Preparing for and Responding to Bioterrorism

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Preparing for and Responding to Bioterrorism:
Information for the Public Health Workforce
Plague and Botulism
Developed by
Jennifer Brennan Braden, MD, MPH
Northwest Center for Public Health Practice
University of Washington
Seattle, Washington
*This manual and the accompanying MS Powerpoint slides are current as of Dec 2002.
Please refer to http://nwcphp.org/bttrain/ for updates to the material.
Last Revised December 2002
Acknowledgements
This manual and the accompanying MS PowerPoint slides were prepared for
the purpose of educating the public health workforce in relevant aspects of
bioterrorism preparedness and response. Instructors are encouraged to freely use
portions or all of the material for its intended purpose.
Project Coordinator
Patrick O’Carroll, MD, MPH
Northwest Center for Public Health Practice, University of Washington, Seattle, WA
Centers for Disease Control and Prevention; Atlanta, GA
Lead Developer
Jennifer Brennan Braden, MD, MPH
Northwest Center for Public Health Practice, University of Washington, Seattle, WA
Design and Editing
Judith Yarrow
Health Policy Analysis Program, University of Washington, Seattle, WA
The following people provided technical assistance or review of the materials:
Jeffrey S. Duchin, MD: Communicable Disease Control, Epidemiology and Immunization Section,
Public Health – Seattle & King County
Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA
Jane Koehler, DVM, MPH: Communicable Disease Control, Epidemiology and Immunization
Section, Public Health – Seattle & King County; Seattle, WA
Dennis Anderson, MA: Office of Risk and Emergency Management, Washington State Department of
Health; Olympia, WA
Nancy Barros, MA: State of Alaska, Division of Public Health; Juneau, AK
Janice Boase, RN, MS, CIC: Communicable Disease Control, Epidemiology and Immunization
Section Public Health – Seattle & King County, Seattle, WA
Jeanne Conner, RN, BSN: Sweet Grass Community Health; Big Timber, MT
Marcia Goldoft, MD, MPH: Communicable Disease Epidemiology, Washington State Department of
Health; Shoreline, WA
Nancy Goodloe: Kittitas County Health Department; Ellensburg, WA
Sandy Kuntz, RN: University of Montana School of Nursing; Missoula, MT
Mike McDowell, BSc, RM: Public Health Laboratories, Washington State Department of Health;
Shoreline, WA
Patrick O’Carroll, MD, MPH: Centers for Disease Control and Prevention; Atlanta, GA
Maryann O’Garro: Grant County Health Department, Ephrata, WA
Carl Osaki, RS, MSPH: Department of Environmental Health, University of Washington; Seattle, WA
Sandy Paciotti, RN, BSN: Skagit County Health Department, Mount Vernon, WA
Eric Thompson: Public Health Laboratories, Washington State Department of Health; Shoreline, WA
Matias Valenzuela, Ph.D.: Public Health – Seattle & King County; Seattle, WA
Ed Walker, MD: Department of Psychiatry, University of Washington, Seattle, WA
Contact Information
Northwest Center for Public Health Practice
School of Public Health and Community Medicine
University of Washington
1107 NE 45th St., Suite 400
Seattle, WA 98105
Phone: (206) 685-2931, Fax: (206) 616-9415
Table of Contents
About This Course ................................................................................... 1
How to Use This Manual .......................................................................... 2
Plague and Botulism ................................................................................ 3
Learning Objectives (Slide 4) ........................................................................... 5
Plague (Slides 5-19) ........................................................................................ 6
History, Epidemiology, and Microbiology (Slides 5-7) .............................. 6
Case Definition and Classification (Slides 8-10). ...................................... 7
Clinical Presentation (Slides 11-15) ......................................................... 8
Treatment and Infection Control (Slides 16-17). .....................................10
Summary of Key Points (Slide 18) .........................................................11
Case Reports (Slide 19) .........................................................................11
Botulism (Slides 20-30) ..................................................................................12
Microbiology, Epidemiology, and Pathogenesis (Slides 20-22) .............13
Clinical Forms and Case Definition (Slides 23-25). .................................15
Treatment and Prophylaxis (Slides 26-27). .............................................16
Summary of Key Points (Slides 28-29) ..................................................18
Case Reports (Slide 30) .........................................................................18
Resources (Slides 31-33) .............................................................................19
References ............................................................................................ 20
Appendix A: Modules. ............................................................................ 26
Appendix B: Glossary. ............................................................................ 27
Last Revised December 2002
1
Plague and Botulism
About This Course
Preparing for and Responding to Bioterrorism: Information for the Public
Health Workforce is intended to provide public health employees with a basic
understanding of bioterrorism preparedness and response and how their work fits
into the overall response. The course was designed by the Northwest Center for
Public Health Practice in Seattle, Washington, and Public Health – Seattle &
King County’s Communicable Disease, Epidemiology & Immunization section.
The target audience for the course includes public health leaders and medical
examiners, clinical, communicable disease, environmental health, public
information, technical and support staff, and other public health professional
staff. Health officers may also want to review the more detailed modules on
diseases of bioterrorism in Preparing for and Responding to Bioterrorism:
Information for Primary Care Clinicians: Northwest Center for Public Health Practice
(available at http://nwcphp.org/bttrain). Public health workers are a very
heterogeneous group, and the level of detailed knowledge needed in the different
aspects of bioterrorism preparedness and response will vary by job description
and community. Therefore, the curriculum is divided into modules, described in
Appendix A.
Last Revised December 2002
2
Preparing for and Responding to Bioterrorism
The course incorporates information from a variety of sources, including the
Centers for Disease Control and Prevention, the United States Army Medical
Research Institute in Infectious Disease (USAMRIID), the Working Group on
Civilian Biodefense, the Federal Emergency Management Agency, Public Health
– Seattle & King County, and the Washington State Department of Health,
among others (a complete list of references is given at the end of the manual).
The curriculum reflects the core competencies and capacities outlined in the
following documents:
CDC. Bioterrorism preparedness and response: core capacity project 2001
(draft), August 2001.
http://www.bt.cdc.gov/Documents/CoreCapacity082801.pdf
CDC. Cooperative Agreement U90/CCUXXXXXX-03-X Public Health
Preparedness and Response for Bioterrorism.
http://www.bt.cdc.gov/Planning/CoopAgreementAward/index.asp
CDC. The public health response to biological and chemical terrorism: interim
planning guidance for state public health officials, July 2001.
www.bt.cdc.gov/Documents/Planning/PlanningGuidance.PDF
Center for Health Policy, Columbia University School of Nursing. Core public
health worker competencies for emergency preparedness and response, April
2001: http://cpmcnet.columbia.edu/dept/nursing/institute-centers/chphsr/
Center for Health Policy, Columbia University School of Nursing. Bioterrorism
and emergency readiness: competencies for all public health workers (preview
version II), November 2002. http://cpmcnet.columbia.edu/dept/nursing/institutecenters/chphsr/
The course is not copyrighted and may be used freely for the education of public
health employees and other biological emergency response partners.
Course materials will be updated on an as-needed basis with new information
(e.g., guidelines and consensus statements, research study results) as it becomes
available. For the most current version of the curriculum, please refer to:
http://nwcphp.org/bttrain.
Last Revised December 2002
3
Plague and Botulism
How to Use This Manual
This manual provides the instructor with additional useful information related to
the accompanying MS PowerPoint slides. The manual and slides are divided
into six topic areas: Introduction to Bioterrorism, Emergency Response Planning,
Diseases of Bioterrorist Potential, Health Surveillance and Epidemiologic
Investigation, Consequence Management, and Communications. Links to Web
sites of interest are included in the lower right-hand corner of some slides and
can be accessed by clicking the link while in the “Slide Show” view. Blocks of
material in the manual are periodically summarized in the “Key Point” sections,
to assist the instructor in deciding what material to include in a particular
presentation. A Summary of Key Points is indicated in bold, at the beginning of
each module.
The level of detailed knowledge required may vary for some topics by job duties.
Therefore, less detailed custom shows are included in the Emergency Response
Planning and Diseases of Bioterrorist Potential: Overview modules for those
workers without planning oversight or health care responsibilities, respectively.
In addition, there are three Consequence Management modules: for public health
leaders, for public health professionals, and for other public health staff (see
Appendix A).
Last Revised December 2002
4
Preparing for and Responding to Bioterrorism
Diseases of Bioterrorist Potential
Slide 1: Curriculum Title
Slide 2: Acknowledgements
Slide 3: Module Title
Last Revised December 2002
5
Plague and Botulism
Learning Objectives (Slide 4)
The learning objectives for this module are:
1. Describe the epidemiology, mode of transmission, and presenting
symptoms of disease caused by the CDC-defined Category A agents
2. Identify the infection control and prophylactic measures to implement
in the event of a suspected or confirmed Category A case or outbreak
Last Revised December 2002
6
Preparing for and Responding to Bioterrorism
Plague (Slides 5-19)
Summary of Key Points
(Listed in slide 18)
1. The most likely presentation in a BT attack is pneumonic plague.
2. Unlike other forms of plague, pneumonic plague is transmitted person
to person, and thus respiratory droplet precautions are indicated in
suspected cases until 48 hours after the initiation of antibiotic therapy.
History, Epidemiology, and Microbiology (Slides 5-7)
Naturally occurring plague is transmitted to
rats and other rodents following the bite of
an infected flea. When the natural rat
reservoir is unavailable, fleas will bite
humans, as was the case historically during
plague epidemics. The resulting form of
plague – bubonic plague – is the most
common naturally occurring form, and is
different from that expected in the event of a
bioterrorist attack. Although the Japanese
used plague-infected fleas as a biowarfare
weapon during WW II to create a bubonic
plague epidemic, this is not as efficient a
weapon as a plague aerosol.
Currently, a bioterrorist attack is more likely
to employ aerosolization of Y. pestis, and
victims of the attack will present with
pneumonic plague. Plague bacilli are killed
by sunlight and estimated to remain viable
in an aerosol for no longer than one hour
following release (Inglesby, et al., JAMA
2000;283:2281-90).
Last Revised December 2002
7
Plague and Botulism
Yersinia
pestis,
a
gram
negative
bacillus, is the causative agent of
plague. Slide 7 shows a peripheral blood
smear from a patient with septicemic
plague.
Case Definition and Classification (Slides 8-10)
The case definition for plague is listed
in slides 8 and 9, and the criteria for
case classification, in slide 10.
Last Revised December 2002
8
Preparing for and Responding to Bioterrorism
Clinical Presentation (Slides 11-15)
Key Points
1. Bubonic, pneumonic, and septicemic plague each begin with the
acute onset of a non-specific febrile illness.
2. Pneumonia (without buboes) is the most likely presentation of plague
in a BT attack.
3. Pneumonic plague progresses rapidly to respiratory failure and death
if not treated early.
Slides 11-15 describe the three clinical
forms of plague, and their presentations. All
three forms begin with the acute onset of
fever, chills, myalgia, and malaise.
Last Revised December 2002
9
Plague and Botulism
Pneumonic plague is the most likely
form expected after
a BT attack.
Approximately 12 percent of cases of
septicemic
plague
also
result
in
pneumonic involvement. Since a BT
attack is most likely to occur via an
aerosol release, it is unlikely that the
patient with pneumonic plague in this
scenario will have a bubo. Pneumonic
plague
may
present
community-acquired
chest
pain,
as
a
pneumonia
dyspnea
severe
with
(difficulty
breathing), and cough. Gastrointestinal
symptoms may be prominent, and the
disease progresses rapidly; both features
are also consistent with inhalational
anthrax. Unlike inhalational anthrax,
patients with pneumonic plague usually
have bloody sputum and are infectious.
Bubonic
plague
involves
infection,
inflammation, and marked tenderness of
the regional lymph nodes draining the
inoculation (bite) site. Bacteria gain
access to the bloodstream and cause
septicemia
and
endotoxemia
with
associated complications. Most cases of
naturally occurring plague are bubonic
plague.
Last Revised December 2002
10
Preparing for and Responding to Bioterrorism
Slide 15: The photo on the right is from the CDC
National Center for Infectious Disease, Division
of Vector-borne Diseases. The photo on the right
shows an inguinal bubo on a person with bubonic
plague. The photo on the left illlustrates gangrene
secondary to thrombosis of acral blood vessels in
septicemic plague (giving the name “black death”
to fatal cases in previous plague pandemics).
Treatment and Infection Control (Slides 16-17)
Person-to-person transmission of pneumonic
plague is thought to occur via respiratory
droplets.
Patient
respiratory
droplet
isolation,
standard
precautions,
and
disposable surgical masks are recommended
to prevent transmission for at least the first
48 hours of antimicrobial therapy (Bolyard,
et al, Am J Infect Control, 1998;26:289354). Patients should wear surgical masks
during transport. Exposed persons refusing
antibiotic prophylaxis should be closely
watched for development of fever or cough
for seven days after last exposure and
treated
immediately
if
either
occur.
Microbiology lab personnel should be
alerted
when
specimen
testing
from
suspected or confirmed plague cases is
requested. Bodies of patients who have died
of plague should be handled with strict
precautions.
Aerosol generation procedures should be avoided, and appropriate high
efficiency particulate respirators and negative pressure rooms employed if such
procedures are necessary.
Last Revised December 2002
11
Plague and Botulism
Antibiotic prophylaxis is recommended for individuals exposed to a presumed
plague aerosol and for close contacts of pneumonic plague patients. Antibiotics
should be continued seven days from the time of exposure or last contact with an
infected patient. Antibiotic prophylaxis is not necessary for contacts of bubonic
plague patients in the absence of symptoms.
Summary of Key Points (Slide 18)
Case Reports (Slide 19)
Slide 19 contains links to two Morbidity
and Mortality Weekly case reports of
pneumonic plague.
Last Revised December 2002
12
Preparing for and Responding to Bioterrorism
Botulism (Slides 20-30)
Summary of Key Points
(Listed in slides 28-29)
1. An outbreak of botulism occurring with a common geographic factor,
but with no common food exposure, would suggest a deliberate
aerosol exposure.
2. Inhalational botulism does not occur naturally, and any potential cases
suggest a deliberate source of infection.
3. Gastrointestinal symptoms may not occur with inhalational botulism or
with food-borne botulism (e.g., resulting from deliberate contamination
of the food supply).
4. Botulinum antitoxin must be administered as soon as possible for
optimum results.
Last Revised December 2002
13
Plague and Botulism
Microbiology, Epidemiology, and Pathogenesis (Slides 20-22)
Key Points
1. Naturally occurring forms of botulism include infant, food-borne, and
wound botulism.
2. A bioterrorist attack with botulinum toxin is most likely to be via
aerosol (inhalational botulism), or possibly through contamination of
the food supply.
Botulism is caused by botulism toxin, a
zinc protease produced by Clostridium
botulinum. C. botulinum, a ubiquitous soil
bacteria,
produces
hardy
spores
that
survive for extended periods in the
environment. Vegetative cells germinated
from spores produce toxin under anaerobic
conditions. Several toxin types, A-G, have
been classified based on reactivity with
specific antitoxins, but all have similar
effects. Types A, B, and E are most often
associated with human disease. The toxin is
easily inactivated by heat, sunlight, and
chlorine. Contamination of the water supply
is thus unlikely (this would also require a
large, impractical amount to achieve a high
enough
concentration
in
the
water).
Contamination of untreated beverages and
food is possible, and could result in disease
if
not
heated
sufficiently
prior
to
consumption.
Last Revised December 2002
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Preparing for and Responding to Bioterrorism
The
incubation
period for
food-borne
botulism is 12-72 hours and is dosedependent. Inhalational botulism does not
occur naturally and should always suggest a
deliberate source. It is likely that the
incubation period for botulism following an
aerosol exposure would be less than that
following
a
food-borne
exposure.
No
person-to-person spread occurs, and no
special infection control precautions are
indicated for botulism cases.
Botulinum
toxin
has
been
studied
extensively for use as a biological weapon.
Although botulism is rarely fatal when
treated early and appropriately, ventilatory
support is often necessary. An outbreak
could thus severely task the health care
system’s resources. The need for significant
supportive care and the relative availability
of botulinum spores (spores can be found
worldwide in soil) make botulinum toxin a
likely biological weapon.
Last Revised December 2002
15
Plague and Botulism
Clinical Forms and Case Definition (Slides 23-25)
The clinical forms of botulism are listed in
slide 23. Inhalation botulism is considered
the most likely presentation in a biological
attack. Food-borne botulism is another
possible bioterrorism-related presentation.
Food-borne
botulism
results
from
production of toxin in foods contaminated
with botulism spores that are canned or
processed under conditions favorable for
toxin production. Wound botulism results
from
toxin
production
by
spores
contaminating devitalized tissue. Infant
botulism is the most common form reported
in the U.S. and results from toxin production
by organisms residing in the intestinal tract.
The case definition for botulism is listed
in slide 24.
Last Revised December 2002
16
Preparing for and Responding to Bioterrorism
Slide
25
lists
the
case
classification
categories for food-borne botulism and other
cases of botulism not meeting the criteria for
food-borne, wound, or infant botulism (i.e.,
inhalation botulism would be considered
“botulism,
other”).
Infant
and
wound
botulism are unlikely presentations in a
biological attack, and thus case criteria are
not listed here. Detection of botulinum toxin
in clinical specimens is via mouse bioassay,
performed at LRN laboratories, Level B or
higher. The age parameter for a confirmed
case of “botulism, other” (i.e., ³ 1 year),
differentiates this classification from infant
botulism. An aerosolized biological attack,
however, may result in victims with a wide
range
of
ages,
and
thus
the
case
classification may require revision.
Treatment and Prophylaxis (Slides 26-27)
Botulinum antitoxin is most effective when
given early in the course of illness. It
prevents the binding of additional toxin to
nerve receptors, but does not reverse the
effects of already-bound toxin. Damaged
nerves must regenerate, and recovery may
take weeks to months. The currently
licensed antitoxin, available from CDC, is
effective against the three most commonly
occurring toxins – A, B & E. A botulism
outbreak resulting from a biological attack
could potentially occur with toxins C, D, F,
or G.
Last Revised December 2002
17
Plague and Botulism
Adverse effects of botulism antitoxin include a spectrum of hypersensitivity
reactions to equine antiserum including urticaria, serum sickness, and
anaphylaxis. Patients should be screened for hypersensitivity to horse serum
before receiving the equine antitoxin, and desensitized if necessary. Patients
should be closely monitored during treatment, and diphenhydramine and
epinephrine should be on-hand during administration of antitoxin to treat
hypersensitivity reactions.
Many cases require intensive care, prolonged mechanical ventilation, and
extensive rehabilitation. In addition to antitoxin, ventilation, and supportive care
including nutrition through tube or parenteral feeding, fluid balance, and
treatment of complications (e.g. pneumonia and other infections, pressure ulcers)
must be provided.
Prophylactic use of botulism antitoxin for
potentially
exposed
but
asymptomatic
persons is not recommended. Asymptomatic persons who may have been
exposed to botulism toxin should be under
medical observation and treated at the first
signs
of
illness.
An
investigational
pentavalent botulism toxoid vaccine has
been used by the military and for certain
laboratory workers, but is not available for
general use and is not effective in postexposure prophylaxis.
Last Revised December 2002
18
Preparing for and Responding to Bioterrorism
Summary of Key Points (Slides 28-29)
Case Reports (Slide 30)
This slide contains links to case reports on
botulism. Note that these are not BT-related
cases.
Last Revised December 2002
Plague and Botulism
19
Resources (Slides 31-33)
Last Revised December 2002
20
Preparing for and Responding to Bioterrorism
References
General Bioterrorism Information and Web Sites
American College of Occupational and Environmental Medicine. Emergency
Preparedness/Disaster Response. January 2002.
http://www.acoem.org/member/trauma.htm
Centers for Disease Control and Prevention. Public Health Emergency
Preparedness and Response. January 2002. http://www.bt.cdc.gov
Center for the Study of Bioterrorism and Emerging Infections at Saint Louis
University School of Public Health. Home Page. January 2002.
http://www.bioterrorism.slu.edu
Historical perspective of bioterrorism. Wyoming Epidemiology Bulletin;5(5):1-2,
Sept-Oct 2000.
Journal of the American Medical Association. Bioterrorism articles. April 2002.
http://pubs.ama-assn.org/bioterr.html
Johns Hopkins Center for Civilian Biodefense Studies. Home Page. January
2002. http://www.hopkins-biodefense.org/
Pavlin JA. Epidemiology of bioterrorism. Emerging Infect Dis [serial online]
1999 Jul-Aug; 5(4). http://www.cdc.gov/ncidod/EID/eid.htm
Tucker JB. Historical trends related to bioterrorism: an empirical analysis.
Emerging Infect Dis [serial online] 1999 Jul-Aug; 5(4).
http://www.cdc.gov/ncidod/EID/eid.htm
Washington State Department of Health. Home Page. January 2002.
http://www.doh.wa.gov
Emergency Response Planning
Bioterrorism and emergency response plan clearinghouse.
http://bt.nacchoweb.naccho.org/
Butler JC, Mitchell LC, Friedman CR, Scripp RM, Watz CG. Collaboration
between public health and law enforcement: new paradigms and partnerships for
bioterrorism planning and response. Emerging Infect Dis [serial online] 2002
Oct; 8(10):1152-55. http://www.cdc.gov/ncidod/EID/eid.htm
CDC. Biological and chemical terrorism: strategic plan for preparedness and
response. MMWR Recommendations and Reports 2000 April 21;49(RR-4):1-14.
CDC. Bioterrorism preparedness and response: core capacity project 2001
(draft), August 8, 2001.
http://www.bt.cdc.gov/Documents/CoreCapacity082801.pdf
CDC. Cooperative agreement U90/CCUXXXXXX-03-X public health
preparedness and response for bioterrorism.
http://www.bt.cdc.gov/Planning/CoopAgreementAward/index.asp
Last Revised December 2002
21
Plague and Botulism
CDC. The public health response to biological and chemical terrorism: interim
planning guidance for state public health officials, July 2001.
http://www.bt.cdc.gov/Documents/Planning/PlanningGuidance.PDF
Center for Health Policy, Columbia University School of Nursing. Bioterrorism
and emergency readiness: competencies for all public health workers (preview
version II), November 2002. http://cpmcnet.columbia.edu/dept/nursing/institutecenters/chphsr/
Center for Health Policy, Columbia University School of Nursing. Core public
health worker competencies for emergency preparedness and response, April
2001. http://cpmcnet.columbia.edu/dept/nursing/institute-centers/chphsr/
Environmental Protection Agency. Emergency planning and community right-toknow act overview.
http://yosemite.epa.gov/oswer/ceppoweb.nsf/content/epcraOverview.htm
Federal Emergency Management Agency. Emergency management guide for
business & industry. http://www.fema.gov/library/bizindst.pdf
Federal Emergency Management Agency & United States Fire AdministrationNational Fire Academy. Emergency response to terrorism: self-study (ERT:SS)
(Q534), June 1999. http://www.usfa.fema.gov/pdf/ertss.pdf
Federal Emergency Management Agency. Independent study course on the
incident command system. http://www.fema.gov/emi/is195lst.htm
Medical response in emergencies: HHS role.
http://www.hhs.gov/news/press/2001pres/01fsemergencyresponse.html
Public Health Program Office, Centers for Disease Control and Prevention. Local
emergency preparedness and response inventory, April 2002.
http://www.phppo.cdc.gov/documents/localinventory.PDF
Washington state comprehensive emergency management plan.
http://www.wa.gov/wsem/3-map/a-p/cemp/cemp-idx.htm
Health Surveillance and Epidemiologic
Investigation
CDC. Case definitions under public health surveillance. MMWR; 1997:46(RR10):1-55.
CDC. Updated guidelines for evaluating public health surveillance systems:
recommendations from the Guidelines Working Group. MMWR. 2001;
50(RR13):1-35. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm
CDC Epidemiology Program Office. Excellence in curriculum integration
through teaching epidemiology (Web-based curriculum).
http://www.cdc.gov/excite/index.htm
Koehler J, Communicable Disease Control, Epidemiology & Immunization
Section, Public Health – Seattle & King County. Surveillance and Preparedness
for Agents of Biological Terrorism (presentation). 2001.
Koo, D. Public health surveillance (slide set).
http://www.cdc.gov/epo/dphsi/phs/overview.htm
Last Revised December 2002
22
Preparing for and Responding to Bioterrorism
List of nationally notifiable infectious diseases.
http://www.cdc.gov/epo/dphsi/phs/infdis.htm
Lober WB, Karras BT, Wagner MM, Overhage JM, Davidson AJ, Fraser H, et al.
Roundtable on bioterrorism detection: information system–based surveillance.
JAMIA 2002;9:105-115. http://www.jamia.org/cgi/content/full/9/2/105
Diseases of Bioterrorist Potential
Advisory Committee on Immunization Practices (ACIP). Use of smallpox
(vaccinia vaccine), June 2002: supplemental recommendation of the ACIP.
Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deithman
SD. HICPAC. Guideline for infection control in health care personnel, 1998. Am
J Infect Control 1998;26:289-354.
http://www.bt.cdc.gov/ncidod/hip/GUIDE/infectcont98.htm
Breman JG & Henderson DA. Diagnosis and management of smallpox. N Engl J
Med 2002;346(17):1300-1308.
CDC. CDC Responds: Smallpox: What Every Clinician Should Know, Dec.
13th, 2001.
Webcast: http://www.sph.unc.edu/about/webcasts/
CDC. CDC Responds: Update on Options for Preventive Treatment for Persons
at Risk for Inhalational Anthrax, Dec 21, 2001.
Webcast: http://www.sph.unc.edu/about/webcasts/
CDC. Considerations for distinguishing influenza-like illness from inhalational
anthrax. MMWR 2001;50(44):984-986.
CDC. Notice to readers update: management of patients with suspected viral
hemorrhagic fever – United States. MMWR. 1995;44(25):475-79.
CDC. The use of anthrax vaccine in the United States. MMWR 2000;49(RR15):1-20.
CDC. Update: investigation of bioterrorism-related anthrax --- Connecticut,
2001. MMWR 2001;50(48):1077-9.
CDC. Vaccinia (smallpox) vaccine: recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR 2001;50(RR-10):1-25.
Centers for Disease Control and Prevention. Smallpox response plan and
guidelines (version 3.0). Sep 21, 2002.
Centers for Disease Control and Prevention. Smallpox vaccination and adverse
events training module, 2002.
http://www.bt.cdc.gov/training/smallpoxvaccine/reactions/default.htm
Centers for Disease Control and Prevention, American Society for Microbiology
& American Public Health Laboratories. Basic diagnostic testing protocols for
level A laboratories.
http://www.asmusa.org/pcsrc/biodetection.htm#Level%20A%20Laboratory%20
Protocols
Chin J, ed. Control of Communicable Diseases Manual (17th ed), 2000:
Washington DC.
Last Revised December 2002
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Plague and Botulism
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Last Revised December 2002
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Preparing for and Responding to Bioterrorism
Appendix A: Modules (MS® Powerpoint files)
Introduction to Bioterrorism
One module (33 slides)
Emergency Response Planning
One module, with one custom show for personnel without planning oversight
responsibilities
-Public health leaders (36 slides)
-Other public health staff (24 slides)
Diseases of Bioterrorist Potential
Six modules
Overview (25 slides, with 20-slide custom show for staff without health
care responsibilities)
Anthrax (29 slides)
Smallpox (44 slides)
Plague and Botulism (33 slides)
Tularemia and VHF (38 slides)
Environmental Sampling and Decontamination (43 slides)
Health Surveillance & Epidemiologic Investigation
One module (32 slides)
Consequence Management
Three modules
-Public health leaders (51 slides)
-Public health professional staff (51 slides)
-Other public health staff (30 slides)
Communication & Informatics
One module (42 slides)
Last Revised December 2002
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Plague and Botulism
Appendix B: Glossary
Bulbar: Referring to the cranial nerves
Coagulopathy: A disease affecting the coagulability (clotting) of the blood
Confluent: Joining, running together
Conjunctivitis: Inflammation of the conjunctiva; “red eye”
Depigmentation: Loss of pigmentation (color)
Diplopia: Double vision
Dyspnea: Shortness of breath
Edema: An accumulation of an excessive amount of watery fluid in cells or
tissues
Enanthem: A mucous membrane eruption (rash)
Epistaxis: Nose bleed
Erythema: Redness
Eschar: A thick, coagulated crust or slough
Exanthem: A skin eruption (rash) occurring as a symptom of an acute viral or
coccal disease
HAZMAT: Hazardous materials management; HAZMAT workers respond to
discharges and/or releases of oil, chemical, biological, radiological, or other
hazardous substances .
Hematemesis: Vomiting of blood
Hemoptysis: Coughing up blood
Hemorrhagic mediastinitis: Bloody inflammation in the chest cavity
Hypotension: Low blood pressure
Indolent ulcer: Chronic ulcer, showing no tendency to heal
Leukocytosis: Elevated white blood cell count
Lymphadenitis: Inflammation of a lymph node or lymph nodes
Last Revised December 2002
28
Preparing for and Responding to Bioterrorism
Lymphadenopathy: A disease process (e.g., swelling) affecting a lymph node or
nodes
Macule: A small, discolored patch or spot on the skin, neither elevated above nor
depressed below the skin's surface
Malaise: General ill feeling
Myalgia: Muscle aches
Papule: A small, circumscribed solid elevation on the skin
Percutaneous: Denoting the passage of substances through unbroken skin;
passage through the skin by needle puncture
Petechiae: Pin-head sized hemorrhagic spots in the skin
Pharyngitis: Inflammation of the tissues of the pharynx; “Sore throat”
Pleuropulmonary: Relating to the pleura and the lungs
Preauricular: Anterior to the auricle of the ear
Prodrome: An early or premonitory symptom of a disease
Prophylaxis: Prevention of a disease, or of a process that can lead to disease
Prostration: A marked loss of strength, as in exhaustion
Pustule: A small circumscribed elevation of the skin, containing purulent
material
Sepsis: The presence of various pus-forming and other pathogenic organisms, or
their toxins, in the blood or tissues
Stomatitis: Inflammation of the mucous membrane of the mouth
Vesicle: A small, circumscribed elevation on the skin containing fluid (I.e.,
blister)
*Reference: Stedman’s Medical Dictionary, 26th Ed.
Last Revised December 2002

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