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Biological Warfare
History of Issue
- Biological Weapons are NOT new!! - The first Biological Weapon incident: 6th Century B.C. - 3 Major forms of BW before 20th Century - 1925 Geneva Protocol - 1945 1950 THE UNITED STATES BW PROGRAM - 1966 A SIMULATED BW ATTACK - 1969 Thats What they said A REPORT FROM THE WORLD HEALTH ORGANIZATION - 1966-1971 THE UNITED STATES REACTS - 1972 Biological Weapons Convention - BW In Recent Times - CLOSE to HOME - EASY ACCESS FOR ALL!
Chemistry of Issue
How many BW agents exist? The ideal candidate for BW PRODUCTION OF BIOLOGICAL AGENTS Delivery of Agents WERE NOT GOD, ITS NO MORE CONTROLLABLE THAN THE WIND - AND WE ALL FALL DOWN THE INFRASTRUCTURE OF A COUNTRY
Our future enemies strategies Our future enemies resources Our blind spots
Index of Suspicion Are there an unusual number of patients presenting with similar symptoms? Is there an unusual presentation of symptoms? Many cases of unexplained diseases or deaths Patients presenting with similar set of exposures? Diseases normally transmitted by vector not present in area Is this an unexplained case of a previously healthy individual with an apparently infectious disease? Disease outbreak with zoonotic impact
Report ALL suspected or confirmed illness due to these agents to health authorities immediately
Covert
Delayed Delayed
Early
Traditional First Responders
Delayed
Health Care Workers
Pneumonic Anthrax, Tularemia, Plague, Melioidosis Brucellosis, Q Fever, Histoplasmosis Severe atypical CAP (Legionella, Mycoplasma) Hantavirus pulmonary syndrome (HPS)
Prophylaxis
Fluoroquinolones (all) Vibramycin
Hemorrhagic Meningitis
50%
24 - 36 hours
GI
20%
Resolve
Chest Radiograph Inhalation Anthrax Note: widened mediastinum diminished air space
Gastrointestinal Useful in later stages of disease. Collect prior to antibiotic use, Anthrax Blood cultures if possible. Nasal swab Collect only within 24 h of exposure Inhalation Anthrax Sputum Collect if respiratory symptoms occur and sputum is being produced. Provides minimal recovery of agent.
Cultures collected 2-8 days post-exposure may yield the Blood cultures organism. Collect prior to antibiotic use.
Cutaneous Anthrax
black eschar (anthracis, Greek for coal) typical red areola
Arm
Neck
Hemorrhagic Meningitis
Inhalational
2 -3 Sudden days onset Fever, URI syndrome Pharyngitis
Fulminant Pneumonia
Systemic Toxicity
Liver enzymes
6% late meningitis
Standard, contact, and droplet precautions for at least 48 hrs until sputum cultures are negative or pneumonic plague is excluded
Blood cultures Collect at least three cultures 15 20 minutes apart to detect bacteremia Sputum, Minimal recovery from sputum. Bronchial or tracheal aspirate bronchial or preferred because of fewer contaminating organisms Pneumonic tracheal Plague Blood cultures Nasal swab Lymphoid Postmortem tissue Examinations Bone marrow Lung tissue Collect only within 24 h of exposure
Clinical clues
Anthrax
Incubation 1 60 d
Plague
2 10 d 12d High T, tender LN, pneumonia
Brucella
56d Variabel Flu-like, aching joints, myalgia
Duration of 1 2 d illness Major S&S High fever, diff breathing pneumonia & death in 2 3 d
GI symptoms
Low WBC and platelets
Bubonic Staph/streptococcal adenitis Glandular tularemia Cat scratch disease Septicemic Other gram-negative sepsis Meningococcemia RMSF TTP
Nasal swab Collect only within 24 h of exposure Blood Sputum Ulcer Eye Collect or induce specimen from symptomatic patients. Bronchial or tracheal wash may produce better yield. Collect swab specimen from ulcer on skin or throat Collect swab specimen if eyes affected
Late complications
Mild LFT
AT PRESENTATION
3 DAYS LATER
Comments Collect an acute phase sample as soon as possible after onset of disease. Collect convalescent phase sample 10-14 days after the acute sample. (10 -12 ml, 2.5ml minimum)
Clinical clues
Tularemia
Incubation Duration of illness Major S&S 1 10 d 1 3 wks T, headache,
Q-fever
2 14 d 2 14 d Flu-like
Influenza
Rickettsiae Coxiella burnetti Symptoms: acute non-differentiated febrile illness with cough, aches, fever, chest pain, pneumonia Leukocytosis in 30%, elevated LFT Prophylaxis: Vaccine available Chemoprophylaxis:Doxycycline 100 mg bid for at least 7 days but start only 8 12 days post exposure. If started too early, prophylaxis prolongs the disease Treatment: Doxycycline 100 mg bid for 5 - 7 days
Flat Smallpox variants Hemorrhagic Smallpox rapid death before typical lesions
USAMRICD
USAMRICD
Varicella
14-21 days minimal/none centripetal asynchronous 4-7 d p <14 d p
Do not collect or ship any specimens without consultation from MDCH or CDC
Vesicle fluid may be placed as a drop on a clean microscope slide. Store each slide in a separate slide holder. As an alternative, collect fluid from separate lesions onto separate swabs. Include cellular material from base of lesion. Store at 4C for for not more than 6 h. For longer periods store at 20 to 70 C. Aseptically collect material or scrapings and place into a sterile, leakproof, freezable container. Store at 4C for not more than 6 h. For longer periods store at 20 to 70C. Place tissue into a sterile, leakproof, freezable container. Store at 4C for not more than 6 h. For longer periods store at 20 to 70C. Formalin fixed tissue acceptable for histopathology. Place into sterile, freezable, leakproof container. Store frozen at 20 to 70C.
Vesicles
Scabs
Recovery
10 - 37% mortality
Congo fever
Jaundice Syndrome
Do not collect or ship any specimens without consultation from MDCH or CDC
Ebola, Marburg, Argentine, Junin, Bolivian hemorrhagic fevers and Lassa fever Serum Collect 10 12 ml of serum
Approx 12 d
severa1 wks
36d
1 2 wks T, myalgia, prostration. Easy bleeding
Minor S&S
Specific Highly contagious
Ricin
Few hrs 3d Sudden T, weakness, cough, APE Convulsions, liver failure
SEB
3 12 hrs Up to 4 wks T, chills, headache, nausea, cough
Food sample
Wound or tissue
Conclusions
The zebra card Unlikely is not unthinkable Be suspicious Protect thyself Assess the patient Decontaminate as appropriate Diagnose Treat Infection control Alert authorities Spread the gospel