Anthrax How common is anthrax and who can get it?
Anthrax is most common in agricultural regions of the world, where it occurs in animals. These include South and Central America, Southern and Eastern Europe, Asia, Africa, the Caribbean, and the Middle East. When anthrax affects humans, it is usually due to an occupational exposure to infected animals or their products. Workers who are exposed to dead animals and animal products (industrial anthrax) from other countries where anthrax is more common may become infected with B. anthracis. Anthrax in animals rarely occurs in the United States. Most reports of animal infection are received from Texas, Louisiana, Mississippi, Oklahoma and South Dakota
Anthrax also can be used as a biological weapon in a powdered form. Infection is caused by breathing in spores, skin contact with spores, or ingestion of spores that are in the powder form. How is anthrax diagnosed?
Anthrax is diagnosed by isolating B. anthracis from the blood, skin lesions, or respiratory secretions or by measuring specific antibodies in the blood of suspected cases. How is Anthrax transmitted? Can I get it from someone who is infected?
Anthrax cannot be spread from person to person. There are three forms of anthrax infection: cutaneous anthrax, inhalation anthrax and intestinal anthrax.
About 95% of anthrax infections are cutaneous or skin infections which occur when the bacteria enter the skin after handling contaminated wool, hides and goat hair of infected animals. It can also be transmitted in a powdered form. A boil-like lesion appears that eventually forms an ulcer with a black center.
Inhalation anthrax occurs when a person breathes anthrax spores into their lungs. Even after symptoms develop, persons are not contagious to others.
Intestinal anthrax occurs when an individual eats undercooked meat from an animal that has died of anthrax. Anthrax is not spread person-to-person by casual contact, sharing office space, or by coughing or sneezing. What are the symptoms of anthrax?
Symptoms of anthrax usually develop in less than seven days of exposure and most cases occur within 48 hours. Cutaneous anthrax occurs when the bacteria enter the skin through a cut or abrasion. Skin infection begins as a raised, itchy bump which becomes a blister and then an ulcer-like lesion appears with a black area in the center. Death is rare with cutaneous anthrax when treated appropriately with antibiotics.
Inhalation anthrax occurs when the spores are inhaled and get into the lungs. Initial symptoms of inhalation anthrax include fever, fatigue, cough and difficulty breathing. Congestion is not usually associated with inhalation anthrax. Without immediate treatment, inhalation anthrax is often fatal.
Intestinal anthrax is caused by the consumption of meat from animals that have died from anthrax. Symptoms include nausea, loss of appetite, vomiting and fever. The symptoms are followed several days later by abdominal pain, vomiting of blood and severe diarrhea. How do I help my children cope with the threat of Anthrax?
When should I be concerned about a letter or package?
The U.S. Postal Service has provided some typical characteristics which should trigger suspicion of letters or parcels:
- Have any powdery substance on the outside.
- Are unexpected or from someone unfamiliar to you.
- Have excessive postage, handwritten or poorly typed address, incorrect titles or titles with no name, or misspellings of common words.
- Are addressed to someone no longer with your organization or are otherwise outdated.
- Have no return address, or have one that can't be verified as legitimate.
- Are of unusual weight, given their size, or are lopsided or oddly shaped.
- Have an unusual amount of tape.
- Are marked with restrictive endorsements, such as "Personal" or "Confidential."
- Have strange odors or stains.
What should I do if I receive a suspicious letter or package?
Following is a list of steps you should take if you have received a suspicious letter or package where you feel you may have been exposed to anthrax.
- Do not open it.
- If it has already been opened and powder spills out, do not clean it up.
- Keep others away from the area.
- Immediately wash your hands with soap and water.
- Call your local law enforcement agency or 911 to report the incident.
- If the specimen is laboratory-confirmed with anthrax, local and state health officials will promptly notify all individuals who may have come in contact with the specimen. If it has been determined that you have been exposed to anthrax, you will be treated with antibiotics.
Do I need a vaccine or antibiotics to protect myself against anthrax?
The anthrax vaccine is not available or recommended for the public. This vaccine is administered to military personnel at high risk for exposures in combat settings. For additional information, consult the current U.S. Public Health Service's Advisory Committee on Immunization Practices recommendations on anthrax vaccination.
Physicians can prescribe effective antibiotics to treat anthrax. If left untreated, the disease can be fatal. The Department does not recommend the use of antibiotics for people who have no symptoms suggestive of anthrax or known exposure. In addition, using antibiotics without a physician's prescription may cause serious reactions and potentially dangerous interference with other medications. Botulism How common is botulism?
In the United States an average of 110 cases of botulism are reported each year. Of these, approximately 25% are food-borne, 72% are infant botulism, and the rest are wound botulism. Outbreaks of food-borne botulism involving two or more persons occur most years and usually caused by eating contaminated home-canned foods. The number of cases of food-borne and infant botulism has changed little in recent years, but wound botulism has increased because of the use of black-tar heroin, especially in California. Arizona usually reports 1 to 3 cases per year, the majority of which are infant botulism. How would botulism be used as a bioterrorism weapon?
A fourth type of botulism, not mentioned above, is inhalational botulism. This form does not occur in nature, however, the Department of Defense has documented the production of botulinum toxin biowarfare weapons by Iraq and the former Soviet Union. These weapons would distribute aerosolized botulinum toxin, which would result in inhalational botulism. Bioterrorism also could come in the form of food contamination, resulting in food-borne botulism. What are the symptoms of botulism?
The classic symptoms of botulism include double vision, blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, and muscle weakness. Infants with botulism appear lethargic, feed poorly, are constipated, and have a weak cry and poor muscle tone. These are all symptoms of the muscle paralysis caused by the bacterial toxin. If untreated, these symptoms may progress to cause paralysis of the arms, legs, trunk and respiratory muscles. Death due to respiratory failure, occurs in about 8% of cases. In food-borne botulism, symptoms generally begin 18 to 36 hours after eating a contaminated food, but they can occur as early as 6 hours or as late as 10 days. Inhalational botulism would generally show signs 24 - 36 hours after exposure. How is botulism diagnosed?
Physicians may consider the diagnosis if the patient's history and physical examination suggest botulism. However, these clues are usually not enough to allow a diagnosis of botulism. There are other diseases, such as stroke, that have similar symptoms, and special tests may be needed to exclude these other conditions. The most direct way to confirm the diagnosis is to demonstrate the botulinum toxin in the patient's serum or stool by injecting serum or stool into mice and looking for signs of botulism. The bacteria can also be isolated from the stool of persons with food-borne and infant botulism. These tests can be performed at CDC and will soon be available at the Arizona State Health Laboratory. How can botulism be treated?
The respiratory failure and paralysis that occur with severe botulism may require a patient to be on a breathing machine (ventilator) for weeks, plus intensive medical and nursing care. After several weeks, the paralysis slowly improves. If diagnosed early, food-borne and wound botulism can be treated with an antitoxin which blocks the action of toxin circulating in the blood. This can prevent patients from worsening, but recovery still takes many weeks. Physicians may try to remove contaminated food still in the gut by inducing vomiting or by using enemas. Wounds should be treated, usually surgically, to remove the source of the toxin-producing bacteria. Good supportive care in a hospital is the mainstay of therapy for all forms of botulism. Currently, antitoxin is not routinely given for treatment of infant botulism. How can botulism be prevented?
Persons who do home canning should follow strict hygienic procedures to reduce contamination of foods. Oils infused with garlic or herbs should be refrigerated. Potatoes which have been baked while wrapped in aluminum foil should be kept hot until served or refrigerated. Because the botulism toxin is destroyed by high temperatures, persons who eat home-canned foods should consider boiling the food for 10 minutes before eating it to ensure safety. Instructions on safe home canning can be obtained from county extension services or from the US Department of Agriculture. Because honey can contain spores of C. botulinum and this has been a source of infection for infants, children less than 12 months old should not be fed honey. Honey is safe for persons 1 year of age and older. Wound botulism can be prevented by promptly seeking medical care for infected wounds and by not using injectable street drugs. Brucellis How is brucellosis transmitted?
Brucellosis is transmitted to humans through contact with tissues or bodily fluids of animals infected with Brucella bacteria. Therefore, persons at highest risk for brucellosis are those who work with agricultural animals (e.g., cattle, pigs, sheep, and goats) that are infected, such as veterinarians and ranchers. Brucellosis also is spread by the ingestion of unpasteurized dairy products, causing a risk to persons who consume raw milk or cheeses made with raw milk. Airborne infection has occurred in pens and stables of infected animals and in laboratories. Brucellosis may also be transmitted to humans if they are inadvertently exposed to live brucellosis vaccine by a needlestick or other accident. Where does brucellosis occur?
The infection occurs worldwide, and is most common in the Mediterranean countries of Europe and Africa, the Middle East, India, central Asia, Mexico, and Central and South America. In the United States, most cases are reported from California, Florida Texas, and Virginia. In Arizona, 35 cases have been identified over the last twenty years. Most of these cases are associated with consumption of unpasteurized dairy products brought into Arizona from Mexico. How is brucellosis associated with bioterrorism?
Brucella has long been considered a potential candidate for bioterrorism, as it has been weaponized by the former Soviet Union. The organisms are readily freeze-dried, enhancing their infectivity. Brucella can survive in the environment for up to two years, under specific conditions (i.e., darkness, cool temperatures, and high CO2), causing continuing threat to both man and animal. When used as a bioterrorism agent, Brucella would likely be delivered by the aerosol route. What are the symptoms of brucellosis?
This incubation period for this disease can be highly variable, but symptoms usually appear within one to two months after exposure. Brucellosis is characterized by a fever which may be continuous, intermittent or irregular. Some other possible symptoms include headache, weakness, sweating, chills, arthralgia (pain in the joints), depression, weight loss and generalized aching. This disease may last for days, months, or as long as a year if untreated. How is brucellosis diagnosed?
Laboratory diagnosis may be made by several methods, including: 1) isolation of bacteria from the Brucella genus from a bacterial culture; 2) an increase over time in antibodies in the blood that are specific for Brucella; or 3) the demonstration by immunofluorescence of bacteria from the Brucella genus. What is the treatment for brucellosis?
Doctors can prescribe antibiotics, including tetracycline and tetracycline plus streptomycin, for brucellosis. Early diagnosis leading to rapid treatment is needed to prevent chronic infection. How can brucellosis be prevented?
The most important steps to prevent brucellosis in humans are those necessary to control brucellosis in animals. The Brucellosis Eradication Program was established to eradicate the disease from cattle in the United States. From 1956 to 1998, the number of known brucellosis-affected herds decreased from 124,000 to 15. While brucellosis is rare in the United States, one step everyone can take to prevent possible exposure is to avoid consuming raw milk or cheeses made with raw milk, especially those coming from Latin America. Cholera How does a person get cholera?
A person may get cholera by drinking water or eating food contaminated with the cholera bacterium. In an epidemic, the source of the contamination is usually the feces of an infected person. The disease can spread rapidly in areas with inadequate treatment of sewage and drinking water. The cholera bacterium also may live in the environment in brackish rivers and coastal waters. Shellfish eaten raw have been a source of cholera, and a few persons in the United States have contracted cholera after eating raw or undercooked shellfish from the Gulf of Mexico. The disease is not likely to spread directly from one person to another; therefore, casual contact with an infected person is not a risk for becoming ill. How would cholera be used for bioterrorism?
Cholera does not easily spread from human to human, therefore, it appears, that for it to be an effective biological weapon, major drinking supplies would have to be heavily contaminated. Contamination of drinking water recently caused a major outbreak in Peru and neighboring countries, with an estimated 100 million people exposed resulting in 250,000 symptomatic cases. What is the risk for cholera in the United States?
n the United States, cholera was prevalent in the 1800s but has been virtually eliminated by modern sewage and water treatment systems. However, as a result of improved transportation, more persons from the United States travel to parts of Latin America, Africa, or Asia where epidemic cholera is occurring. U.S. travelers to areas with epidemic cholera may be exposed to the cholera bacterium. In addition, travelers may bring contaminated seafood back to the United States; food-borne outbreaks have been caused by contaminated seafood brought into this country by travelers. Cholera cases rarely occur in Arizona and are usually associated with travelers to countries with ongoing cholera problems. Is a vaccine available to prevent cholera?
A vaccine for cholera is available; however, it gives only a brief and incomplete immunity. There are no cholera vaccination requirements for entry or exit in any Latin American country or the United States. Can cholera be treated?
Cholera can be simply and successfully treated by immediate replacement of the fluid and salts lost through diarrhea. Patients can be treated with oral re-hydration solution, a prepackaged mixture of sugar and salts to be mixed with water and drunk in large amounts. This solution is used throughout the world to treat diarrhea. Severe cases also require intravenous fluid replacement. With prompt re-hydration, fewer than 1% of cholera patients die. Antibiotics shorten the course and diminish the severity of the illness, but they are not as important as re-hydration. Persons who develop severe diarrhea and vomiting in countries where cholera occurs should seek medical attention promptly. Ebola What is the Ebola virus?
The Ebola virus is a member of a family of RNA viruses known as filoviruses. When magnified several thousand times by an electron microscope, these viruses have the appearance of long filaments or threads. Ebola virus was discovered in 1976 and was named for a river in Zaire, Africa, where it was first detected. How common is the disease?
Until recently, only a few outbreaks of Ebola hemorrhagic fever among people had been reported. The first two outbreaks were in 1976: one in Zaire and one in western Sudan. These were large outbreaks, resulting in more than 550 cases and 340 deaths. A third outbreak, in 1979 in Sudan, was smaller, with 34 cases and 22 fatalities. More recently, outbreaks have also occurred again in Zaire in 1995-6, with 352 cases and 276 deaths, and in Gabon in 1996, with 60 cases and 45 deaths. During each of these outbreaks, a majority of cases occurred in hospital settings under the challenging conditions of the developing world. These conditions, including a lack of adequate medical supplies and the frequent reusing of needles and syringes, played a major role in the spread of disease. The outbreaks were quickly controlled when appropriate medical supplies and equipment were made available and quarantine procedures were used. Has Ebola ever been found in the United States?
A subtype of the virus, Ebola-Reston, has been found in imported monkeys at quarantine facilities in Virginia, Pennsylvania, and Texas. These monkeys all originated from the Philippines, where the virus has been identified in monkeys at an export facility. This subtype, however, does not appear to cause disease in humans. What is the reservoir for Ebola?
The source of the Ebola virus in nature remains unknown. In an attempt to identify the source, investigators tested thousands of specimens from animals and arthropods captured near the outbreak areas, but their efforts were unsuccessful. Monkeys, like humans, appear to be susceptible to infection and may serve as a source of virus if infected. The outbreak in Gabon was linked to eating a chimpanzee and a single human case in Ivory Coast in 1994 was associated with chimpanzees. What are the symptoms of Ebola hemorrhagic fever?
Symptoms of Ebola hemorrhagic fever begin 4 to 16 days after infection. Persons develop fever, chills, headaches, muscle aches, and loss of appetite. As the disease progresses, vomiting, diarrhea, abdominal pain, sore throat, and chest pain can occur. The blood fails to clot and patients may bleed from injection sites as well as into the gastrointestinal tract, skin, and internal organs. How is the Ebola virus spread from person to person?
Ebola virus is spread through close personal contact with a person who is very ill with the disease. In previous outbreaks, person-to-person spread frequently occurred among hospital care workers or family members who were caring for an ill person infected with Ebola virus. Transmission of the virus has also occurred as a result of hypodermic needles being reused in the treatment of patients. Reusing needles is a common practice in developing countries, such as Zaire and Sudan, where the health care system is underfinanced. Medical facilities in the United States do not reuse needles.
Ebola virus can also be spread from person to person through sexual contact. Close personal contact with persons who are infected but show no signs of active disease is very unlikely to result in infection. Patients who have recovered from an illness caused by Ebola virus do not pose a serious risk for spreading the infection. However, the virus may be present in the genital secretions of such persons for a brief period after their recovery, and therefore it is possible they can spread the virus through sexual contact. How is Ebola hemorrhagic fever diagnosed?
A diagnosis is made by detection of Ebola antigens, antibody, or genetic material, or by culture of the virus from these sources. Diagnostic tests are usually performed on clinical specimens that have been treated to inactivate (kill) the virus. Research on Ebola virus must be done in a special high-containment laboratory to protect scientists working with infected tissues. How do health officials control outbreaks?
Previous outbreaks of Ebola hemorrhagic fever have been limited. These outbreaks were successfully controlled through the isolation of sick persons in a place requiring the wearing of mask, gown, and gloves; careful sterilization of needles and syringes; and proper disposal of waste and corpses. How do hospital personnel isolate an ill person?
Hospital personnel isolate ill persons through a method called "barrier technique." Barrier technique includes the following actions: 1) doctors and nurses wear gowns, mask, gloves, and goggles when caring for patients; 2) the patients visitors are restricted; 3) disposable materials are removed from the room and burned after use; 4) all reusable materials are sterilized before reuse; and 5) since the virus is easily destroyed by disinfectants, all hard surfaces are cleaned with a sanitizing solution. Plague How common is plague in the U.S.?
Human plague in the United States has occurred as mostly scattered cases in rural areas (an average of 10 to 20 persons each year) in the western half of the U. S.. Generally, plague is most common in the southwestern states, particularly New Mexico and Arizona. Globally, the World Health Organization reports 1,000 to 3,000 cases of plague every year. How common is plague in Arizona?
Arizona has had 62 plague cases reported over the last fifty years, giving an average of 1 to 2 cases per year, with much higher numbers during outbreak years. Plague is endemic in the natural rodent populations in northern Arizona, which provides for a constant level of risk for people exposed to rodents, rodent burrows, and fleas. Most cases in Arizona are seen in the northwest portion of the state, although cases can likely occur anywhere in the state above 4000 feet of elevation. What is the concern for plague and bioterrorism?
Plague has been used as a bioweapon of war dating back to the Middle Ages, when foreign invaders would catapult the corpses of plague victims over castle walls. During WWII, the Japanese released millions of plague infected fleas over villages in China. Both the United States (until the 1960s) and the former Soviet Union (until the 1990's) developed plague as a biowarfare agent. During the 1980's the Soviet Union maintained a quota of twenty tons of weaponized plague every year. Other countries have been, or are suspected of, developing this agent as a weapon. Who is at risk for getting plague?
In the U. S., most cases are associated with living in rural areas or participating in outdoor recreational activities, such as hiking and camping. People who are most at risk are those that are exposed to wild rodents, rodent burrows or fleas. These risks can be lessened by not handling wild rodents and wearing insect repellent when visiting or working in areas where plague might be present. Gloves should be worn when skinning or cleaning game. Also, pets should be prevented from roaming, especially in areas near rodent burrows. What is the basic transmission cycle?
Fleas become infected by feeding on rodents, such as the chipmunks, prairie dogs, ground squirrels, mice, and other mammals that are infected with the bacteria Y. pestis. Infected fleas transmit the plague bacteria to humans and other mammals during the feeding process. The plague bacteria are maintained in the blood systems of rodents. When do most cases occur?
Most cases occur in the spring and summer months, although plague can be acquired at anytime during the year. What are the signs and symptoms of plague?
A typical sign of the most common form of human plague is a swollen and very tender lymph gland, accompanied by pain. The swollen gland is called a "bubo" (hence the term "bubonic plague"). Bubonic plague should be suspected when a person develops a swollen gland, fever, chills, headache, and extreme exhaustion, and has a history of possible exposure to infected rodents, rabbits, or fleas. Infection of the lungs, either through droplet inhalation or secondary infection, causes pneumonic plague, a severe respiratory illness. Pneumonic plague patients may experience high fever, chills, cough, and breathing difficulty, and expel bloody sputum. What is the incubation period for plague?
A person usually becomes ill with bubonic plague 2 to 6 days after being infected. When bubonic plague is left untreated, plague bacteria invade the bloodstream. When plague bacteria multiply in the bloodstream, they spread rapidly throughout the body and cause a severe and often fatal condition. If plague patients, especially those with pneumonic plague, are not given specific antibiotic therapy, the disease can progress rapidly to death. What is the mortality rate of plague?
About 14% (1 in 7) of all plague cases in the United States are fatal. The fatality rate for untreated cases of pneumonic plague is nearly 100% How is plague treated?
According to treatment experts, a patient diagnosed with suspected plague should be hospitalized and medically isolated. Laboratory tests should be done, including blood cultures for plague bacteria and microscopic examination of lymph gland, blood, and sputum samples. Antibiotic treatment should begin as soon as possible after laboratory specimens are taken. Streptomycin is the antibiotic of choice. Gentamicin is used when streptomycin is not available. Tetracyclines and chloramphenicol are also effective. Persons who have been in close contact with a plague patient, particularly a patient with plague pneumonia, should be identified and evaluated. The U.S. Public Health Service requires that all cases of suspected plague be reported immediately to local and state health departments and that the diagnosis be confirmed by CDC. As required by the International Health Regulations, CDC reports all U.S. plague cases to the World Health Organization. Q Fever How is Q Fever spread?
The organisms are inhaled along with dust from areas contaminated by placental tissues, birth fluids, and excreta of infected animals. Direct contact with infected animals and other contaminated materials, such as wool, straw, fertilizer, and laundry of infected people has been associated with spread of the disease. Raw milk from infected cows contains organisms and may be another source of infection. Direct transmission from blood or bone marrow transfusion also has been reported. How is Q Fever associated bioterrorism?
The organism, C. burnetti, is resistant to heat and drying and can survive in the environment for months. It is also highly infectious by the aerosol route. Due to these features, Q Fever has been investigated and developed as a bioweapon. It’s use would not be to generate mass fatalities, but rather to act as an incapacitating agent. Who can get Q Fever?
Anybody can get Q Fever but it is found most often in areas where animals may be infected. Laboratory personnel, who work with C. burnetii, veterinarians, meat workers, sheep and dairy workers and farmers are at the most risk. What animals are usually associated with Q Fever?
The organisms are found in sheep, cattle, goats, cats, dogs, some wild animals, birds, and ticks. Infected animals, including sheep and house cats, usually do not appear sick, but shed high levels of organisms during the birthing process. Ticks are not considered a major source of infection in the U.S. What are the symptoms of Q Fever?
After an incubation period of 2 to 3 weeks, some people have a sudden onset of illness with chills, severe headache, weakness, fatigue, and severe sweats. Others may not have any noticeable symptoms or have a general "fever of unknown origin." The fatality rate is generally less than 1%, even in untreated cases, although it may be higher in individuals who go on to develop endocarditis, a potential long term manifestation of Q fever. How is Q Fever diagnosed?
Most diagnoses are based on serologic tests that identify antibody to C. burnetii in the blood. Isolation of the organism is usually impractical, as the organism is difficult to grow in the laboratory, and is extremely infectious to laboratory personnel. What is the treatment for Q Fever?
Treatment is usually with antibiotics such as tetracycline or chloramphenicol started during illness and continued for several days after fever is gone. Is there a vaccine available?
There is no commercially available vaccine in the U.S., although a Q fever vaccine is licensed in Australia. The U.S. Army, however, has an investigational vaccine that is available for its personnel and others who are most at risk, such as laboratory workers. How can Q Fever be prevented?
Prevention is through education of the public on sources of infection and the need for proper disinfection and disposal of animal products after the birthing process. Those operating cow and sheep sheds, barns and laboratories which use such animals should restrict access to these areas. Only pasteurized milk from cows, goats and sheep should be consumed. Ricin How is ricin associated with bioterrorism?
Ricin has been used as a biological weapon for assassinations in the past. It is toxic by numerous exposure routes, however, its use by bioterrorists might involve poisoning of water or foodstuffs, inoculation via ricin-laced projectiles, or aerosolization of liquid ricin or lyophilized powder. Waste from the commercial production of castor oil contains 5% ricin, making it easy for such a substance to fall into the hands of bioterrorists. What are the signs of ricin intoxication?
When inhaled as a small particle aerosol, ricin would likely produce symptoms within 8 hours. Fever, cough, difficulty breathing, nausea, and chest tightness are followed by profuse sweating, skin turning blue, low blood pressure, and finally respiratory failure and circulatory collapse. Time to death would likely be 36-72 hours, depending on the dose received. How is ricin intoxication diagnosed?
The diagnosis of ricin is largely based on symptoms and should be suspected in a setting of mass casualties with a similar and appropriate clinical picture. Failure to respond to antibiotics helps to differentiate ricin exposure from lung infections produced by bacterial agents. A blood antibody test exists but is not readily available. Can ricin intoxication be treated?
No specific treatment exists, and care is thus supportive treatment of symptoms. Is a vaccine available?
No specific vaccine or antitoxin exists. A protective mask would offer protection from aerosol exposure. Smallpox Is Arizona prepared for a smallpox outbreak?
Arizona has been testing bioterrorism response plans for over two years now, at both the state and local level. Recently, the Department participated in a statewide training exercise to test the coordination and distribution of the National Pharmaceutical Stockpile, which could be utilized in an emergency. The Arizona Department of Health Services has submitted a plan to the US. Centers for Disease Control and Prevention outlining the State's response to a suspected case of smallpox. A plan has also been submitted which details a gradual approach to the vaccination of health care workers and public health workers who would investigate a possible smallpox outbreak and would treat suspect cases of smallpox. The Department is working with all county health departments and other stakeholders to ensure coordination of bioterrorism response plans throughout the state. Are we expecting a smallpox attack?
We are not expecting a smallpox attack, but the recent events that include the use of biological agents as weapons have heightened our awareness of the possibility of such an attack. If someone comes in contact with smallpox, how long does it take to show symptoms?
The incubation period is about 12 days (range: 7 to 17 days) following exposure. Initial symptoms include high fever, fatigue, and head and back aches. A characteristic rash, most prominent on the face, arms, and legs, follows in 2-3 days. The rash starts with flat red lesions that evolve at the same rate. Lesions become pus-filled after a few days and then begin to crust early in the second week. Scabs develop and then separate and fall off after about 3-4 weeks. Is smallpox fatal?
The majority of patients with smallpox recover, but death may occur in up to 30% of cases. How is smallpox spread?
In the majority of cases, smallpox is spread from one person to another by infected saliva droplets that expose a susceptible person having face-to-face contact with the ill person. In very rare circumstances, aerosol transmission has occurred between people sharing the same airspace, such as within a hospital ward. People with smallpox are not infectious until the onset of the rash. During the early stages of the rash, persons infected with smallpox are most infectious, because that is when the largest amount of virus is present in saliva. However, some risk of transmission lasts until all scabs have fallen off.
Contaminated clothing or bed linen could also spread the virus. Special precautions need to be taken to ensure that all bedding and clothing of patients are cleaned appropriately with bleach and hot water. Disinfectants such as bleach and quaternary ammonia can be used for cleaning contaminated surfaces. If smallpox is discovered or released in a building, or if a person develops symptoms in a building, how can that area be decontaminated?
The smallpox virus is fragile and in the event of an aerosol release of smallpox, all viruses will be inactivated or dissipated within 1-2 days. Buildings exposed to the initial aerosol release of the virus do not need to be decontaminated. By the time the first cases are identified, typically 2 weeks after the release, the virus in the building will be gone. Infected patients, however, will be capable of spreading the virus and possibly contaminating surfaces while they are sick. Therefore, standard hospital grade disinfectants such as quaternary ammonias are effective in killing the virus on surfaces should be used for disinfecting hospitalized patients' rooms or other contaminated surfaces. Although less desirable because it can damage equipment and furniture, hypochlorite (bleach) is an acceptable alternative. In the hospital setting, patients' linens should be autoclaved or washed in hot water with bleach added. Infectious waste should be placed in biohazard bags and autoclaved before incineration. What should people do if they suspect a patient has smallpox or suspect that smallpox has been released in their area?
Report suspected cases of smallpox or suspected intentional release of smallpox to your local health department. The local health department is responsible for notifying the state health department, the FBI, and local law enforcement. The state health department will notify the CDC. How can we stop the spread of smallpox after someone comes down with it?
Patients infected with smallpox and exhibiting the associated rash are capable of spreading the virus. Patients should be placed in medical isolation so that they will not continue to spread the virus. In addition, people who have come into close contact with smallpox patients should be vaccinated immediately and closely watched for symptoms of smallpox. Vaccine and isolation are the strategies for stopping the spread of smallpox. Is there a test to indicate whether smallpox is in the environment like there is for anthrax?
Scientists believe that if smallpox virus is released as an aerosol and not exposed to UV light, it may persist for as long as 24 hours or somewhat longer under favorable conditions. However, by the time patients become ill, which takes about 10 days to 12 days after infection with the virus, and it has been determined that an aerosol release of smallpox virus had occurred, there would be no viable smallpox virus left in the environment to detect. Trying to detect the virus everywhere at all times without any indications of any illness in people would not be feasible.
The occurrence of smallpox infection among people who handled laundry from infected patients is well documented, and it is believed that virus in such material remains viable for extended periods. In this situation, the virus could be detected in the environment, but investigators would already know it was there because of the presence of the associated illness.
In studies conducted during the smallpox eradication program and by surveillance for cases in newly smallpox-free areas it was reasoned that if the virus were able to persist in nature and infect humans, there would be cases occurring for which no source could be identified. Cases of this type were not observed. When cases were found, there were human cases in people who had direct contact with another infected person.
Is smallpox contagious before the smallpox symptoms show?
Smallpox patients are most infectious during the first week of the rash. At this time, patients have sores in their mouths. These sores release smallpox virus into the patient's saliva. The virus may spread through the air when the infected person breathes, talks, laughs, or coughs. A patient is no longer infectious after all scabs have fallen off, usually about 3 or 4 weeks after the start of the rash.
Symptoms of smallpox begin 12-14 days (range 7-17 days) after exposure. The disease starts with 2-3 days of high fever and extreme tiredness with severe headache and backache. The rash usually begins about 2-4 days after the fever and, at first, is a few red spots on the face and forearms and in the mouth. It then spreads to the trunk and legs. Sores might form on the palms and soles as well. By the fourth day of rash, the spots have turned to blisters (vesicles), and by the seventh day the blisters turn to pustules (blisters filled with pus). Smallpox skin sores are deeply embedded in the skin (dermis) and feel like firm round objects in the skin. The pustules form scabs by the fourteenth day. As the sores heal, the scabs separate and pitted scarring gradually develops. Smallpox Vaccine Is Arizona receiving any of the nation's smallpox vaccine?
The Arizona Department of Health Services has recently submitted a plan to the federal government, which outlines the voluntary vaccination of certain public health and health care workers. At the present time no smallpox vaccine is available to this state, but the Federal Government is planning to make the vaccine available to limited groups in our state, according to our smallpox plan. What should I know about the smallpox vaccine?
Vaccination for the general public is not recommended at this time. In the absence of a confirmed case of smallpox anywhere in the world, there is no need to be vaccinated. The federal government has recommended that certain public health and health care workers be vaccinated in order to effectively respond to a smallpox outbreak, should it occur. These vaccinations may begin in early 2003. There can be severe side effects to the smallpox vaccine, which is another reason we do not recommend vaccination for the public
If I am concerned about a smallpox attack, can I go to my doctor and request the smallpox vaccine?
In the United States, routine vaccination against smallpox ended in 1972. Since the vaccine is no longer recommended, the vaccine is not available. The CDC maintains an emergency supply of vaccine that can be released if necessary. If someone is exposed to smallpox, is it too late to get a vaccination?
Vaccination within 3 days of exposure will prevent or significantly modify smallpox in the vast majority of persons. Vaccination 4 to 7 days after exposure offers some protection from disease or may modify the severity of disease. If people got the vaccination in the past when it was used routinely, will they be immune?
Not necessarily. Routine vaccination against smallpox ended in 1972. The level of immunity, if any, among persons who were vaccinated before 1972 is uncertain; therefore, these persons are assumed to be susceptible. For those who were vaccinated, it is not known how long immunity lasts. Most estimates suggest immunity from the vaccination lasts 3 to 5 years. This means that nearly the entire U.S. population has partial immunity at best. Immunity can be boosted effectively with a single revaccination. Prior infection with the smallpox disease, however, grants lifelong immunity. How many people have not had the vaccination?
Approximately half of the U.S. population has never been vaccinated. Is it possible for people to get smallpox from the vaccination?
No, smallpox vaccine does not contain smallpox virus but another live virus called vaccinia virus. Since this virus is related to smallpox virus, vaccination with vaccinia provides immunity against infection from smallpox virus. How safe is the smallpox vaccine?
Smallpox vaccine is considered very safe. However, some people with pre-existing conditions such as eczema or immune system disorders have a higher risk for having complications from the vaccine. Adverse reactions have been known to occur that range from mild rashes to rare fatal encephalitis and disseminated vaccinia. Smallpox vaccine should not be administered to persons with a history or presence of eczema or other skin conditions, pregnant women, or persons with immunodeficiency diseases and among those with suppressed immune systems as occurs with leukemia, lymphoma, generalized malignancy, or solid organ transplantation. Anyone who falls within these categories, or lives with someone who falls into one of these categories, should NOT get the smallpox vaccine unless they are exposed to the disease. Will the antibiotic ciprofloxacin protect me against smallpox?
No. Because smallpox is a virus, antibiotics such as ciprofloxacin will not fight the smallpox infection. However, smallpox vaccination-even after exposure- is effective in preventing or lessening the severity of the disease. If the decision is made that everyone needs to be vaccinated, how will this occur and who will pay for it?
There will be a systematic administration of the vaccine that will be paid for by the United States government.
When will additional smallpox vaccine be ready?
The production of a new, and somewhat safer, smallpox vaccine is currently underway. It is estimated that the new vaccine may be available in late 2003 or early 2004. At the present time, there is enough smallpox vaccine for every American in an emergency. A recent discovery of a large stockpile of effective vaccine, along with evidence that the vaccine can be diluted, ensures that there is enough existing vaccine to respond to a large-scale smallpox outbreak. What is the difference between a "live vaccine" and a "killed vaccine"?
There are two basic types of vaccines: live (live-attenuated) and killed (inactivated).
Live vaccines are made from viruses or bacteria, sometimes called "wild," that cause disease. These wild viruses or bacteria are weakened in a laboratory. Live vaccine works when the virus replicates in the body of a vaccinated person. This turns on the immune system and prepares the body to fight the disease when exposed to it. The immune response to a live vaccine is almost the same as from natural infection. Sometimes a person getting a live vaccine has mild symptoms of the disease.
Live vaccines rarely may cause severe or fatal reactions as a result of uncontrolled replication (growth) of the vaccine virus. This may occur in persons with weak immune systems, including persons with leukemia or human immunodeficiency virus (HIV) infection or persons undergoing treatment with certain drugs. This is why it is so important to know a person's health status before giving a live vaccine.
Killed vaccines are made by growing bacteria or virus and then treating it with heat and/or chemicals (usually formalin). These vaccines cannot cause disease from infection, even in someone with a weakened immune system.
Killed vaccines always require multiple doses. The first dose does not produce protective immunity. It "primes" the immune system, getting it ready to react. A protective immune response develops after the second or third dose.
If someone had smallpox once, are they immune? Would they need the vaccine?
Most people who have had smallpox disease are protected from the disease for life and do not need to be vaccinated. However, few people living in the United States have had smallpox. Is it possible for someone to receive the smallpox vaccine and have it not "take," i.e., work? How does someone who has been vaccinated for smallpox know that he or she is immune or that the vaccine has "taken"?
Evaluating a person's immunity against smallpox is difficult. In the past, a process called "re-challenging" was the only way to know for sure that a person was still protected. Smallpox vaccination causes a small blister or vesicle to form at the site of the vaccination. When a vaccinated person was "challenged" with a second dose of vaccine in another location and did not develop the telltale scar, then that person was thought to be immune to the virus. The formation of a second blister or vesicle indicated the first vaccination did not take and resulted in a lack of immunity.
Today, it is possible to gauge immunity induced by the smallpox vaccine by measuring levels of antibodies to the virus. However, the absence of antibodies to smallpox on a blood test does not mean that there is not some lingering immunity to the virus, since a person could still have a type of immunity called cellular immunity. Even in the absence of antibodies, the body's cells may be sensitized to smallpox and capable of triggering a protective reaction when exposed to the virus. Are diluted doses of smallpox vaccine as effective?
It is possible that diluted (i.e., watered-down) smallpox vaccine may also be effective in providing immunity. The initial results have shown that diluted vaccine at various strengths is still effective in providing immunity to smallpox. It is possible that diluted smallpox vaccine may also be effective as a booster shot. Results from the dilution studies will help make this determination. What is the smallpox vaccine made of?
Dryvax is the name of the smallpox vaccine that is currently licensed for use in the United States. It is a live-virus preparation of infectious vaccinia virus made by Wyeth Laboratories, Inc., Marietta, Pennsylvania. Vaccinia vaccine does not contain smallpox (variola) virus and cannot cause smallpox. Is there a risk of accidental exposure to persons involved in the production of smallpox vaccine?
Persons involved in the production of smallpox vaccine will not contract smallpox because the vaccine does not contain smallpox virus. The vaccine contains another live virus called vaccinia virus. Because vaccinia is closely related to smallpox, vaccination with that virus provides immunity against infection from smallpox virus.
However, as with all live-virus vaccines, the vaccinia vaccine does carry some risks. To minimize any risk of infection, the limited number of facilities involved in the production of smallpox vaccine should always observe appropriate biosafety guidelines and adhere to published infection-control procedures and recommendations for working with the vaccine virus strain. Why are health responders being vaccinated against smallpox, but the general public is not?
Recently, the President announced the federal policy on smallpox vaccinations. The plan outlines the phased-in approach to vaccinating specific health care and public health workers who would respond to and treat smallpox cases. These vaccinations could begin in early 2003. However, in the absence of a confirmed case of smallpox anywhere in the world, there is no need for the general public to be vaccinated against smallpox. The Centers for Disease Control and Prevention (CDC) maintains an emergency supply of vaccine that can be released if necessary. For smallpox, post-exposure vaccination is effective. In the event of an outbreak, CDC has clear guidelines to swiftly provide vaccine to people exposed to this disease. In addition, Tommy Thompson, U.S. Secretary of Health and Human Services, recently announced plans to accelerate production of a new smallpox vaccine.
Staphylococcal Enterotoxin B How is SEB associated with bioterrorism?
SEB was explored as a possible bioweapon by the United States, presumably the former Soviet Union did also. A bioterrorism attack with aerosol delivery of SEB to the respiratory tract would produce a distinct syndrome causing significant illness and potential death. The sabotage of food and/or water with SEB is also thought to be a possibility for terrorist attack. Although an attack with SEB, especially by food contamination, may not cause many fatalities, it could incapacitate 80% of the public in the area of attack. In rare cases, especially with an aerosol attack, the effect of the toxin may be more severe, leading to shock and death. What are the symptoms of SEB intoxication?
Symptoms of inhaled SEB would be expected to appear 1-12 hours after exposure and would consist of sudden onset of a high fever of 103-106 F, chills, headache, muscle aches, a dry cough and possibly an inflammation of the lining of the eyelids. In a few cases there may be difficulty breathing, chest pain and fluid in the lungs. The fever would last 2-5 days. The cough may persist up to four weeks. If the toxin is ingested, there may be nausea, vomiting, and diarrhea with no symptoms involving the lungs, and the sufferer would recover without special treatment within 24 hours. Is SEB intoxication treatable?
There is no vaccine or antitoxin available to treat SEB before or after exposure. The treatment for SEB once symptoms appear consists of pain relievers and cough suppressants. Additional drug therapies are under investigation. For severe cases which are expected to be rare, more extensive hospital procedures may be needed such as mechanical breathing and replacement of fluid. Is SEB transmitted from person to person?
As a toxin, SEB acts directly on the person who inhales or ingests it and is not an "infection" which is reproduced inside the body. It cannot be passed from person to person, so isolation of affected individuals is not necessary. How is SEB diagnosed?
There is no specific test available for diagnosing SEB intoxication. There are laboratory findings that may help in the diagnosis, such increases in the number of specific types of white blood cells called neutrophils.
Tularemia Where is tularemia found?
Tularemia occurs throughout North America and is also found in Europe and Asia. Approximately 150-300 tularemia cases are reported in the United States annually, with a majority of those from Alaska, Arkansas, Illinois, Oklahoma, Missouri, Tennessee, Texas, Utah, and Virginia. The frequency of tularemia has dropped markedly over the last 50 years and there has been a shift from winter disease (usually from rabbits) to summer disease (more likely from ticks). Tularemia in humans is relatively rare in Arizona. There were five cases reported in Arizona over the last ten years and 28 cases over the last twenty-five years. How is tularemia associated with bioterrorism?
F. tularensis, like the plague and anthrax bacteria, was weaponized by the U.S. (until the 1960's) and the former Soviet Union (until the 1990's). Other countries have been or are suspected to have weaponized this bacteria. This organism can potentially be produced in either a wet or dry form and introduced by aerosolization or contamination of food and water sources. Who is most at risk for tularemia?
Anyone can get tularemia if they spend time outdoors in areas where infected animals, deer flies, or ticks can be found. Rabbit hunters, trappers, and laboratory workers exposed to the bacteria are at higher risk. How is tularemia spread?
Many routes of human exposure to the tularemia germ are known to exist. The common routes include direct contact with blood or tissue while handling infected animals, through the bite of arthropods (e.g., ticks, mosquitoes), or handling or eating undercooked small game animals (e.g., rabbit). The bacteria can remain viable in frozen rabbit meat for longer than 3 years. Less common means of transmission are drinking or swimming in contaminated water, from animal scratches or bites of animals contaminated from eating infected animals, and inhaling dust from contaminated soil or handling contaminated pelts or paws of animals. Tularemia is not directly transmitted from person to person. What are the symptoms of tularemia?
The most common form of tularemia is usually acquired through the bite of blood-sucking arthropods or from contact with infected animals. Patients will develop an ulcer at the site of infection and regional lymph nodes become inflamed and swollen. Severe fever and flu-like symptoms may accompany the ulcer or lesion. Ingestion of the organism in contaminated food or water may result in painful pharyngitis, abdominal pain, diarrhea, and vomiting. Inhalation of the organism will result in sudden chills, fever, weight loss, abdominal pains, tiredness, and headaches. Inhalation of F. tularensis may result in tularemia pneumonia. Patients with this form of tularemia may develop a fever alone or a fever combined with an unusual pneumonia-like illness that can be fatal.
How soon do symptoms appear?
Symptoms generally appear between 1 and 14 days, but usually within 3-5 days. What is the treatment for tularemia?
Certain antibiotics such as streptomycin are effective in treating tularemia. Others such as gentamycin and tobramycin have also been reported to be effective. What can be done to prevent the spread of tularemia?
Rubber gloves should be worn when skinning or handling animals, especially rabbits. Wild rabbit and rodent meat should be cooked thoroughly before eating. Avoid bites of ticks and other arthropods by using standard repellants. Avoid drinking, bathing, swimming or working in untreated water. Viral Hemorrhagic Fever How are hemorrhagic fever viruses associated with bioterrorism?
Some evidence exists for respiratory transmission of certain VHF viruses, certainly most cause high infections rates by direct contact. Some of these viruses were weaponized by the Soviet Union during the 1980s and1990s, including Marburg, Ebola, and Lassa fever viruses. Others were investigated for potential use as bioweapons. What are the reservoirs for viruses that cause VHFs?
Viruses associated with most VHFs are zoonotic. This means that these viruses naturally reside in an animal reservoir host or arthropod vector (insects or ticks). They are totally dependent on their hosts for replication and overall survival. For the most part, rodents and arthropods are the main reservoirs for viruses causing VHFs. The multimammate rat, cotton rat, deer mouse, house mouse, and other field rodents are examples of reservoir hosts. Arthropod ticks and mosquitoes serve as vectors for some of the illnesses. However, the hosts of some viruses remain unknown, including the filoviruses, Ebola and Marburg. Where are cases of viral hemorrhagic fever usually found?
The viruses that cause VHFs are distributed over much of the globe. However, because each virus is associated with one or more particular host species, the virus and the disease it causes are usually seen only where the host species live(s). Some hosts, such as the rodent species carrying several of the New World arenaviruses, live in geographically restricted areas. Other hosts range over continents, such as the rodents that carry viruses which cause various forms of hantavirus pulmonary syndrome (HPS) in North and South America, or the different set of rodents that carry viruses which cause hemorrhagic fever with renal syndrome (HFRS) in Europe and Asia. A few hosts are distributed nearly worldwide, such as the common rat. It can carry Seoul virus, a cause of HFRS; therefore, humans can get HFRS anywhere the common rat is found. How are hemorrhagic fever viruses transmitted?
Some viruses that cause hemorrhagic fever can spread from person to person, once an initial person has become infected. Ebola, Marburg, Lassa and Crimean-Congo hemorrhagic fever viruses are examples. Usually, viruses causing VHFs are initially transmitted to humans when they come in contact with infected reservoir hosts or vectors. The viruses carried in rodent reservoirs are transmitted when humans have contact with urine, fecal matter, saliva, or other body excretions from infected rodents. The viruses associated with arthropod vectors are spread most often when the vector mosquito or tick bites a human, or when a human crushes a tick. However, some of these vectors may spread virus to animals, livestock, for example. Humans then become infected when they care for or slaughter the animals. What are the symptoms of viral hemorrhagic fever illnesses?
Specific signs and symptoms vary by the type of VHF, but initial signs and symptoms often include marked fever, fatigue, dizziness, muscle aches, loss of strength, and exhaustion. Patients with severe cases of VHF often show signs of bleeding under the skin, in internal organs, or from body orifices like the mouth, eyes, or ears. However, although they may bleed from many sites around the body, patients rarely die because of blood loss. Severely ill patients cases may also show shock, nervous system malfunction, coma, delirium, and seizures. Some types of VHF are associated with renal (kidney) failure. Are there treatments for viral hemorrhagic fever?
Patients receive supportive therapy, but generally speaking, there is no other treatment or established cure for VHFs. Ribavirin, an anti-viral drug, has been effective in treating some individuals with Lassa fever or HFRS. Treatment with antiviral antibody has been used with success in some patients with Argentine hemorrhagic fever. |
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