Bioagents of Concern Anthrax, Botulism, Smallpox, Plague

BioAgents of Concern – Anthrax, Botulism, Smallpox, Plague

TABLE OF CONTENTS

Learning Objectives 3

Introduction 3

Anthrax as a Biological Weapon 11

History of Current Threat 13

Epidemiology of Anthrax 14

Microbiology 15

Pathogenesis and Clinical Manifestations 16

Diagnosis 24

Vaccination 26

Therapy 28

Infection Control 33

Decontamination 34

Smallpox as a Biological Weapon 47

History and Potential as a Bioweapon 47

Epidemiology 48

Microbiology 49

Pathongenesis and Clinical Presentation 49

Diagnosis 51

Preexposure Preventive Vaccination 52

Postexposure Therapy 53

Postexposure Infection Control 54

Hospital Epidemiology and Infection Control 55

Vaccine Administration and Complications 56

Decontamination 59

Research 60

Summary 61

Smallpox Update 61

Botulism as a Bioterror Weapon 81

History of Current Threat 81

Microbiology and Virulence Factors 82

Pathogenesis and Clinical Manifestations 83

Epidemiology 84

Diagnosis and Differential Diagnosis 87

Therapy 89

Special Populations 90

Prophylaxis 91

Decontamination 91

Infection Control 92

Research Needs 92

Plague as a Biological Weapon 103

History and Potential as a Bioterrorist Agent 103

Epidemiology 104

Microbiology and Virulence Factors 105

Pathogenesis and Clinical Manifestations 105

Diagnosis 107

Vaccination 108

Therapy 108

Postexposure Prophylaxis Recommendations 112

Infection Control 113

Environmental Decontamination 114

Appendix 125

Examination 145

Learning Objectives

·  Upon successful completion of this continuing education module, you will be able to:

·  Identify and discuss the history, epidemiology, microbiology, pathogenesis, clinical manifestations, diagnosis, treatment and prevention of: Anthrax, Small Pox, Botulism and Plague

Introduction

Bioterrorism has become a common household term ever since anthrax was spread across a wide reach of the nation last fall. Now, it almost appears everyone is involved in serious anti-terrorism campaigns which are not as readily seen as flags attached to cars, homes and clothing.

In the event of another bioterrorist attack, will you as a caregiver be prepared?

RTs and Nurses are in the first line of defense in combating biohazard substances because inhalation is the major pathways for toxic and biological agents to infect humans. The airway is one of the primary routes infectious agents follow to enter the body, and the harm caused by the agent would impact the respiratory system first, so RTs and Nurses need to be alert.

Tom Johnson, MS, RRT, program director of respiratory care and professor at Long Island University in New York, was an officer during the Vietnam era. He trained military personnel about chemical warfare. Thirty years later, he teaches RTs and Nurses about bioterrorism and how they need to be prepared in the event of a biological disaster.

Johnson urges all RTs and Nurses to recognize potential bioterrorist agents. "During the Gulf War, biowarfare became an issue, and I realized I was ignorant and did not know anthrax was already weaponized." Bioterrorism is not a new idea. "We have had the threat of bioterrorism for a long time in history," he said.

Today's need is different. Caregivers need to be prepared and knowledgeable in bioterrorism in order to treat patients in the best manner possible.

Knowledge Is Power
In the event of a bioterrorist attack, every second counts, especially when caregivers are trying to determine whether, in fact, a patient has symptoms of a bioterrorist agent. If health care professionals are keen enough to know what symptoms to look for, the impact of a potentially deadly bioterrorist attack can be lessened.

"RTs and nurses are the front line in an attack," Johnson said. If they have a suspicion and knowledge of which tests to run, the treatment can begin. "RTs and Nurses can help in the epidemiological standpoint and help blunt the attack," Johnson said. The key is to be alert in the event a bioterrorist attack happens. "Therapists need to be aware of which drugs to administer by IV and when to begin intubation," he said.

Early detection of an agent allows health care professionals more time to treat the patient and yield a cured patient. "RTs and Nurses need to be very quick thinking and detect early. Also, RTs and Nurses should have strong airway control skills and be very familiar with oxygenation ventilation issues with biological warfare," he said.

The goal is not to make experts of everyone; it's to heighten awareness. "RTs and Nurses can be under-recognized and underutilized, and we have to not only improve our skills but get those skills recognized, maybe within our licensure laws so if we have another disaster, natural or man-made, we can adequately respond as part of the health care team," Johnson said.

September 11
As Americans watched the events surrounding 9/11 unfold on national television, their gasps and sobs could be heard around the country. Little did they know it was just the beginning, a foreshadowing to the anthrax scare.

"Never before has the U.S. become so acutely aware of biological, chemical and radiological threats," said Frank Rando, MS, Ph, CRT, CVT, EMT-P, a certified hazardous materials specialist. Rando is a special adviser on counter-terrorism and public health preparedness and respiratory causality management.

"Respiratory therapists have never received detailed instruction or reading materials on how to handle these types of casualties," said Rando, who became a part of counter-terrorism because he felt RTs and Nurses need to become more aware and oriented about how to medically manage biological, chemical and radiological casualties since they are first-line health care providers. There is a one in 10 chance, he explained, there would be casualties with some degree of respiratory impairment.

Crisis Plans
One of the things that would help galvanize hospital staff is to have them prepare response plans and enforce them. Response plans are one key step in advancing a response system to alert staff members and operationalize a plan.

Patrick Libbey, director of Thurston County Public Health and Social Service Department, Olympia, Wash., and the president of the National Association of County and City Health Officials, recognizes the importance of crisis management plans in the event of natural or terrorism events.

"When you have an earthquake or a flood, you have a very set geographic and time-specific event to respond to. Bioterrorism may roll out very differently," he said.

As a result of national campaigns, numerous agencies are creating more concise and structured plans to augment earlier models. Other agencies are creating disaster plans for the first time. All emergency agencies need to be alerted in the event of a disaster. If a hospital activates as a result of an existing condition, it acts in conjunction with the emergency management agency of that jurisdiction, Libbey explained.

Emergency response systems must work cohesively with each other, he added. "If any of the systems are acting independently, that is where the troubles are. They need to work together to make the earliest and most complete intervention," he said.

Crisis drills help prepare individuals involved to have at least a vague idea of what to expect when something does happen. "The more you can think through a scenario, the needs for accessing resources, and who needs to be involved, the better prepared you will be when a situation does occur," Libbey said.

Public Safety
September 11 was a wake up call, not only to public safety and law enforcement officers but to the health care establishment as well because the country discovered how vulnerable it is to terrorist attacks and how devastating terrorist attacks can be.

We have become more acutely aware of bioterrorism because of the anthrax mailings, subsequent to the 9/11 attacks. The events of September and beyond have lead health care facilities to revamp and reevaluate their existing disaster response capabilities. Everyone has become leery of planes passing overhead and suspicious looking letters in the mailbox.

"The tricky piece is that many biologic agents can be used, and the initial presenting symptoms are very parallel to other on-going ailments," Johnson said. One of the keys is spotting unusual signs, "to notice if there is something specific in the presenting characteristics of the individual."

Secondly, health care personnel should notice if there is something unusual going on within the community. If there are some out of the ordinary occurring, that merits broader attention, Libbey said. When treating any patient today, clinicians need to be more aware of things they have not thought of before.

"I think it's prudent that RTs and Nurses have a knowledge of this," Johnson said. "We don't all have to be experts in neonatal or geriatrics; we just need to know something about bioterrorism."

Top Five Issues for RTs and Nurses In Bio-Terrorism Attacks

1. Have some familiarity with the top seven biological weapons: anthrax, smallpox, botulism, tularemia, bubonic/pneumonic plague, viral encephalitis, and Staphylococcus enterotoxin B. Therapists need to remembers terrorists get creative and may not use traditional agents.

2. Early warning: The therapist is a part of the early warning system of an attack.

3. Necessary Lab Tests: This will help determine which agent was used and what antibiotic will help treat it.

4. Personal protection: Health care professionals need to protect themselves and their facility. There are bioagents which require only standard precautions.

5. Therapeutic Interventions: This may include oxygen and ventilation as necessary, especially with a botulism attack.

Physicians Urged to Learn ABCs Of Highly Infectious Q Fever

Q fever, is not the most deadly agent to be used as a biological weapon, but it could be one of the most effective because of its ability to spread easily through the air and cause widespread debilitating illness, according to a report in the April 20 issue of Bioterror Medical Alert.

Q fever typically occurs when the bacteria is passed from farm animals to humans and can cause flu-like symptoms, in many cases followed by pneumonia and hepatitis. In some cases, infection leads to a particularly hard-to-treat form of endocarditis.

Public health officials worry about the use of Q fever by bioterrorists because it is already known to have been put into a weapon form by Russia and possibly by Iraq. No licensed vaccine exists, although the U.S. army is working rapidly to develop one.

FAQs regarding Anthrax

What is anthrax?

Anthrax is an infectious disease caused by a spore-forming bacterium called Bacillus anthracis. Anthrax is most often seen in hoofed mammals, but may also infect humans.

Are there different types of anthrax?

Three different types of anthrax infections that can occur in humans. These are: inhalation (breathing in spores), cutaneous (deposit of spores into skin that has cuts or abrasions) and intestinal (deposit of spores in intestinal tract due to the eating of contaminated meat)

How often is anthrax disease observed in the U.S?

Anthrax is primarily an occupational disease. It is occasionally identified in individuals exposed to dead animals and animal products or individuals who handle the hides of animals (e.g. farmers) and has been called “wool sorter’s disease.”

In the United States, the incidence of anthrax is extremely low. In the U.S. between 1944-1994, 224 cases of cutaneous anthrax were reported. Until this more recent exposure in Florida, no cases of inhalation anthrax were reported in the U.S. since 1978. Gastrointestinal anthrax is uncommonly reported, although outbreaks have occurred in Africa and Asia.

What are the symptoms of anthrax?

The symptoms of anthrax are different depending on how the disease was contracted Symptoms will generally occur within seven days after exposure, however it may take as long as sixty days.

Specific symptoms are as follows:

 Inhalation anthrax: initial symptoms may resemble the flu and can include, cough, headache, vomiting, chills and general weakness. This can last from a few hours to a few days. The second stage of the illness may occur directly after the first, or following a short recovery period. The second stage develops with sudden fever, shortness of breath, perspiration and shock.

 Cutaneous anthrax: areas of exposed skin, such as arms, hands and face are most frequently affected. Skin infection begins as a raised itchy bump that resembles an insect bite but within 1-2 days develops into a fluid filled bump and then a painless ulcer, usually 1-3 cm in diameter, with a characteristic black necrotic (dying) area in the center.

 Gastrointestinal anthrax: Initial signs of the disease include nausea, loss of appetite, vomiting, fever are followed by abdominal pain, vomiting of blood, and severe diarrhea

How is anthrax diagnosed?

For people who have been exposed to anthrax, laboratory testing must be conducted to perform an accurate diagnosis.

These lab tests may include:

 Examination of tissue under a microscope

 Cultures of a person’s blood or spinal fluid (must be done before antibiotics are given)

 Cultures of tissue or fluid from an affected area

 The polymerase chain reaction (PCR) test can increase small amounts of anthrax DNA to show that the anthrax bacteria are present.

Nasal swabs can be used to detect anthrax spores that may be resting in the nose. Swabs may document exposure, but cannot rule it out, even if they are negative. Nasal swabs are useful to provide clues regarding exposure for investigative purposes, but are not a definitive measure.

How is anthrax spread?

The inhalation form of anthrax is contracted by breathing in spores. The cutaneous form is spread by contact of spores with a break in the skin, such as a scratch. The intestinal form is by eating contaminated meat.

Person to person transmission of anthrax is extremely rare and has only been reported with cutaneous anthrax. Spread of the disease is not a concern in managing or visiting patients with inhalation anthrax.

What is the treatment for anthrax?

The Food and Drug Administration has approved three antibiotics to treat or prevent the development of anthrax in exposed individuals: These are: penicillin, doxycycline, and cirprofloxacin.

Most naturally occurring strains of anthrax are sensitive to these antibiotics. Early antibiotic treatment of anthrax is essential as delay reduces the chances for survival.

Persons will exposure or contact with an environment known or suspected to be contaminated with anthrax should be considered for antibiotic treatment. Exposure or contact, not lab test results, should be the deciding factor for beginning treatment.