH��WR��IDFH�FRQWDFW��6LQFH�SXVWXOHV�ÀUVW�IRUP�LQ�WKH�PRXWK��VDOLYD�that is spread through coughing, sneez-

ing, speaking, or breathing can transmit

WKH� YLUXV� WR� RWKHUV�� $OWKRXJK� LQGLUHFW�FRQWDFW� LV� OHVV� HIILFLHQW� IRU� WKH� YLUXV�WR�VSUHDG��IRPLWHV�PD\�DOVR�VSUHDG�WKH�YLUXV��,W�LV�XQFHUWDLQ�LI�JHQHWLFDOO\�HQJL-QHHUHG�VPDOOSR[�YLUXV�ZRXOG�EH�VSUHDG�in the same manner as the naturally oc-

curring virus. The incubation period is

��WR��GD\V��ZLWK�DQ�DYHUDJH�RI��WR��GD\V�SRVWH[SRVXUH�IRU�V\PSWRPV�WR�begin. During this incubation, people

are not contagious. The greatest problem

IDFHG�E\�HSLGHPLRORJLVWV��KRZHYHU��LV�WKH�IDFW�WKDW�LGHQWLÀFDWLRQ�RI�WKH�index case

�WKH�ÀUVW�SHUVRQ�IRXQG�WR�KDYH�WKH�GLVHDVH�OHDGLQJ�WR�WKH�GLDJQRVLV�RI�RWKHUV�ZLWK�the same disease in a population) occurs

ZHHNV�SRVWH[SRVXUH��DQG�E\�WKH�WLPH�D�diagnosis is made, there may have been

PDQ\�SHUVRQV�H[SRVHG��,W�LV�PRVW�OLNHO\�that variola would be released by air-

ERUQH�GLVSHUVLRQ�LI�XVHG�DV�D�ELRZHDSRQ��

Clinical Presentation, Diagnosis, and Treatment6PDOOSR[�EHJLQV�ZLWK�DQ�DFXWH�ÁX�OLNH�

Prodrome phase which can last up to 4

GD\V��6\PSWRPV�FDQ�LQFOXGH�KLJK�IHYHU��)�� FKLOOV�� EDFN� SDLQ�� ERG\�aches, headache, vomiting, abdominal

pain, malaise, and rigors. Patients are

SRVVLEO\�FRQWDJLRXV��7KH�QH[W�SKDVH�LV�(DUO\�5DVK�when small red spots appear

on the mouth and tongue. Persons are

KLJKO\�FRQWDJLRXV�DW�WKLV�WLPH��$V�PRXWK�sores break down, rash appears on the

skin and can spread to all body parts in

��KRXUV��)HYHU�PD\�IDOO�DQG�WKH�SDWLHQW�IHHOV�EHWWHU��,W�VKRXOG�EH�QRWHG�KHUH�WKDW�patients are contagious in all phases

LQYROYLQJ� UDVK�� $IWHU� WKH��UG�GD\�� WKH�rash becomes raised bumps. On the 4th

GD\��WKH�EXPSV�EHFRPH�ÀOOHG�ZLWK�WKLFN��RSDTXH�ÁXLG� DQG�KDYH� D� FKDUDFWHULVWLF�GHSUHVVLRQ� LQ� WKH� FHQWHU� �OLNH� D� ´EHOO\�EXWWRQµ��WKDW�LV�GLDJQRVWLF�RI�VPDOOSR[��)HYHU�ZLOO�XVXDOO\�ULVH�DJDLQ�DQG�UHPDLQ�XQWLO� VFDEV� IRUP�� $�Pustular Rash

SKDVH��ODVWLQJ�DERXW��GD\V��IROORZV�DV�bumps become sharply raised pustules

WKDW�DUH�URXQG�DQG�ÀUP��7KH�OHVLRQV�DUH�LQ�WKH�GHHS�OD\HUV�RI�VNLQ�DQG�IHHO�KDUG�DV�LI�DQ�REMHFW�LV�HPEHGGHG�WKHUH��1H[W�is the Pustules and Scabs phase, lasting

Figure 5:� 6PDOOSR[� SXVWXOHV� RQ�WKH�IDFH�RI�D�\RXQJ�ER\��3KRWR�WDNHQ�IURP�&'&�3XEOLF�+HDOWK�,PDJH�/L-EUDU\� �3+,/� �� DYDLO� DW�� KWWS��HPHUJHQF\�FGF�JRY�DJHQW�VPDOOSR[�VPDOOSR[�LPDJHV�VPDOOSR[��KWP

Figure 6: Distribution of rash in smallpox and chickenpox.Image taken from CDC


DQRWKHU��GD\V��ZKHQ�SXVWXOHV� IRUP�D�FUXVW� DQG� WKHQ� D� VFDE�� 0RVW� SXVWXOHV�ZLOO�KDYH�VFDEV�E\�WKH�HQG�RI�WKH�VHFRQG�ZHHN�RI�UDVK��$�5HVROYLQJ�6FDEV phase

IROORZV��ODVWLQJ�DERXW��GD\V��$V�VFDEV�IDOO�RII��WKH�DUHD�RQ�WKH�VNLQ�ZLOO�HYHQWX-

ally become a pitted scar. The person is

considered no longer contagious when

the last scab is gone. The total disease

duration is about 4 weeks.

6PDOOSR[�FDQ�EH�GLIIHUHQWLDWHG�IURP�FKLFNHQ�SR[�E\� WKH�SDWWHUQ�RI� UDVK�RQ�the body (see Figure 6�� 6PDOOSR[�LV�GLVWULEXWHG�LQ�FHQWULIXJDO�IDVKLRQ��ZLWK�OHVLRQV� DSSHDULQJ�RQ� WKH� SHULSKHU\� RI�the body. The rash is common on the

SDOPV� DQG� VROHV�� &KLFNHQSR[� UDVK� LV�GLVWULEXWHG�LQ�FHQWULSHWDO�IDVKLRQ��ZLWK�more rash appearing on the trunk, and

IHZ�RU�QR�OHVLRQV�RQ�WKH�SDOPV�DQG�VROHV��&KLFNHQSR[�FDQ�DOVR�EH�GLVWLQJXLVKHG�IURP�VPDOOSR[�EHFDXVH�WKH�IHYHU�EHJLQV�at the same time as the rash (as opposed

WR�VPDOOSR[�ZLWK�D��GD\�IHYHU�3UR-

dromal stage and no lesions), and the

OHVLRQV�ZLOO� EH� LQ� GLIIHUHQW� VWDJHV� �DV�RSSRVHG�WR�VPDOOSR[�ZLWK�OHVLRQV�DOO�LQ�the same stage).

Diagnosis is made by patient history

RI�D�SURGURPDO�VWDJH�SULRU�WR�UDVK��ZLWK�IHYHU�JUHDWHU�WKDQ��)��DQG�DW�OHDVW�RQH�symptom including headache, backache,

vomiting, chills, or abdominal pain.

2EVHUYDWLRQ�RI�WKH�OHVLRQV�FKDUDFWHULVWLF�RI�VPDOOSR[�ZLWK�OHVLRQV�DOO�LQ�WKH�VDPH�VWDJH�RI�GHYHORSPHQW�DUH�DOVR�GLDJQRV-WLF�� $Q\� VDPSOHV� VHQW� IRU� ODERUDWRU\�LGHQWLÀFDWLRQ�PXVW� EH� FROOHFWHG� E\� D�previously vaccinated individual and

H[DPLQHG�RQO\�DW�D�GHVLJQDWHG�ELRVDIHW\�OHYHO��%6/��ODERUDWRU\��$Q\�FDVHV�RI�VXVSHFWHG�VPDOOSR[�PXVW�EH�LPPHGL-DWHO\�UHSRUWHG�WR�SXEOLF�KHDOWK�RIÀFLDOV��,QIHFWLRXV�GLVHDVH�VSHFLDOLVWV�DW�WKH�&'&�should be consulted.

7KHUH� LV� QR� WUHDWPHQW� IRU� VPDOOSR[��Patients can be managed with support-

ive care and should be isolated until

all scabs have separated. It is debat-

able whether YDFFLQLD�LPPXQRJORELQ��9,*��LV�KHOSIXO�LQ�VHYHUH�FDVHV��

Vaccination5RXWLQH� YDFFLQDWLRQ� RI�$PHULFDQV�

ZDV�HQGHG�LQ��$W�SUHVHQW��WKHUH�LV�uncertainty as to whether or not there

is any residual immunity in persons

YDFFLQDWHG� SULRU� WR� �� WKHUHIRUH��the CDC considers these persons to be

VXVFHSWLEOH��,Q�WKH�HYHQW�RI�DQ�DWWDFN�RI�ELRWHUURULVP�XVLQJ� VPDOOSR[�� YDFFLQD-WLRQ�RI�DQ\�SHUVRQV�H[SRVHG�WR�WKH�YLUXV�is highly recommended. The CDC has

VWDWHG�WKDW�YDFFLQDWLRQ�ZLWKLQ��GD\V�RI�H[SRVXUH�ZLOO� SUHYHQW� RU� VLJQLÀFDQWO\�OHVVHQ� WKH� VHYHULW\� RI� VPDOOSR[� V\PS-

WRPV�LQ�WKH�YDVW�PDMRULW\�RI�SHRSOH��DQG�YDFFLQDWLRQ��GD\V�SRVWH[SRVXUH�OLNHO\�RIIHUV�VRPH�SURWHFWLRQ�IURP�WKH�GLVHDVH�RU�PD\�PRGLI\�WKH�VHYHULW\�RI�GLVHDVH��$Q�RXWEUHDN�RI�VPDOOSR[�FDQ�EH�KDOWHG�E\�YDFFLQDWLQJ�D�́ ULQJµ�RI�SHRSOH�DURXQG�HDFK�FDVH�DQG�WKHLU�FRQWDFWV��0DVV�YDF-FLQDWLRQ�RI�WKH�SXEOLF�LV�RQO\�D�ODVW�UHVRUW�

The avai lable vaccine (ei ther

$&$0��RU�'U\YD[�� LV�PDGH�ZLWK�live attenuated (decreased pathogenicity)

vaccinia virus, not variola�YLUXV��9DF-cination is done on the deltoid (recom-

PHQGHG�E\�WKH�&'&��ZLWK�D�ELIXUFDWHG�QHHGOH�� $� YDFFLQDWLRQ� LV� FRQVLGHUHG�VXFFHVVIXO�LI�WKHUH�LV�D�́ WDNHµ�RU�VXIÀFLHQW�UHDFWLRQ�LQGXFHG��7KH�WDNH�FRQVLVWV�RI�SDSXOH�DQG�YHVLFOH�IRUPDWLRQ��IROORZHG�E\�D�ZHOO�IRUPHG�SXVWXOH�� WKHQ�D�VFDE��DQG�ÀQDOO\�VFDE�GHWDFKPHQW�DQG�D�UHVXOW-ing scar. In addition to the localized

UHDFWLRQ�DQG�VFDU�IRUPDWLRQ��KHDGDFKH��and body aches, the vaccine has other

LPSRUWDQW�SRWHQWLDO�VLGH�HIIHFWV�1. ,QDGYHUWHQW� LQRFXODWLRQ� The

vaccination site must be kept well

covered to prevent inadvertent

LQRFXODWLRQ��WUDQVIHU��WR�RWKHU�VLWHV�RQ�the body. This is the most common

adverse reaction. Rate = 529 per

million persons vaccinated.

2. *HQHUDOL]HG�YDFFLQLD� Occurs when

the virus spreads throughout the body

via the bloodstream. Rate = 250 per

million persons vaccinated.

3. (U\WKHPD� PXOWLIRUPH�� $� UDVK�characterized by symmetric red

patchy areas. Rate = 165 per million

persons vaccinated.

4. 3RVWYDFFLQDO� HQFHSKDOLWLV��$� OLIH�threatening, demyelinating acute

LQÁDPPDWLRQ�RI�WKH�EUDLQ��5DWH� ��per million vaccinated

5. (F]HPD� YDFFLQDWXP� � � $� OLIH�threatening reaction that occurs

in persons with eczema or atopic

dermatitis when the vaccinia virus

spreads to these areas. This can also

RFFXU�LI�WKH�HF]HPD�RU�GHUPDWLWLV�LV�LQDFWLYH� DW� WKH� WLPH�RI� YDFFLQDWLRQ��RU�LI�D�SHUVRQ�KDV�HYHQ�RQO\�RQFH�KDG�eczema or other skin conditions. Rate

= 38.5 per million vaccinated.

6. 3URJUHVVLYH� YDFFLQLD�� $� OLIH�threatening reaction that occurs when

lesions go through muscle down to

the bone. Rate = 1.5 per million

persons vaccinated.

7. 0RUWDOLW\� UDWH�� The mortality

UDWH� IURP�YDFFLQDWLRQ� LV� �� WR� �� SHU�million persons vaccinated, equal to

WKH�PRUWDOLW\�UDWH�UHVXOWLQJ�IURP�ÁX�vaccination.

The vaccine is contraindicated in vari-

ous persons, including children under

��PRQWKV�� SUHJQDQW� RU� EUHDVWIHHGLQJ�mothers, persons with heart conditions,

LPPXQRGHÀFLHQW� LQGLYLGXDOV�� SHUVRQV�undergoing immunosuppressive therapy,

persons with active eye disease, and

WKRVH�ZKR�DUH�VHYHUHO\�LOO��$�FRPSOHWH�OLVW�RI�FRQWUDLQGLFDWLRQV�DQG�PRUH�LQIRU-PDWLRQ�RQ�WKH�YDFFLQH�FDQ�EH�IRXQG�DW�KWWS��ZZZ�EW�FGF�JRY�DJHQW�VPDOOSR[��

PPE, Infection Control, and Decontamination

Isolation precautions are combined

standard, contact, and airborne until all

scabs have separated. The CDC recom-

PHQGV�WKDW�ÀW�WHVWHG�1��PDVNV�EH�XVHG�E\�DQ\RQH�FDULQJ�IRU�VPDOOSR[�SDWLHQWV�LQ�D�FRQWUROOHG�KHDOWKFDUH�VHWWLQJ��$IWHU�FRQÀUPDWLRQ�RI�YDFFLQH�WDNH��KHDOWKFDUH�workers are no longer required to wear

1��PDVNV��)RU�FRQWDPLQDWHG�SDWLHQW�DU-HDV��33(�PXVW�LQFOXGH�GLVSRVDEOH�JRZQV�DQG�JORYHV�WKDW�DUH�GLVSRVHG�RI�SULRU�WR�leaving those areas. Laundry and linens

must be bagged and laundered on the

premises by only vaccinated workers,

RU�ÀUVW�DXWRFODYHG�LI�ODXQGHUHG�E\�QRQ�vaccinated persons. Laundry should be

washed in hottest water and hot air dried.

Disposable items should be used when-

HYHU�SRVVLEOH��)RRG�VKRXOG�EH�SUHSDUHG�on the premises or brought in using dis-

SRVDEOH�VHUYLQJ�ZDUH��0RUH�LQIRUPDWLRQ�is available on the CDC website at http://

HPHUJHQF\�FGF�JRY�DJHQW�VPDOOSR[�UHVSRQVH�SODQ�ÀOHV�JXLGH�F�SDUW��SGI��1R�SURGXFWV�DUH�UHJLVWHUHG�E\�WKH�En-

YLURQPHQWDO�3URWHFWLRQ�$JHQF\��(3$��DV�VSHFLÀF�IRU�variola virus inactivation

RQ�VXUIDFHV��6LQFH�variola is physically

and biochemically similar to Vaccinia,

which is inactivated by low or interme-

GLDWH� OHYHO� GLVLQIHFWLQJ� SURGXFWV�� LW� LV�presumed that these products would be

HIIHFWLYH�DJDLQVW�Variola�DV�ZHOO��0RVW�KHDOWKFDUH� IDFLOLWLHV� XVH� KLJKHU� OHYHO�GLVLQIHFWDQWV�WKDQ�WKRVH�ZKLFK�LQDFWLYDWH�


Vaccinia��VR�LW�LV�H[SHFWHG�WKDW�WKHVH�GLV-LQIHFWDQWV�ZLOO�DOVR�LQDFWLYDWH�Variola in

SDWLHQW�FDUH�DUHDV��)RU�PRUH�LQIRUPDWLRQ��see the CDC website at http://emergency.

FGF�JRY�DJHQW�VPDOOSR[�UHVSRQVH�SODQ�ÀOHV�JXLGH�I�SGI��

Plague

(WLRORJ\Plague is caused by the bacterium

Yersinia pestis,� D�PHPEHU� RI� WKH�En-

terobacteriaceae� IDPLO\��Y. pestis is a

gram-negative coccobacillus that shows

D�FKDUDFWHULVWLF�´VDIHW\�SLQµ�DSSHDUDQFH�with staining. These bacteria are easily

destroyed by sunlight and drying but

may survive up to 1 hour when released

into the air. Y. pestis causes three main

W\SHV� RI� SODJXH� LQ� KXPDQV�� EXERQLF��septicemic, and pneumonic. Pharyngeal

plague, meningeal plague, and ocular

SODJXH�DUH�OHVV�FRPPRQ�IRUPV�

(SLGHPLRORJ\

Plague has long been recorded in

KLVWRU\��7KH�SDQGHPLF�3ODJXH�RI�-XVWLQ-

LDQ��$'��ZDV�GXH�WR�EXERQLF�plague likely originating in China. It was

VSUHDG� WKURXJK� WKH� LPSRUWLQJ� RI� HQRU-PRXV� DPRXQWV�RI� JUDLQ� IURP�(J\SW� WR�&RQVWDQWLQRSOH�DV�UDWV�DQG�ÁHDV�RQ�JUDLQ�VKLSV�LQIHVWHG�WKH�JUDLQ��7KH�%ODFN�'HDWK�pandemic (1347-1351) that occurred in

&KLQD��$VLD��(XURSH��DQG�$IULFD�IROORZHG�later, killing an estimated 75-100 mil-

OLRQ�SHRSOH��7KH�´EODFN�GHDWKµ�UHIHUUHG�to the characteristic black color due to

F\DQRVLV�DQG�JDQJUHQH�RI�WKH�ÀQJHUV�DQG�WRHV�DV�WKH�GLVHDVH�SURJUHVVHG��$�WKLUG�pandemic that began in China in 1855

killed more than 12 million in China and

India alone and involved both bubonic

DQG�SQHXPRQLF�IRUPV��5HPQDQWV�RI�WKLV�SDQGHPLF�DUH�WKH�OLNHO\�VRXUFH�IRU�WKH�Y.

pestis currently present in the U.S.

Plague is transmitted to humans by

ÁHDV�WKDW�KDYH�ELWWHQ�DQ�LQIHFWHG�DQLPDO�and then bite a human. Plague can also

EH�WUDQVPLWWHG�E\�KDQGOLQJ�DQ�LQIHFWHG�animal or by close person- to- person

FRQWDFW� LQ�FDVHV�RI�SQHXPRQLF�SODJXH��7KH�:+2�UHSRUWV��WR��FDVHV�RI�ZRUOGZLGH�SODJXH�HDFK�\HDU��3ODJXH�naturally occurs in animals throughout

WKH�ZHVWHUQ�8QLWHG�6WDWHV��$FFRUGLQJ�WR�the CDC, human cases in the U.S. occur

LQ�WZR�PDLQ�UHJLRQV��QRUWKHUQ�1HZ�0H[LFR��QRUWKHUQ�$UL]RQD��DQG�VRXWKHUQ�&RORUDGR��SULPDULO\�IURP�URFN�VTXLUUHOV�DQG�WKHLU�ÁHDV��DQG��&DOLIRUQLD��VRXWK-

HUQ�2UHJRQ�� DQG� IDU�ZHVWHUQ�1HYDGD��SULPDULO\� IURP� JURXQG� VTXLUUHOV� DQG�WKHLU�ÁHDV��'RPHVWLF�FDWV�DUH�DOVR�HDVLO\�LQIHFWHG�DQG�FDQ�EULQJ�LQIHFWHG�ÁHDV�RU�rodents into the home. Dogs are some-

WLPHV�LQIHFWHG��7KHUH�DUH��FDVHV�RI�plague in the U.S. each year, primarily

in rural areas.

It is most likely that Y. pestis would be

DHURVROL]HG�LQ�DQ�DWWDFN�RI�ELRWHUURULVP��FDXVLQJ�WKH�FRQWDJLRXV�SQHXPRQLF�IRUP�RI�SODJXH�

Clinical Presentation, Diagnosis, and Treatment

Bubonic plague has an incubation

SHULRG�RI��WR��GD\V��,QLWLDO�V\PSWRPV�LQFOXGH�IHYHU��KHDGDFKH��H[KDXVWLRQ��DQG�JHQHUDO�PDODLVH�� IROORZHG� E\� SDLQIXO�swollen lymph nodes. The diagnostic

VLJQ�RI� SODJXH� LV� WKH�SUHVHQFH�RI� YHU\�ODUJH�� VZROOHQ��SDLQIXO�� DQG�KRW� O\PSK�nodes (especially in the groin area)

called buboes (see Figure 7). The dis-

ease progresses rapidly and can lead to

septicemic plague as bacteria invade

WKH� EORRGVWUHDP�� ,I� DQWLELRWLF� WKHUDS\�is not started, pneumonic plague may

IROORZ�� 3ULPDU\�SQHXPRQLF� SODJXH KDV�DQ�LQFXEDWLRQ�SHULRG�RI��WR��GD\V��3DWLHQWV�SUHVHQW�ZLWK�KLJK�IHYHU��FKLOOV��FRXJK��DQG�EORRG\�VSXWXP��'LDJQRVLV�RI�plague is made by patient history, symp-

toms, and blood and lymph node speci-

PHQ�FXOWXUHV�� /DE� LGHQWLÀFDWLRQ�PXVW�EH�KDQGOHG�DW�D�PLQLPXP�RI�ELRVDIHW\�OHYHO��%6/�� or at ELRVDIHW\�OHYHO��%6/�� LI� FXOWXUHV� KDYH� SRWHQWLDO� IRU�antibiotic resistance or there is aerosol

production.

3DWLHQWV� VXVSHFWHG� RI� KDYLQJ� SODJXH�should be isolated and promptly treated

with streptomycin or gentamicin as

SUHIHUUHG� DQWLELRWLFV�� 'R[\F\FOLQH� LV�DOVR� HIIHFWLYH� DV� DQ� DOWHUQDWLYH� GUXJ��7HWUDF\FOLQH� LV� XVXDOO\� VXEVWLWXWHG� IRU�VWUHSWRP\FLQ�WR�PLQLPL]H�WR[LFLW\�DIWHU�VHYHUDO�GD\V�RI�WKHUDS\��7UHDWPHQW�PD\�DOVR� LQFOXGH� LQFLVLRQ� DQG� GUDLQDJH� RI�buboes. Without antibiotic treatment,

bubonic plague has a 13.5% mortality

rate, septicemic plague has a near 100%

mortality rate, and pneumonic plague has

a 57% mortality rate.

Prophylactic antibiotic treatment with

FLSURÁR[DFLQ�RU�GR[\F\FOLQH�IRU��GD\V�LV� UHFRPPHQGHG� IRU� DQ\� FRQWDFWV� RI�SHUVRQV�RU�SHWV�ZLWK�FRQÀUPHG�RU�VXV-pected pneumonic plague. Prophylactic

WUHDWPHQW�LV�QRW�QHFHVVDU\�IRU�FRQWDFWV�RI�EXERQLF�RU�VHSWLFHPLF�SODJXH��$QWLELRWLF�WKHUDS\� LV� DOVR� UHFRPPHQGHG� IRU� DQ\�SHUVRQV�H[SRVHG�WR�ÁHD�ELWHV�RI�ZLOG�UR-

GHQWV�RU�WLVVXHV�DQG�ÁXLGV�RI�DQ�LQIHFWHG�DQLPDO�GXULQJ�DQ�RXWEUHDN�RI�SODJXH�

In 1999, plague vaccine production

was stopped because it was unlikely to

SURWHFW�IURP�SULPDU\�SQHXPRQLF�SODJXH��There is now no commercially available

vaccine in the U.S., but new vaccines

being developed against primary pneu-

monic plague are in clinical trials.

,W�LV�WKH�ODZ�WKDW�DOO�FDVHV�RI�VXVSHFWHG�plague be immediately reported to lo-

cal and state public health departments

DQG�WKDW�D�GLDJQRVLV�LV�FRQÀUPHG�E\�WKH�CDC. The CDC must then report all

FDVHV�RI�SODJXH�WR�WKH�:+2��


Isolation precautions are standard

IRU� SHUVRQV�ZLWK�EXERQLF� SODJXH��ZLWK�GURSOHW� SUHFDXWLRQV� DGGHG� IRU� DQ\RQH�ZLWK�SQHXPRQLF�SODJXH�XQWLO��KRXUV�RI�antibiotic therapy have elapsed. Droplet

SUHFDXWLRQV� DUH� DOVR� UHFRPPHQGHG� IRU�all patients until pneumonia has been

UXOHG�RXW�DQG�WUHDWPHQW�KDV�EHJXQ��$Q\�laboratory spills should be covered in

DEVRUEHQW�PDWHULDO� DQG�ÁRRGHG�ZLWK� D��EOHDFK�VROXWLRQ�WKDW�LV�OHIW�RQ�IRU��PLQXWHV�DQG�WKHQ�FOHDQHG��([SRVHG�VNLQ�should be cleaned with a nonabrasive

VRDS�DQG�ZDWHU��$Q\�FRQWDPLQDWHG�PDWH-ULDO�VKRXOG�EH�GLVSRVHG�RI�LQ�ELRKD]DUG�waste bags and autoclaved. Workers

H[SRVHG�LQ�WKH�ÀHOG�PXVW�ZHDU�SURWHFWLYH�clothing, gloves, booties, and positive

Figure 7: Patient with plague showing a swollen and ruptured inguinal lymph node known as a bubo. Photo taken from CDC Public Health Image Library


SUHVVXUH�+(3$�ÀOWHUHG�UHVSLUDWRUV��33(�PXVW�EH�GHFRQWDPLQDWHG�RU�GLVSRVHG�RI�as biohazardous waste.

7XODUHPLD

(WLRORJ\7XODUHPLD��DOVR�NQRZQ�DV�UDEELW�IHYHU�

RU�GHHU�Á\�IHYHU��LV�D�KLJKO\�LQIHFWLRXV�zoonotic disease that is endemic in many

SDUWV�RI�WKH�ZRUOG�DQG�LQ�1RUWK�$PHULFD��It is caused by the gram-negative,

nonmotile coccobacillus Francisella

tularensis. F. tularensis is an intracel-

lular bacterium that lives and multiplies

within the host’s macrophage cells.

(SLGHPLRORJ\7XODUHPLD�LV�VSUHDG�E\�WKH�ELWH�RI�WLFNV��

GHHU�ÁLHV��RU�RWKHU�DUWKURSRGV�� FRQWDFW�ZLWK�DQ�LQIHFWHG�DQLPDO��PRVW�FRPPRQO\�UDEELWV��LQJHVWLRQ�RI�XQGHUFRRNHG�PHDW�RI� LQIHFWHG� DQLPDOV�� LQJHVWLRQ� RI� FRQ-

WDPLQDWHG�ZDWHU�� RU� LQKDODWLRQ�RI� FRQ-

taminated dusts or aerosols. There are

DERXW��FDVHV�RI�QDWXUDOO\�RFFXUULQJ�tularemia per year in the U.S., and it has

EHHQ�UHSRUWHG�LQ�HYHU\�VWDWH�H[FHSW�+D-waii. Domestic cats are very susceptible

and can transmit the disease to humans.

F. tularensis in natural conditions can

VXUYLYH�H[WHQGHG�SHULRGV�LQ�FROG��PRLVW�environments.

It is most likely that F. tularensis

ZRXOG� EH� DHURVROL]HG� LQ� DQ� DWWDFN� RI�bioterrorism, causing primarily the

SQHXPRQLF�IRUP�RI�WKH�GLVHDVH�

Clinical Presentation, Diagnosis, and Treatment

Patients with tularemia present with

GLIIHUHQW�V\PSWRPV�GHSHQGLQJ�RQ�KRZ�the bacteria enters the body. Onset may

EH�DEUXSW��ZLWK�IHYHU��FKLOOV��KHDGDFKH��ERG\� DFKHV�� DQG� VRUH� WKURDW�� 1DXVHD��vomiting, and diarrhea may also be pres-

HQW��8S�WR��RI�SDWLHQWV�PD\�VKRZ�D�blotchy rash that may become pustular.

2WKHU� V\PSWRPV�PD\� YDU\� E\� VLWH� RI�bacterial entry:

1. Ulceroglandular: �0RVW� FRPPRQ�IRUP��IURP�HLWKHU�WKH�ELWH�RI�D�WLFN�RU�GHHUÁ\�RU�IURP�KDQGOLQJ�DQ�LQIHFWHG�DQLPDO��$�VNLQ�XOFHU�IRUPV�DW�WKH�VLWH��DQG�VZHOOLQJ�RI�O\PSK�JODQGV�LQ�WKH�armpit or groin is common.

2. Glandular: Likely occurs when

bacteria enter through an unseen

DEUDVLRQ��VLPLODU� WR�XOFHURJODQGXODU�but without an ulcer.

3. Oculoglandular: Occurs when a

SHUVRQ�WRXFKHV�WKH�H\H�DQG�WUDQVIHUV�the bacteria there. Symptoms include

SXUXOHQW� FRQMXQFWLYLWLV� RI� WKH� H\H��SHULRUELWDO� HGHPD�� DQG� VZHOOLQJ� RI�O\PSK�JODQGV�LQ�IURQW�RI�WKH�HDU�

4. 2URSKDU\QJHDO�� 2FFXUV� IURP�consuming contaminated meat

(usually rabbit) or water. Symptoms

LQFOXGH� VRUH� WKURDW�� H[XGDWLYH�tonsillitis, mouth ulcers, and swollen

lymph glands in the neck.

5. Pneumonic: 0RVW� VHULRXV� IRUP��FRQWUDFWHG� DIWHU� EUHDWKLQJ� GXVW� RU�aerosols containing the bacteria or

ZKHQ� RWKHU� IRUPV� RI� WXODUHPLD� DUH�OHIW�XQWUHDWHG�DQG�GLVHDVH�SURJUHVVHV�to the lungs via the bloodstream.

Symptoms include dry cough,

VXEVWHUQDO�FKHVW�SDLQ��DQG�GLIÀFXOW\�breathing.

6. 7\SKRLGDO��VHSWLFHPLF�� Symptoms

LQFOXGH�IHYHU��FKLOOV��ZHLJKW�ORVV��DQG�malaise, and possibly pneumonia.

'LIÀFXOW� WR� GLDJQRVH� EHFDXVH� WKHUH�LV�XVXDOO\�DQ�DEVHQFH�RI�XOFHUV� DQG�lymphadenopathy.

'LDJQRVLV�RI�WXODUHPLD�LV�GLIÀFXOW�EH-cause the disease is rare and symptoms

UHVHPEOH�WKRVH�RI�RWKHU�LOOQHVVHV��5RX-

WLQH�ODE�ZRUN�LV�QRW�GLDJQRVWLF��$�WKRU-RXJK�SDWLHQW�KLVWRU\�VKRZLQJ�H[SRVXUH�to animals or insect bites is important.

Diagnosis is generally made with sero-

logical testing. Blood and tissue cultures

VKRZLQJ�JURZWK�RI�F. tularensis are also

GLDJQRVWLF�� /DEV� VKRXOG� EH� DOHUWHG� LI�tularemia is suspected because special

FXOWXUH�PHGLD� LV� UHTXLUHG� IRU� EDFWHULDO�SURSDJDWLRQ��$GGLWLRQDOO\��ODE�LGHQWLÀFD-tion must be handled at ELRVDIHW\�OHYHO��%6/�� or at ELRVDIHW\�OHYHO��%6/��LI�SURFHGXUHV�DUH�PRUH�FRPSOLFDWHG�RU�might produce aerosols.

The CDC recommends intravenous

antibiotic treatment with streptomycin as

WKH�GUXJ�RI�FKRLFH�DQG�JHQWDP\FLQ�DV�DQ�DFFHSWDEOH�DOWHUQDWLYH��$��GD\�FRXUVH�is recommended. Tetracyclines and

FKORUDPSKHQLFRO� �XVHG�IRU�D�PLQLPXP�RI��GD\V��VKRXOG�EH�XVHG�ZLWK�FDXWLRQ�due to relapses and primary treatment

IDLOXUH�� $OWKRXJK� FLSURIOR[DFLQ� DQG�ÁXRURTXLQRORQHV� DUH� QRW� DSSURYHG� IRU�WUHDWPHQW��WKHUH�KDV�EHHQ�JRRG�HIÀFDF\�in both animals and humans. F. tularensis

LV� UHVLVWDQW� WR�SHQLFLOOLQV�DQG�ÀUVW�JHQ-

eration cephlasporins. Patients should

respond quickly with correct antibiotic

treatment, and dramatic changes should

be observed within 24-48 hours.

Currently, there is a live attenuated

vaccine that has been used to protect

ODE�ZRUNHUV� WKDW� LV�XQGHU�)'$�UHYLHZ��There is no immune globulin available

IRU� WUHDWPHQW�� DQG� QR� DQWLELRWLFV� DUH�OLFHQVHG� IRU� SUH�H[SRVXUH� SURSK\OD[LV��3RVWH[SRVXUH� SURSK\OD[LV� ODVWLQJ� ��GD\V�VKRXOG�EHJLQ�ZLWKLQ��KRXUV�DIWHU�H[SRVXUH�ZLWK�HLWKHU�GR[\F\FOLQH�RU�FLS-

URÁR[DFLQ�DV�WKH�GUXJV�RI�FKRLFH��


Isolation precautions are standard and

SDWLHQW�LVRODWLRQ�LV�QRW�UHFRPPHQGHG�IRU�tularemia because person- to- person

transmission is rare. Standard hospital

GHFRQWDPLQDWLRQ�SURFHGXUHV�IRU�VXUIDFHV�DQG�ODXQGU\�DUH�VXIÀFLHQW��

%RWXOLQXP�7R[LQ

(WLRORJ\%RWXOLQXP�WR[LQV�DUH�SURGXFHG�E\�WKH�

DQDHURELF�JUDP�SRVLWLYH�VSRUH�IRUPLQJ�bacillus Clostridium botulinum and two

other Clostridium species. There are

VHYHQ� QHXURWR[LQV�� NQRZQ� DV� W\SHV�$�through G, which are produced when the

bacterial spores return to the vegetative

state under anaerobic conditions. The

$��%��DQG�(�W\SHV�FDXVH�KXPDQ�GLVHDVH��Types C and D cause animal disease.

%RWXOLQXP� WR[LQV� DUH� WKH�PRVW� WR[LF�compounds per weight known to man.

They can be absorbed through the respi-

ratory tract, eyes, skin breaks, and mu-

FRXV�PHPEUDQHV��7KH�WR[LQV�FDQ�ELQG�WR�WKH�SUHV\QDSWLF�MXQFWLRQ�RI�HLWKHU�QHXUR-

muscular or autonomic nerve junctions.

Once bound, the damage is irreversible.

7KH�WR[LQV�ZRUN�WR�EORFN�QHXURPXVFXODU�WUDQVPLVVLRQ�E\�SUHYHQWLQJ�WKH�UHOHDVH�RI�acetylcholine across the nerve synapse.

5HFRYHU\�FDQ�RFFXU�RQO\�LI�WKH�QHXURQ�GHYHORSV�D�QHZ�D[RQ��D�SURFHVV�WKDW�PD\�take several months. Without treatment,

GHDWK�RFFXUV�GXH�WR�SDUDO\VLV�RI�UHVSLUD-WRU\�PXVFOHV�� %RWXOLQXP�WR[LQ� LV�DOVR�XVHG� IRU�PHGLFDO� SXUSRVHV�� LQFOXGLQJ�WUHDWPHQW� RI� VWUDELVPXV��PXVFOH� SDLQ�GLVRUGHUV��H[FHVVLYH�XQGHUDUP�VZHDWLQJ��and chronic migraines. It is also used in

FRVPHWLF�SURFHGXUHV��%RWR[��

(SLGHPLRORJ\&DVHV�RI�ERWXOLVP�KDYH�EHHQ�GHVFULEHG�


Family Virus & mortality rate

Disease Natural Reservoir

Regions Found

Filoviridae

These viruses are transmitted through

exposure to natural reservoir, and person to

person transmission.

Marburg (mortality up to 25%)

Marburg Fever Likely to be

Fruit bats

Marburg W. Germany, Yugoslavia, Africa

Ebola (mortality as high

as 90% with certain strains of Ebola)

Ebola HF Tropical Regions of

Africa

Arenaviridae Lassa (<10% of cases are severe but mortality

can reach 25% in these)

Lassa Fever Old world

rats and mice

Rural W. Africa

These viruses are

transmitted through inhalation of aerosols

from rodent urine or excrement, ingestion of

rodent-contaminated food, or direct contact

of broken skin with rodent excreta. Also

person to person transmission.

Lujo Unnamed HF LUsaka, Zambia, and

JOhannesburg, S. Africa

Junin (mortality 15-30%)

Argentine HF New World

rats

and mice.

Argentina

Machupo (mortality 15-

30%)

Bolivian HF Bolivia

Guanarito (mortality

15-30%)

Venezuelan HF Venezuela

Sabia Brazilian HF Brazil

Chapare Unnamed HF Bolivia

Whitewater Arroyo Whitewater Arroyo HF W. United States

�� throughout literature. Clostridia spp.

FDQ�EH� IRXQG� WKURXJKRXW� WKH�ZRUOG� LQ�VDPSOHV� WDNHQ� IURP� VRLO��PDULQH� VHGL-PHQWV��KRXVHKROG�GXVW��DQG�WKH�VXUIDFHV�RI�IRRG�7KHUH�DUH�6L[�W\SHV�RI�ERWXOLVP�

1. Foodborne botulism IURP� HDWLQJ�IRRGV�WKDW�ZHUH�LPSURSHUO\�FDQQHG�RU�preserved and are contaminated with

SUHIRUPHG�WR[LQ��2FFXUV�SULPDULO\�LQ�KRPH��FDQQHG�IRRGV�

2. Wound botulism � I URP� WR[LQ�SURGXFHG� LQ� DQ� LQIHFWHG� ZRXQG��0D\�EH�IRXQG�LQ�FDVHV�VHFRQGDU\�WR�

VXUJHU\�RU�WUDXPD��LQ�FDVHV�RI�VLQXVLWLV�IURP� LQWUDQDVDO� FRFDLQH� DEXVH�� RU�LQ� FDVHV� RI� VXEFXWDQHRXV� KHURLQ�injection (especially black tar heroin

XVH�LQ�&DOLIRUQLD��3. Infant botulism� RFFXUV� LQ� LQIDQWV�XQGHU��\HDU�ROG�IURP�FRQVXPSWLRQ�RI�VSRUHV�LQ�IRRG��KRQH\��WKDW�JHUPLQDWH�and colonize the intestines.

4. Adult intestinal toxemia botulism RFFXUV� DIWHU� SHUVRQV� ZLWK� ERZHO�conditions that disrupt normal

LQWHVWLQDO� IORUD� FRQVXPH� VSRUH�FRQWDLQLQJ�IRRG�

5. Iatrogenic botulism� RFFXUV� IURP�DFFLGHQWDO�RYHUGRVH�RI�SKDUPDFHXWLFDO�ERWXOLQXP� WR[LQ�� &DVHV� DUH� UDUH�EHFDXVH�WKH�)'$�UHTXLUHV�GRVHV�WR�EH�EHORZ�KXPDQ�WR[LFLW\�OHYHO��

6. Inhalational botulism is rare and

only recently seen in lab workers who

DFFLGHQWDOO\�LQKDOHG�WR[LQ�7KHUH�DUH�DERXW��UHSRUWHG�FDVHV�RI�

ERWXOLVP�LQ�WKH�8�6��SHU�\HDU��,Q�D�FDVH�RI�ELRWHUURULVP��ERWXOLQXP�WR[LQ�FRXOG�EH�spread through aerosolization or through

Table 5: Characteristics of Filoviruses and Arenaviruses 6RXUFH��1&&(�*UDSKLFV


IRRG�DQG�ZDWHU�FRQWDPLQDWLRQ�

Clinical Presentation, Diagnosis, and Treatment:LWKLQ� �� KRXUV� RI� H[SRVXUH� WR� WKH�

WR[LQ�� SDWLHQWV� SUHVHQW� ZLWK� FODVVLF�symptoms, including dry mouth, double

vision, blurred vision, ptosis, slurred

speech, dysphagia, and muscle weak-

QHVV��)HYHU�LV�DEVHQW��DQG�SDWLHQWV�DUH�IXOO\� DOHUW�ZLWK� IXOO\� LQWDFW� VHQVDWLRQ��Overall, a descending motor paralysis

can be seen as respiratory muscles, arms

�DQG�OHJV�EHFRPH�DIIHFWHG��,QIDQWV�DUH�OH-thargic and have a weak cry, poor muscle

WRQH��SRRU�IHHGLQJ��DQG�FRQVWLSDWLRQ��Diagnosis is based on patient his-

WRU\�DQG�SK\VLFDO�DQG�QHXURORJLF�H[DPV�DQG�LV�FRQÀUPHG�E\�ODE�DQDO\VLV�� /DE�LGHQWLÀFDWLRQ�PXVW� EH� KDQGOHG� DW�bio-VDIHW\� OHYHO��%6/�� or at ELRVDIHW\�OHYHO��%6/��LI�SURFHGXUHV�DUH�PRUH�complicated or might produce aerosols.

Suspected cases must be immediately

reported to state health departments that

ZLOO�WKHQ�QRWLI\�WKH�&'&��7UHDWPHQW�FRQVLVWV�RI�SURPSW�GRVLQJ�

RI� DQWLWR[LQ� DQG� LQWHQVLYH� VXSSRUWLYH�WKHUDS\��,I�ERWXOLVP�LV�VXVSHFWHG��DQWL-WR[LQ�VKRXOG�EH�JLYHQ�DV�VRRQ�DV�SRVVLEOH��SULRU� WR� ODE� FRQÀUPDWLRQ�� EHFDXVH� LW�can minimize subsequent nerve damage

and speed recovery. It will not reverse

DQ\� H[LVWLQJ� SDUDO\VLV��7KH�KHSWDYD-OHQW� ERWXOLVP� DQWLWR[LQ� �+%$7�� RI�equine origin is available through a

&'&�VSRQVRUHG� )'$� ,QYHVWLJDWLRQDO�1HZ�'UXJ��,1'��SURWRFRO�IRU�QRQLQIDQW��naturally occurring botulism. It is now

WKH�RQO\�DQWLWR[LQ�DYDLODEOH�IRU�QRQLQIDQW�ERWXOLVP�� ,QIDQW�botulism immune JORELQ� �%DE\�%,*�� LV� DYDLODEOH� IURP�WKH�&DOLIRUQLD�6WDWH�+HDOWK�'HSDUWPHQW��6NLQ�WHVWLQJ�IRU�VHQVLWLYLW\�WR�VHUXP�RU�DQWLWR[LQ�PXVW� EH� SHUIRUPHG� SULRU� WR�DGPLQLVWUDWLRQ� RI� DQWLWR[LQ�� 3DWLHQWV�placed on mechanical ventilation usually

UHTXLUH��WR��ZHHNV�RI�WKHUDS\�EXW�PD\�require up to seven months. There is no

FXUUHQW�YDFFLQH�IRU�ERWXOLVP�

PPE, Infection Control, and Decontamination3HUVRQ�� WR�� SHUVRQ� WUDQVPLVVLRQ� RI�

botulism does not occur, and isolation

precautions are standard. In a bioweapon

VLWXDWLRQ��WKH�SULPDU\�ULVN�RI�DHURVROL]HG�WR[LQ�IURP�D�SDWLHQW·V�ZRXQG�RU�VNLQ�LV�

ORZ��$Q\RQH�GHFRQWDPLQDWLQJ�D�SDWLHQW�H[SRVHG� WR�C. botulinum� WR[LQ� VKRXOG�ZHDU�VSODVK��SURRI�DQG�ZDWHUSURRI�RXWHU�garments, chemical resistant gloves, eye

SURWHFWLRQ��DQG�D�1,26+�DSSURYHG�1��ÀW�WHVWHG�UHVSLUDWRU��C. botulinum is in-

DFWLYDWHG�E\�D��GLOXWLRQ�RI�KRXVHKROG�bleach with a 30 minute contact time.

%RWXOLVP�WR[LQ�LQ�IRRG�LV�GHVWUR\HG�E\�KHDWLQJ�IRRG�WR�DQ�LQWHUQDO�WHPSHUDWXUH�RI��&�IRU�DW�OHDVW��PLQXWHV�

7KH�9LUDO�+HPRUUKDJLF�Fevers

(WLRORJ\�DQG�(SLGHPLRORJ\The YLUDO�KHPRUUKDJLF�IHYHUV��9+)�

DUH�D�JURXS�RI�GLVHDVHV�FDXVHG�E\�VHY-

HUDO�IDPLOLHV�RI�YLUXVHV��7KHVH�YLUXVHV�damage the body’s vascular system and

DIIHFW�PXOWLSOH� RUJDQ� V\VWHPV�� 7KH�YLUXVHV� DUH� JURXSHG� LQWR� IRXU� JURXSV��ÀORYLUXVHV��DUHQDYLUXVHV��EXQ\DYLUXVHV��DQG�ÁDYLYLUXVHV�� $OO�DUH�51$�YLUXVHV�DQG�WKH\�DUH�IRXQG�LQ�DUHDV�ZKHUH�WKHLU�QDWXUDO�UHVHUYRLUV�OLYH��KXPDQV�DUH�QRW�their natural reservoirs. This course will

IRFXV�RQ�WKH�ÀORYLUXVHV�DQG�DUHQDYLUXVHV�because they are in the CDC category

$�OLVW�� Table 5�VKRZV�FKDUDFWHULVWLFV�RI�ÀORYLUXVHV�DQG�DUHQDYLUXVHV�)LORYLUXVHV� EHORQJ� WR� WKH�ÀORYLULGDH

IDPLO\��7KH�WZR�PHPEHUV�RI�WKLV�IDPLO\�WKDW� KDYH� EHHQ� LGHQWLÀHG� DUH�0DUEXUJ�YLUXV�DQG�(EROD�YLUXV��7KH�QDWXUDO�UHV-ervoir is still unknown but is suspected

WR� EH� IUXLW� EDWV�� 7UDQVPLVVLRQ� RFFXUV�IURP�H[SRVXUH�WR� WKH�QDWXUDO�UHVHUYRLU��Once the virus is in a human, transmis-

sion is by close personal contact with an

LQIHFWHG�SHUVRQ��LQIHFWHG�EORRG��LQIHFWHG�ERG\�ÁXLGV��RU�FDGDYHUV��7KH\�DUH�DOVR�known to spread in laboratories through

VPDOO�SDUWLFOH�DHURVROV��$HURVRO�VSUHDG�among humans is unclear.

$UHQDYLUXVHV�EHORQJ�WR�WKH�arenaviri-

dae�IDPLO\��0HPEHUV�RI�WKLV�IDPLO\�DUH�/DVVD� YLUXV� �/DVVD� IHYHU�� -XQLQ� YLUXV��$UJHQWLQH�KHPRUUKDJLF�IHYHU��0DFKX-

SR�YLUXV��%ROLYLDQ�KHPRUUKDJLF�IHYHU��*XDQDULWR� YLUXV� �9HQH]XHODQ� KHPRU-UKDJLF� IHYHU�� 6DELD� YLUXV� �%UD]LOLDQ�KHPRUUKDJLF�IHYHU��:KLWHZDWHU�$UUR\R�virus (whitewater arroyo hemorrhagic

IHYHU��DQG�PRVW�UHFHQWO\�WKH�/XMR�YLUXV�discovered in 2009. These viruses are

VSUHDG�WKURXJK�H[SRVXUH�WR�URGHQWV�DQG�human- to- human contact.

,Q�D�FDVH�RI�ELRWHUURULVP��YLUXVHV�FDXV-

LQJ�KHPRUUKDJLF�IHYHU�FRXOG�PRVW�OLNHO\�be spread through aerosolization.

Clinical Presentation, Diagnosis, and Treatment,QFXEDWLRQ�IRU�9+)V�LV��WR��GD\V��

$OWKRXJK�WKHUH�DUH�GLIIHUHQFHV�LQ�V\PS-

WRPV�EHWZHHQ�WKH�GLIIHUHQW�KHPRUUKDJLF�IHYHUV�� FRPPRQ� V\PSWRPV� LQFOXGH�DEUXSW� RQVHW� RI� IHYHU�� VHYHUH� H[KDXV-tion, myalgia, headache, and various

EOHHGLQJ�PDQLIHVWDWLRQV�WKDW�UDQJH�IURP�HFFK\PRVLV�WR�RYHUW�EOHHGLQJ��1DXVHD��vomiting, bloody diarrhea, abdominal

pain, maculopapular rash, sore throat,

chest pain, and jaundice are also com-

mon symptoms. Tremor, seizures, coma,

DQG�GHDWK�PD\�IROORZ�Diagnosis is made by a thorough pa-

WLHQW�KLVWRU\�DQG�GHÀQLWLYH�ODE�DQDO\VLV��$Q\� VXVSHFWHG� FDVHV� RI�9+)�PXVW� EH�LPPHGLDWHO\�UHSRUWHG�WR�WKH�&'&·V�9LUDO�6SHFLDO�3DWKRJHQV�%UDQFK��$OO�ODE�ZRUN�must be done at�ELRVDIHW\�OHYHOV��DQG��%6/��DQG�%6/�� due to the ability

RI�WKH�YLUXVHV�WR�LQIHFW�YLD�DHURVROV�DQG�WKHLU�DELOLW\�WR�FDXVH�UDSLG�RQVHW�RI�OLIH�threatening disease.

7KHUH�LV�QR�FXUH�IRU�WKH�9+)V��7UHDW-PHQW� FRQVLVWV� SULPDULO\� RI� VXSSRUWLYH�WKHUDS\�� LQFOXGLQJ� PDLQWHQDQFH� RI�electrolytes, mechanical ventilation,

DQG�PDQDJHPHQW�RI�EOHHGLQJ��$OWKRXJK�QRW�)'$�DSSURYHG��5LEDYLULQ��DYDLODEOH�RQO\�DV�DQ�,1'��KDV�EHHQ�VKRZQ�WR�EH�HIIHFWLYH�DJDLQVW�DUHQDYLUXVHV�EXW�LV�QRW�HIIHFWLYH�DQG�QRW�UHFRPPHQGHG�IRU�ÀOR-

viruses. Ribavirin is teratogenic.

$Q\� SHUVRQV� H[SRVHG� WR� D�9+)� RU�ZKR� DUH� FRQWDFWV� RI� D� SDWLHQW�ZLWK� D�9+)� VKRXOG� EH� FORVHO\� PRQLWRUHG��Prophylactic antiviral therapy is NOT

UHFRPPHQGHG��,I�WHPSHUDWXUH�LV��)�RU�JUHDWHU��RU�LI�RWKHU�V\PSWRPV�RI�9+)�are present, and the suspected virus is not

(EROD��0DUEXUJ��RU�D�ÁDYLYLUXV��ULEDYLULQ�should be initiated.


Isolation precautions are strict contact

precautions with airborne precautions

DGGHG�XQWLO�D�PRGH�RI�WUDQVPLVVLRQ�KDV�EHHQ�FRQÀUPHG��,I�WKH�GLVHDVH�ZDV�QDWX-

rally acquired, droplet precautions can

EH� VXEVWLWXWHG� IRU� DLUERUQH�� (PSKDVLV�VKRXOG�EH�SODFHG�RQ�VKDUSV�VDIHW\��EDUULHU�precautions, hand hygiene, and patient

LVRODWLRQ��33(�FRQVLVWV�RI�JRZQV��GRXEOH�


JORYHV�� VKRH� DQG� OHJ� FRYHUV�� DQG� IDFH�VKLHOGV�RU�JRJJOHV��$LUERUQH�SUHFDXWLRQV�UHTXLUH��DW�PLQLPXP��D�ÀW�WHVWHG�1��UHV-SLUDWRU��%DWWHU\��RSHUDWHG�DLU�SXULI\LQJ�respirators, or positive pressure supplied

DLU�UHVSLUDWRUV��PXVW�EH�ZRUQ�LI�WKHUH�LV�FRQWDFW�ZLWKLQ�� IHHW�RI� D�SDWLHQW�ZLWK�9+)��$Q\�GLUHFW�FRQWDFW�ZLWK�FDGDYHUV�RI� SDWLHQWV� VXVSHFWHG� RI� KDYLQJ� GLHG�IURP�+)�VKRXOG�EH�DYRLGHG��)RU�PRUH�LQIRUPDWLRQ�RQ�9+)��VHH�ZZZ�FGF�JRY��

&KHPLFDO�DQG�1XFOHDU�7HUURULVP$OWKRXJK� FKHPLFDO� DQG� QXFOHDU� WHU-

URULVP�GR�QRW�IDOO�XQGHU�WKH�ELRWHUURULVP�category, it is important to have a basic

XQGHUVWDQGLQJ�RI� WKHVH�RWKHU� WKUHDWV� LQ�VLWXDWLRQV� RI� HPHUJHQF\� SUHSDUHGQHVV�and response.

&KHPLFDO�7HUURULVPSymptoms associated with chemical

H[SRVXUH� LQFOXGH� FKHPLFDO� EXUQV�� VNLQ�EOLVWHULQJ� DQG� UHGQHVV�� H[WUHPH� SDLQ��coughing, choking, dyspnea, lung and

airway irritation, sore throat, tearing,

conjunctival and corneal damage,

blurred vision, miosis or mydriasis,

nausea, vomiting, sweating, diarrhea,

VHL]XUHV��FRQIXVLRQ�DQG�KDOOXFLQDWLRQV�In chemical emergencies, victims

VKRXOG�EH�ÀUVW� DVVHVVHG� IRU� DQ� DLUZD\��DGHTXDWH� UHVSLUDWLRQ�� DQG� D� SXOVH�� ,I�trauma is suspected, the patient must

be stabilized with a cervical collar and

backboard. Because most chemical

agents can penetrate clothing and are

quickly absorbed through the skin,

decontamination must be done as soon

DV�SRVVLEOH�WR�EH�PRVW�HIIHFWLYH��SUHIHU-DEO\�ZLWKLQ�� WR��PLQXWHV�DIWHU�H[SR-

sure. Contaminated clothing should be

UHPRYHG� DV� TXLFNO\� DV� SRVVLEOH�� $Q\�

clothing that must be pulled over the

KHDG�WR�UHPRYH�VKRXOG�EH�FXW�RII�LQVWHDG�WR�SUHYHQW�IXUWKHU�H[SRVXUH�RI�H\HV�DQG�PXFRXV�PHPEUDQHV�� ,I� SRVVLEOH�� DQ\�H[SRVHG�DUHDV�RI�VNLQ�VKRXOG�EH�ZDVKHG�ZLWK� ODUJH�DPRXQWV�RI�VRDS�DQG�ZDWHU��(\HV�VKRXOG�EH�LUULJDWHG�ZLWK�ZDWHU�RU�saline. Contact lenses should be removed

and discarded with contaminated cloth-

LQJ�� $OO� FRQWDPLQDWHG�PDWHULDO� DQG�clothing should be double- bagged in

plastic bags and tightly sealed. Persons

who have undergone decontamination

should avoid contact with others who

have not been decontaminated and

should avoid areas where the chemical

release occurred.

7UHDWPHQW� IRU� FKHPLFDO� H[SRVXUH�ZLOO�YDU\�EDVHG�RQ�WKH�W\SH�RI�FKHPLFDO�DQG� V\PSWRPV�� 0HGLFDO�PDQDJHPHQW�JXLGHOLQHV� IRU� DFXWH� FKHPLFDO� H[SR-

sure as compiled by the $JHQF\� IRU�7R[LF�6XEVWDQFHV�DQG�'LVHDVH�5HJLVWU\�

Chemical Explosion Nuclear Explosion

Amount of heat produced Several thousand degrees Millions of degrees where matter becomes plasma

Size of gaseous fireball Several meters in diameter (1meter=3.28ft)

1,450ft (~442 meters) for a 10KT nuclear device (�mile=1320ft)

Energy Released Derived from reactions between molecules

Derived from splitting (fission) of the ~atomic nuclei of uranium or plutonium

Amount of energy released when compared pound for pound

1X energy ~10 million X energy

Equivalents ~1000 tons of TNT‡

~10,000 tons of TNT

Low yield nuclear device= 1KT

Low yield nuclear device=10KT*

��

Table 6: A Comparison of Chemical vs. Nuclear Explosions

Table adapted from the federal interagency document Planning Guidance for Response to a Nuclear Detonation. Available at http://www.hps.org/hsc/documents/Planning_Guidance_for_Response_to_a_Nuclear_Detonation-2nd_Edition_FINAL.pdf‡For comparison, the blast in the Oklahoma City, OK, bombing of the Murrah Federal Building in 1995 was equivalent to 2 tons of TNT.*Department of Homeland Security bases its planning factors on a low-yield nuclear device of 10KT (kilotons) detonated at ground level in an urban area.


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VKHOWHULQJIDFWV�DVS�

1XFOHDU�7HUURULVP�DQG�Radiation

Radiation emergencies could be

caused by dirty bombs, nuclear blasts,

DWWDFNV�RU�SUREOHPV�DW�D�QXFOHDU�IDFLOLW\��RU�DFFLGHQWV� LQYROYLQJ� WKH� WUDQVSRUW�RI�UDGLRDFWLYH�PDWHULDOV�� 1XFOHDU� H[SOR-

VLRQV�DUH�LPPHQVHO\�PRUH�SRZHUIXO�WKDQ�FKHPLFDO�H[SORVLRQV��Table 6 shows a

FRPSDULVRQ�RI�FKHPLFDO�YHUVXV�QXFOHDU�H[SORVLRQV��1XFOHDU�H[SORVLRQV�SURGXFH�blast injuries, thermal injuries, and radia-

WLRQ� LQMXULHV�� 7KH�SURJQRVLV� IRU� WKRVH�with both radiation and traumatic injuries

LV�ZRUVH�WKDQ�WKH�SURJQRVLV�IRU�WKRVH�ZLWK�UDGLDWLRQ�H[SRVXUH�DORQH�

Radiation fallout is the term used to

GHVFULEH� WKH� SDUWLFOHV� WKDW� IRUP�ZKHQ�vaporized dirt particles are drawn up into

WKH�PXVKURRP�FORXG�SURGXFHG�IURP�DQ�H[SORVLRQ�� 5DGLRDFWLYH�PDWHULDOV� WKHQ�FRQGHQVH�RQ�WKHVH�SDUWLFOHV�DQG�IDOO�EDFN�WR� HDUWK�� 7KH�PRVW� KD]DUGRXV� IDOORXW�

ZLOO�EH�YLVLEOH�DV�ÀQH�SDUWLFOHV�WKH�VL]H�RI� VDQG�� 7KH� ODFN� RI� DSSDUHQW� IDOORXW�does not mean there is no radiation. The

DUHD�RI�VLJQLÀFDQW�IDOORXW�IRU�D��.7��WKH�VL]H�RI�EODVW�WKDW�'+6�EDVHV�LWV�SODQQLQJ�IDFWRUV�RQ��H[SORVLRQ�ZLOO�H[WHQG��PLOHV� IURP�ground zero, or the initial

ORFDWLRQ�RI�WKH�EODVW��3HUVRQV�ZKR�WDNH�shelter ZLWKLQ� WKH�ÀUVW��PLQXWHV�RI�D�QXFOHDU� H[SORVLRQ� DQG�ZKR� shelter in place (go immediately indoors to the

nearest most protective structure) will

KDYH�WKH�PRVW�HIIHFWLYH�OLIH�VDYLQJ�RS-

SRUWXQLW\��7KH�PRVW�LPSRUWDQW�IDFWRUV�LQ�SURWHFWLRQ�IURP�UDGLDWLRQ�DQG�IDOORXW�DUH��1. Distance. The greater the distance

between a person and radiation/

IDOORXW� SDUWLFOHV�� WKH� JUHDWHU� WKH�protection. Underground rooms and

EDVHPHQWV� RIIHU� JUHDWHU� SURWHFWLRQ�WKDQ� ERWWRP� IORRUV�� DQG� PLGGOH�ÁRRUV� LQ� KLJK�� ULVH� EXLOGLQJV� RIIHU�JUHDWHU�SURWHFWLRQ�WKDQ�XSSHU�ÁRRUV��)ODW� URRIWRSV� ZLOO� FROOHFW� IDOORXW�SDUWLFOHV� PDNLQJ� XSSHU� IORRUV� D�poorer choice. Figure 8 shows

WKH� GLIIHUHQW� DPRXQWV� RI� VKLHOGLQJ�SURWHFWLRQ�RIIHUHG�GHSHQGLQJ�RQ�WKH�ORFDWLRQ�RI�SHUVRQV�ZLWKLQ�D�EXLOGLQJ��7KHVH� IDFWRUV� DSSO\� RQO\� WR� IDOORXW�

IURP� D� QXFOHDU� GHWRQDWLRQ� DQG� DUH�QRW�DSSURSULDWH�IRU�UHDFWRU�LQFLGHQWV��dirty bombs, or chemical/biological

events.

2. Shielding. The heavier and denser

the material between a person and

UDGLDWLRQ�IDOORXW�SDUWLFOHV��WKH�JUHDWHU�the protection. The more earth, rock,

FRQFUHWH�� DQG� VR� IRUWK�� EHWZHHQ� D�SHUVRQ� DQG� IDOORXW� SDUWLFOHV�� WKH�better.

3. Time. The greater the time spent

LQ� VKHOWHUV� DZD\� IURP� UDGLDWLRQ�IDOORXW�� WKH� JUHDWHU� WKH� SURWHFWLRQ��)DOORXW� SRVHV� WKH� JUHDWHVW� WKUHDW� LQ�WKH� �� ZHHNV� IROORZLQJ� D� QXFOHDU�HPHUJHQF\��DIWHU��ZHHNV� WKH� OHYHO�RI� UDGLDWLRQ� LV� DERXW� �� RI� WKH�LQLWLDO� UDGLDWLRQ� OHYHO��7KH� GRVH� RI�radiation a person receives is directly

SURSRUWLRQDO�WR�WKH�WLPH�RI�H[SRVXUH��The�HOHFWURPDJQHWLF�SXOVH��(03�� or

KLJK��GHQVLW\�HOHFWURPDJQHWLF�ÀHOG�WKDW�IROORZV�D�QXFOHDU�ZHDSRQ�GHWRQDWLRQ��LV�similar to a lightning strike but is stron-

JHU�� IDVWHU�DQG�VKRUWHU�� 'HSHQGLQJ�RQ�where the detonation occurs, electronic

devices connected to power sources

DQG�DQWHQQDV�FDQ�EH�GDPDJHG�IRU�PDQ\�miles. This includes computers, cell

Figure 8: Protection/Shielding Offered by Various Locations within a Building*

*Figure used with permission: Brooke Buddemeier, Lawrence Livermore National Laboratory. Protection factors ap-ply only to fallout from a nuclear detonation and are not appropriate for use after reactor incidents, dirty bombs, or chemical/biological events.


phones and communication systems,

electrical appliances, and ignition sys-

WHPV�RI�DXWRPRELOHV�DQG�DLUFUDIW��:LWK�D�high altitude detonation, most equipment

ZLWKLQ�D�GLVWDQFH�RI��PLOHV�FRXOG�EH�GDPDJHG��$Q�(03�PD\�DOVR�KDUP�SDFH-makers and other electronic implants.

Radiation cannot be detected by

WKH�ÀYH�KXPDQ�VHQVHV�� ,W�FDQ�RQO\�EH�detected by radiation monitoring equip-

PHQW��3HUVRQV�H[SRVHG�WR�UDGLDWLRQ�PD\�QRW�UHDOL]H�ZKDW�OHYHO�RU�OHQJWK�RI�H[SR-

VXUH�WKH\�PD\�KDYH�KDG��6\PSWRPV�RI�DFXWH�UDGLDWLRQ�V\QGURPH��$56�, also

known as radiation sickness or radia-

tion poisoning, vary depending on the

DPRXQW�DQG�OHQJWK�RI�UDGLDWLRQ�H[SRVXUH��Prodromal symptoms include headache,

IHYHU��QDXVHD��YRPLWLQJ��DQG�IDWLJXH��$V�time progresses, symptoms include low

EORRG� FHOO� FRXQWV�� DQHPLD�� LQIHFWLRQV��neurological problems, and bleeding.

Treatment is supportive therapy includ-

ing antibiotics and blood products.

,I�D�SHUVRQ�KDV�EHHQ�H[SRVHG�WR�UDGLD-tion, clothing should be removed as soon

as possible, sealed in a plastic bag, and

SODFHG�DV�IDU�DZD\�DV�IHDVLEOH�IURP�KX-

PDQV�DQG�DQLPDOV��,I�SRVVLEOH��SHUVRQV�should be decontaminated by showering

ZLWK� ODUJH�DPRXQWV�RI�VRDS�DQG�ZDWHU��taking care not to scrub or scratch the

VNLQ�� +DLU� VKRXOG� EH� VKDPSRRHG� EXW�no conditioner used because it will bind

radioactive particles to the hair. The nose

should be thoroughly blown to help get

ULG� RI� DQ\� UDGLRDFWLYH� SDUWLFOHV� WKHUH��(\HV�DQG�H\HOLGV�VKRXOG�EH�ZLSHG�ZLWK�a clean wet cloth. Contamination that

LV�QRW�ZDVKHG�RII�RU�EUXVKHG�DZD\�FDQ�FDXVH�EHWD�EXUQV� WR� WKH�VNLQ�� WKHUHIRUH�,any action (such as brushing/dusting

RII�DV�PXFK�DV�SRVVLEOH�� WR� UHGXFH� WKH�FRQWDPLQDWLRQ�LV�EHWWHU�WKDQ�QRQH��)RU�PRUH�LQIRUPDWLRQ�RQ�QXFOHDU�WHUURULVP��VHH�ZZZ�UHDG\�JRY� RU� WKH� H[FHOOHQW�IHGHUDO�LQWHUDJHQF\�GRFXPHQW�Planning

Guidance for Response to a Nuclear

Detonation available at http://www.

hps.org/hsc/documents/Planning_Guid-

DQFHBIRUB5HVSRQVHBWRBDB1XFOHDUB'HW-RQDWLRQ��QGB(GLWLRQB),1$/�SGI�

Conclusion5DLVLQJ� WKH� OHYHO� RI� SUHSDUHGQHVV�

among healthcare workers through edu-

FDWLRQ�ZLOO�HQDEOH�WKHP�WR�PRUH�HIIHF-tively deal with any incident they might

encounter and will save countless lives.

5HJDUGOHVV� RI� WKH� WKUHDW�� KHDOWKFDUH�ZRUNHUV�FDQ�IHHO�PRUH�FRQÀGHQW�LI�WKH\�KDYH�D�IDPLOLDULW\�ZLWK�DQG�NQRZOHGJH�RI�WKH�YDULRXV�DJHQWV�RI�ELRWHUURULVP��DV�ZHOO�DV�D�ZRUNLQJ�NQRZOHGJH�RI�FKHPL-cal, radiological, and nuclear threats.

7KLV�SUHSDUHGQHVV�ZLOO�KHOS�WKHP�HIIHF-tively manage an emergency situation

when it arises.

6XJJHVWHG�5HDGLQJ�and References )HGHUDO�(PHUJHQF\�0DQDJHPHQW�$JHQF\��7KH�5HDG\�&DPSDLJQ��$YDLO�DW��ZZZ�UHDG\�JRY�WHUURULVP��$FFHVVHG�$SULO��

)HGHUDWLRQ�RI�$PHULFDQ�6FLHQWLVWV��Biosecurity: Biological and

FKHPLFDO�ZHDSRQV��$YDLO�DW��KWWS��ZZZ�IDV�RUJ�SURJUDPV�ELR�LQGH[�KWPO��$FFHVVHG�$SULO��

&HQWHU�IRU�%LRVHFXULW\�RI�830&��$YDLO�DW��KWWS��ZZZ�XSPF�ELRVHFXULW\�RUJ�ZHEVLWH��$FFHVVHG�$SULO��

8QLWHG�6WDWHV�'HSDUWPHQW�RI�/DERU��2FFXSDWLRQDO�6DIHW\�DQG�+HDOWK�$GPLQLVWUDWLRQ��26+$�%HVW�SUDFWLFHV�IRU�KRVSLWDO�EDVHG�ÀUVW�UHFHLYHUV�RI�YLFWLPV�IURP�PDVV�casualty incidents involving the

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EOXHERRNSGI�86$05,,'��%OXH%RRN��WK��(GLWLRQ��6HS��SGI��$FFHVVHG�$SULO��

&KRVHZRRG�/&��:LOVRQ�'(��HGV��8�6��'HSDUWPHQW�RI�+HDOWK�DQG�+XPDQ�6HUYLFHV��&HQWHUV�IRU�'LVHDVH�&RQWURO�DQG�1DWLRQDO�,QVWLWXWH�RI�+HDOWK��%LRVDIHW\�LQ�PLFURELRORJLFDO�and biomedical laboratories 5th ed.

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6WHUQ�(-��8KGH�.%��6KDGRP\�69��0HVVRQQLHU�1��&RQIHUHQFH�UHSRUW�RQ�public health and clinical guidelines

IRU�DQWKUD[��FRQIHUHQFH�VXPPDU\��(PHUJ�,QIHFW�'LV��$SU��$YDLO�DW��KWWS��ZZZQF�FGF�JRY�HLG�article/14/4/07-0969_article.htm.

$FFHVVHG�$SULO��

&HQWHUV�IRU�'LVHDVH�&RQWURO�DQG�Prevention. Update: Investigation

RI�ELRWHUURULVP�UHODWHG�DQWKUD[�DQG�LQWHULP�JXLGHOLQHV�IRU�H[SRVXUH�management and antimicrobial

WKHUDS\��2FWREHU��00:5��$YDLO�at: http://www.cdc.gov/mmwr/

preview/mmwrhtml/mm5042a1.htm

$FFHVVHG�$SULO��

&HQWHUV�IRU�'LVHDVH�&RQWURO�DQG�Prevention. Bacillus anthracis slide

VHW��2FW��$YDLO�DW��KWWS��HPHUJHQF\�FGF�JRY�DJHQW�DQWKUD[�6OLGH6HW$QWKUD[�SGI��$FFHVVHG�$SULO��

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mmwrhtml/mm5044a5.htm.

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