USAMRIID's

MEDICAL MANAGEMENT

OF BIOLOGICAL CASUALTIES

#### HANDBOOK {#handbook .unnumbered}

![](media/image1.png)

***Fourth Edition***

***February 2001***

**U.S. ARMY MEDICAL RESEARCH**

**INSTITUTE OF INFECTIOUS DISEASES**

####### FORT DETRICK

**FREDERICK, MARYLAND**

**Sources of information:**

National Response Center **1-800-424-8802 or**

(for chem/bio hazards & terrorist events) **1-202-267-2675**

National Domestic Preparedness Office: **1-202-324-9025**

(for civilian use)

Domestic Preparedness Chem/Bio Help line: **1-410-436-4484 or**

(Edgewood Ops Center - for military use) **DSN 584-4484**

### USAMRIID Emergency Response Line: 1-888-872-7443 {#usamriid-emergency-response-line-1-888-872-7443 .unnumbered}

CDC\'S Bioterrorism Preparedness

and Response Center: **1-770-488-7100**

John\'s Hopkins Center for Civilian Biodefense: **1-410-223-1667**

(Civilian Biodefense Studies)

An Adobe Acrobat Reader (pdf file) version and a Palm OS Electronic
version of this Handbook can both be downloaded from the Internet at:

**http://www.usamriid.army.mil/education/bluebook.html**

## USAMRIID's {#usamriids .unnumbered}

## MEDICAL MANAGEMENT {#medical-management .unnumbered}

**OF BIOLOGICAL CASUALTIES**

## HANDBOOK {#handbook-1 .unnumbered}

#########  {#section .unnumbered}

***Fourth Edition***

######### *February 2001* {#february-2001 .unnumbered}

**Editors:**

**LTC Mark Kortepeter**

**LTC George Christopher**

**COL Ted Cieslak**

**CDR Randall Culpepper**

**CDR Robert Darling**

**MAJ Julie Pavlin**

**LTC John Rowe**

**COL Kelly McKee, Jr.**

**COL Edward Eitzen, Jr.**

**Comments and suggestions are appreciated**

**and should be addressed to:**

***Operational Medicine Department***

***Attn: MCMR-UIM-O***

***U.S. Army Medical Research***

***Institute of Infectious Diseases (USAMRIID)***

***Fort Detrick*, *Maryland 21702-5011***

# PREFACE TO THE FOURTH EDITION {#preface-to-the-fourth-edition .unnumbered}

The Medical Management of Biological Casualties Handbook, which has
become affectionately known as the \"Blue Book,\" has been enormously
successful - far beyond our expectations. Since the first edition in
1993**,** the awareness of biological weapons in the United States has
increased dramatically. Over 100,000 copies have been distributed to
military and civilian health care providers around the world, primarily
through USAMRIID\'s on-site and road Medical Management of Biological
Casualties course and its four annual satellite broadcasts on this
subject.

This fourth edition has been completely re-edited and updated. New
chapters have been added on melioidosis, the medical management of a
biological weapon attack, and the use of epidemiologic clues in
determining whether an outbreak might have been intentionally spread. In
addition, a reference appendix has been added for those interested in
more in-depth reading on this subject.

Our goal is to make this a reference for the health care provider on the
front lines, whether on the battlefield or in a clinic, who needs basic
summary and treatment information quickly. We believe we have been
successful in this regard. We appreciate any feedback that might make
future editions more useful. Thank you for your interest in this
important subject.

-The Editors

#  {#section-1 .unnumbered}

#  {#section-2 .unnumbered}

# ACKNOWLEDGMENTS {#acknowledgments .unnumbered}

This handbook would not be possible without the generous assistance and
support of LTC(P) Les Caudle (editor of prior editions), Dr. Richard
Dukes, COL(ret) David Franz, COL Gerald Parker, COL Gerald Jennings, SGM
Raymond Alston, COL James Arthur, COL W. Russell Byrne, Dr. John Ezzell,
COL Arthur Friedlander, Dr. Robert Hawley, COL Erik Henchal, COL(ret)
Ted Hussey, Dr. Peter Jahrling, LTC Ross LeClaire, Dr. George Ludwig,
Mr. William Patrick, Dr. Mark Poli, Dr. Fred Sidell, Dr. Jonathon Smith,
Mr. Richard Stevens, Dr. Jeff Teska, COL Stanley Wiener and others too
numerous to mention. The exclusion of anyone on this page is purely
accidental and in no way lessens the gratitude we feel for contributions
received.

The **Palm OS Version** of this Handbook was made possible by the
Countermeasures to Biological and Chemical Threats Program: Dr. Steve
Kornguth, Countermeasures Program Director, The Institute for Advance
Technology (IAT); Dr. Harry Fair, Director, The Institute for Advanced
Technology (IAT); Dr. Jerry Davis, Director, The Center for Strategic
Analysis (CSA); COL Daniel J. Dire, MC, USAR, U.S. Army War College
Senior Service Fellow, Center for Strategic Analysis at The University
of Texas at Austin; and Mr. D. Hampton Finger, Systems Administrator for
The Institute for Advanced Technology.

#  {#section-3 .unnumbered}

#  {#section-4 .unnumbered}

#  {#section-5 .unnumbered}

#  {#section-6 .unnumbered}

# DISCLAIMER {#disclaimer .unnumbered}

The purpose of this Handbook is to provide concise supplemental reading
material to assist in education of biological casualty management.
Although every effort has been made to make the information in this
handbook consistent with official policy and doctrine (see FM 8-284),
the information contained in this handbook is **not** official
Department of the Army policy or doctrine, and it should not be
construed as such.

As you review this handbook, you will find specific therapies and
prophylactic regimens for the diseases mentioned. The majority of these
are based on standard treatment guidelines; however some of the regimens
noted may vary from information found in standard reference materials.
The reason for this is that the clinical presentation of certain
biological weapon diseases may vary from the endemic form of the
disease. For ethical reasons, human challenge studies can only be done
with a limited number of these agents. Therefore, treatment and
prophylaxis regimens may be derived from in vitro data, animal models,
and limited human data. Occasionally you will find various
investigational new drug (IND) products mentioned. They are often used
in the laboratory setting to protect healthcare workers. These products
are not available commercially, and can only be given under a specific
protocol with informed consent. They are mentioned for scientific
completeness of the handbook, and are not necessarily to be construed as
recommendations for therapy.

## EXECUTIVE ORDER 13139: {#executive-order-13139 .unnumbered}

# IMPROVING HEALTH PROTECTION OF MILITARY PERSONNEL PARTICIPATING IN PARTICULAR MILITARY OPERATIONS {#improving-health-protection-of-military-personnel-participating-in-particular-military-operations .unnumbered}

#  {#section-7 .unnumbered}

On 30 September 1999, the President of the United States issued
Executive Order 13139, which outlines the conditions under which IND and
off-label pharmaceuticals could be administered to U.S. service members.
This handbook discusses numerous pharmaceutical products, some of which
are investigational new drugs (IND). In certain other cases, licensed
pharmaceuticals are discussed for use in a manner or for a condition
other than that for which they were originally licensed (i.e. An
"off-label\" indication).

This executive order does not intend to alter the traditional
physician-patient relationship or individual physician prescribing
practices. Health care providers remain free to exercise clinical
judgement and prescribe licensed pharmaceutical products as they deem
appropriate for the optimal care of their patients. This policy does,
however, potentially influence recommendations that might be made by
U.S. government agencies and that might be applied to large numbers of
service members outside of the individual physician-patient
relationship. The following text presents a brief overview of EO 13139
for the benefit of the individual provider.

EO13139:

## Provides the Secretary of Defense guidance regarding the provision of IND products or products unapproved for their intended use as antidotes to chemical, biological, or radiological weapons;

## Stipulates that the US Government will administer products approved by the Food and Drug Administration (FDA) only for their intended use;

## Provides the circumstances and controls under which IND products may be used.

##  {#section-8 .unnumbered}

## In order to administer an IND product: {#in-order-to-administer-an-ind-product .unnumbered}

## Informed consent must be obtained from individual service members;

## The President may waive informed consent (at the request of the Secretary of Defense and only the Secretary of Defense) if:

### Informed consent is not feasible

### Informed consent is contrary to the best interests of the service member

# Obtaining informed consent is not in the best interests of national security. 

**[Table of Contents]{.underline}**

> **Introduction** 8
>
> **History of Biological Warfare and Current Threat** 9
>
> **Distinguishing Between Natural and Intentional**
>
> **Disease Outbreaks** 13
>
> **Ten Steps in the Management of Biological Casualties**
>
> **on the Battlefield** 15
>
> **Bacterial Agents** 20
>
> Anthrax 21
>
> Brucellosis 26
>
> Glanders and Melioidosis 30
>
> Plague 35
>
> Q Fever 40
>
> Tularemia 44
>
> **Viral Agents** 50
>
> Smallpox 51
>
> Venezuelan Equine Encephalitis 56
>
> Viral Hemorrhagic Fevers 61
>
> **Biological Toxins** 69
>
> Botulinum 70
>
> Ricin 76
>
> Staphylococcal Enterotoxin B 80
>
> T-2 Mycotoxins 84
>
> **Detection** 88
>
> **Personal Protection** 89
>
> **Decontamination** 92
>
> **Appendix A:** Glossary of Medical Terms
>
> **Appendix B:** Patient Isolation Precautions
>
> **Appendix C:** BW Agent Characteristics
>
> **Appendix D:** BW Agent Vaccines, Therapeutics and Prophylactics
>
> **Appendix E:** Medical Sample Collection for BW Agents
>
> **Appendix F:** Specimens for Laboratory Diagnosis
>
> **Appendix G:** BW Agent Laboratory Identification
>
> **Appendix H:** Differential Diagnosis - Toxins vs. Nerve Agents
>
> **Appendix I:** Comparative Lethality - Toxins vs. Chemical Agents
>
> **Appendix J:** Aerosol Toxicity
>
> **Appendix K:** References and Emergency Response Contacts

#### INTRODUCTION {#introduction .unnumbered}

Medical defense against biological warfare or terrorism is an area of
study unfamiliar to most military and civilian health care providers
during peacetime. In the aftermath of Operations Desert Shield/Desert
Storm, it became obvious that the threat of biological attacks against
our soldiers was real. Increased incidents and threats of domestic
terrorism (e.g., New York City World Trade Center bombing, Tokyo subway
sarin release, Oklahoma City federal building bombing, Atlanta
Centennial Park bombing) as well as numerous anthrax hoaxes around the
country have brought the issue home to civilians as well. Other issues,
including the disclosure of a sophisticated offensive biological warfare
program in the Former Soviet Union (FSU), have reinforced the need for
increased training and education of health care professionals on how to
prevent and treat biological warfare casualties.

Numerous measures to improve preparedness for and response to biological
warfare or terrorism are ongoing at local, state, and federal levels.
Training efforts have increased both in the military and civilian
sectors. The Medical Management of Chemical and Biological Casualties
Course taught at both USAMRIID and USAMRICD trains over 560 military
medical professionals each year on both biological and chemical medical
defense. The highly successful 3-day USAMRIID satellite course on the
Medical Management of Biological Casualties has reached over 40,000
medical personnel over the last three years.

Through this handbook and the training courses noted above, medical
professionals will learn that effective medical countermeasures are
available against many of the bacteria, viruses, and toxins, which might
be, used as biological weapons against our military forces or civilian
communities. The importance of this education cannot be overemphasized
and it is hoped that our physicians, nurses, and allied medical
professionals will develop a solid understanding of the biological
threats we face and the medical armamentarium useful in defending
against these threats.

The global biological warfare threat is serious, and the potential for
devastating casualties is high for certain biological agents. There are
at least 10 countries around the world currently that have offensive
biological weapons programs. However, with appropriate use of medical
countermeasures either already developed or under development, many
casualties can be prevented or minimized.

The purpose for this handbook is to serve as a concise pocket-sized
manual that will guide medical personnel in the prophylaxis and
management of biological casualties. It is designed as a quick reference
and overview, and is not intended as a definitive text on the medical
management of biological casualties.

#### HISTORY OF BIOLOGICAL WARFARE {#history-of-biological-warfare .unnumbered}

#### AND CURRENT THREAT  {#and-current-threat .unnumbered}

The use of biological weapons in warfare has been recorded throughout
history. Two of the earliest reported uses occurred in the 6th century
BC, with the Assyrians poisoning enemy wells with rye ergot, and Solon's
use of the purgative herb hellebore during the siege of Krissa. In 1346,
plague broke out in the Tartar army during its siege of Kaffa (at
present day Feodosia in Crimea). The attackers hurled the corpses of
plague victims over the city walls; the plague epidemic that followed
forced the defenders to surrender, and some infected people who left
Kaffa may have started the Black Death pandemic, which spread throughout
Europe. Russian troops may have used the same tactic against Sweden in
1710.

On several occasions, smallpox was used as a biological weapon. Pizarro
is said to have presented South American natives with
variola-contaminated clothing in the 15th century, and the English did
the same when Sir Jeffery Amherst provided Indians loyal to the French
with smallpox-laden blankets during the French and Indian War of 1754 to
1767. Native Americans defending Fort Carillon sustained epidemic
casualties which directly contributed to the loss of the fort to the
English.

In this century, there is evidence that during World War I, German
agents inoculated horses and cattle with glanders in the U.S. before the
animals were shipped to France. In 1937, Japan started an ambitious
biological warfare program, located 40 miles south of Harbin, Manchuria,
in a laboratory complex code-named "Unit 731". Studies directed by
Japanese General Ishii continued there until 1945, when the complex was
burned. A post World War II investigation revealed that the Japanese
researched numerous organisms and used prisoners of war as research
subjects. Slightly less than 1,000 human autopsies apparently were
carried out at Unit 731, mostly on victims exposed to aerosolized
anthrax. Many more prisoners and Chinese nationals may have died in this
facility - some have estimated up to 3,000 human deaths. Following
reported overflights by Japanese planes suspected of dropping
plague-infected fleas, a plague epidemic ensued in China and Manchuria.
By 1945, the Japanese program had stockpiled 400 kilograms of anthrax to
be used in a specially designed fragmentation bomb.

In 1943, the United States began research into the use of biological
agents for offensive purposes. This work was started, interestingly
enough, in response to a perceived German biological warfare (BW) threat
as opposed to a Japanese one. The United States conducted this research
at Camp Detrick (now Fort Detrick), which was a small National Guard
airfield prior to that time, and produced agents at other sites until
1969, when President Nixon stopped all offensive biological and toxin
weapon research and production by executive order. Between May 1971 and
May 1972, all stockpiles of biological agents and munitions from the now
defunct U.S. program were destroyed in the presence of monitors
representing the United States Department of Agriculture, the Department
of Health, Education, and Welfare, and the states of Arkansas, Colorado,
and Maryland. Included among the destroyed agents were *Bacillus
anthracis*, botulinum toxin, *Francisella tularensis*, *Coxiella
burnetii*, Venezuelan equine encephalitis virus, *Brucella suis*, and
Staphylococcal enterotoxin B. The United States began a medical
defensive program in 1953 that continues today at USAMRIID.

In 1972, the United States, UK, and USSR signed the Convention on the
Prohibition of the Development, Production and Stockpiling of
Bacteriological (Biological) and Toxin Weapons and on Their Destruction,
commonly called the Biological Weapons Convention. Over 140 countries
have since added their ratification. This treaty prohibits the
stockpiling of biological agents for offensive military purposes, and
also forbids research into such offensive employment of biological
agents. However, despite this historic agreement among nations,
biological warfare research continued to flourish in many countries
hostile to the United States. Moreover, there have been several cases of
suspected or actual use of biological weapons. Among the most notorious
of these were the "yellow rain" incidents in Southeast Asia, the use of
ricin as an assassination weapon in London in 1978, and the accidental
release of anthrax spores at Sverdlovsk in 1979.

Testimony from the late 1970's indicated that Laos and Kampuchea were
attacked by planes and helicopters delivering aerosols of several
colors. After being exposed, people and animals became disoriented and
ill, and a small percentage of those stricken died. Some of these clouds
were thought to be comprised of trichothecene toxins (in particular, T2
mycotoxin). These attacks are grouped under the label "yellow rain".
There has been a great deal of controversy about whether these clouds
were truly biological warfare agents. Some have argued that the clouds
were nothing more than feces produced by swarms of bees.

In 1978, a Bulgarian exile named Georgi Markov was attacked in London
with a device disguised as an umbrella. The device injected a tiny
pellet filled with ricin toxin into the subcutaneous tissue of his leg
while he was waiting for a bus. He died several days later. On autopsy,
the tiny pellet was found and determined to contain the toxin. It was
later revealed that the Bulgarian secret service carried out the
assassination, and the technology to commit the crime was supplied by
the former Soviet Union.

In April, 1979, an incident occurred in Sverdlovsk (now Yekaterinburg)
in the former Soviet Union which appeared to be an accidental aerosol
release of *Bacillus anthracis* spores from a Soviet Military
microbiology facility: Compound 19. Residents living downwind from this
compound developed high fever and difficulty breathing, and a large
number died. The Soviet Ministry of Health blamed the deaths on the
consumption of contaminated meat, and for years controversy raged in the
press over the actual cause of the outbreak. All evidence available to
the United States government indicated a massive release of aerosolized
*B. anthracis* spores. In the summer of 1992, U.S. intelligence
officials were proven correct when the new Russian President, Boris
Yeltsin, acknowledged that the Sverdlovsk incident was in fact related
to military developments at the microbiology facility. In 1994, Meselson
and colleagues published an in-depth analysis of the Sverdlovsk incident
(*Science* 266:1202-1208). They documented that all of the cases from
1979 occurred within a narrow zone extending 4 kilometers downwind in a
southerly direction from Compound 19. There were 66 fatalities of the 77
patients identified.

In August, 1991, the United Nations carried out its first inspection of
Iraq's biological warfare capabilities in the aftermath of the Gulf War.
On August 2, 1991, representatives of the Iraqi government announced to
leaders of United Nations Special Commission Team 7 that they had
conducted research into the offensive use of *Bacillus anthracis*,
botulinum toxins, and *Clostridium perfringens* (presumably one of its
toxins). This open admission of biological weapons research verified
many of the concerns of the U.S. intelligence community. Iraq had
extensive and redundant research facilities at Salman Pak and other
sites, many of which were destroyed during the war.

In 1995, further information on Iraq's offensive program was made
available to United Nations inspectors. Iraq conducted research and
development work on anthrax, botulinum toxins, *Clostridium
perfringens*, aflatoxins, wheat cover smut, and ricin. Field trials were
conducted with *Bacillus subtilis* (a simulant for anthrax), botulinum
toxin, and aflatoxin. Biological agents were tested in various delivery
systems, including rockets, aerial bombs, and spray tanks. In December
1990, the Iraqis filled 100 R400 bombs with botulinum toxin, 50 with
anthrax, and 16 with aflatoxin. In addition, 13 Al Hussein (SCUD)
warheads were filled with botulinum toxin, 10 with anthrax, and 2 with
aflatoxin. These weapons were deployed in January 1991 to four
locations. In all, Iraq produced 19,000 liters of concentrated botulinum
toxin (nearly 10,000 liters filled into munitions), 8,500 liters of
concentrated anthrax (6,500 liters filled into munitions) and 2,200
liters of aflatoxin (1,580 liters filled into munitions).

The threat of biological warfare has increased in the last two decades,
with a number of countries working on the offensive use of these agents.
The extensive program of the former Soviet Union is now primarily under
the control of Russia. Former Russian president Boris Yeltsin stated
that he would put an end to further offensive biological research;
however, the degree to which the program was scaled back is not known.
Recent revelations from a senior BW program manager who defected from
Russia in 1992 outlined a remarkably robust biological warfare program,
which included active research into genetic engineering, binary
biologicals and chimeras, and industrial capacity to produce agents.
There is also growing concern that the smallpox virus, now stored in
only two laboratories at the CDC in Atlanta and the Institute for Viral
Precautions in Moscow, may be in other countries around the globe.

There is intense concern in the West about the possibility of
proliferation or enhancement of offensive programs in countries hostile
to the western democracies, due to the potential hiring of expatriate
Russian scientists. It was reported in January 1998 that Iraq had sent
about a dozen scientists involved in BW research to Libya to help that
country develop a biological warfare complex disguised as a medical
facility in the Tripoli area. In a report issued in November 1997,
Secretary of Defense William Cohen singled out Libya, Iraq, Iran, and
Syria as countries "aggressively seeking" nuclear, biological, and
chemical weapons.

Finally, there is an increasing amount of concern over the possibility
of the terrorist use of biological agents to threaten either military or
civilian populations. There have been cases of extremist groups trying
to obtain microorganisms that could be used as biological weapons. The
1995 sarin nerve agent attack in the Tokyo subway system raised
awareness that terrorist organizations could potentially acquire or
develop WMD\'s for use against civilian populations. Subsequent
investigations revealed the organization had attempted to release
botulinum toxins and anthrax on several occasions. The Department of
Defense has been leading a federal effort to train the first responders
in 120 American cities to be prepared to act in case of a domestic
terrorist incident involving WMD. The program will be handed over to the
Department of Justice on October 1, 2000. In the past two years, first
responders, public health and medical personnel, and law enforcement
agencies have dealt with the exponential increase in biological weapons
hoaxes around the country.

Certainly the threat of biological weapons being used against U.S.
military forces and civilians is broader and more likely in various
geographic scenarios than at any point in our history. Therefore,
awareness of this potential threat and education of our leaders, medical
care providers, public health officials, and law enforcement personnel
on how to combat it are crucial.

### DISTINGUISHING BETWEEN NATURAL AND INTENTIONAL DISEASE OUTBREAKS {#distinguishing-between-natural-and-intentional-disease-outbreaks .unnumbered}

With a covert biological agent attack, the most likely first indicator
of an event would be an increased number of patients presenting with
clinical features caused by the disseminated disease agent. Therefore,
health care providers must use epidemiology to detect and respond
rapidly to a biological agent attack.

A sound epidemiologic investigation of a disease outbreak, whether
natural or human-engineered, will assist medical personnel in
identifying the pathogen, as well as instituting the appropriate medical
interventions. Documenting the affected population, possible routes of
exposure, signs and symptoms of disease, along with rapid laboratory
identification of the causative agents, will greatly increase the
ability to institute an appropriate medical and public health response.
Good epidemiologic information can guide the appropriate follow-up of
those potentially exposed, as well as assist in risk communication and
responses to the media.

Many diseases caused by weaponized biological agents present with
nonspecific clinical features that could be difficult to diagnose and
recognize as a biological attack. The disease pattern that develops is
an important factor in differentiating between a natural and a terrorist
or warfare attack. Epidemiologic clues that can potentially indicate an
intentional attack are listed in Table 1. While a helpful guide, it is
important to remember that naturally occurring epidemics can have one or
more of these characteristics and a biological attack may have none.

Once a biological attack or any outbreak of disease is suspected, the
epidemiologic investigation should begin. The conduct of the
investigation will not differ significantly whether or not the outbreak
is intentional. The first step is to confirm that a disease outbreak has
occurred. A case definition should be constructed to determine the
number of cases and the attack rate. The case definition allows
investigators who are separated geographically to use the same criteria
when evaluating the outbreak. The use of objective criteria in the
development of a case definition is very important in determining an
accurate case number, as additional cases may be found and some cases
may be excluded, especially as the potential exists for hysteria to be
confused with actual disease. The estimated rate of illness should be
compared with rates during previous years to determine if the rate
constitutes a deviation from the norm.

Once the attack rate has been determined, the outbreak can be described
by time, place, and person. These data will provide crucial information
in determining the potential source of the outbreak. The epidemic curve
is calculated based on cases over time. In a point-source outbreak,
which is most likely in a biological attack or terrorism situation, the
early parts of the epidemic curve will tend to be compressed compared
with propagated outbreaks. The peak may be in a matter of days or even
hours. Later phases of the curve may also help determine if the disease
appears to spread from person to person, which can be extremely
important for determining effective disease control measures.

Well before any event, public health authorities must implement
surveillance systems so they can recognize patterns of nonspecific
syndromes that could indicate the early manifestations of a biological
warfare attack. The system must be timely, sensitive, specific, and
practical. To recognize any unusual changes in disease occurrence,
surveil­lance of background disease activity should be ongoing, and any
variation should be followed up promptly with a directed examination of
the facts regarding the change.

It is important to remember that recognition of and preparation for a
biological attack is similar to that for any disease outbreak, but the
surveillance, response, and other demands on resources would likely be
of an unparalleled intensity. A strong public health infrastructure with
epidemiologic investigation capability, practical training programs, and
preparedness plans are essential to prevent and control disease
outbreaks, whether they are naturally occurring or otherwise.

Table 1. **Epidemiologic Clues of a Biologic Warfare or Terrorist
Attack**

• The presence of a large epidemic with a similar disease or syndrome,
especially in a discrete population

• Many cases of unexplained diseases or deaths

• More severe disease than is usually expected for a specific pathogen
or failure to respond to standard therapy

• Unusual routes of exposure for a pathogen, such as the inhalational
route for diseases that normally occur through other exposures

• A disease that is unusual for a given geographic area or transmission
season

• Disease normally transmitted by a vector that is not present in the
local area

• Multiple simultaneous or serial epidemics of different diseases in the
same population

• A single case of disease by an uncommon agent (smallpox, some viral
hemorrhagic fevers)

• A disease that is unusual for an age group

• Unusual strains or variants of organisms or antimicrobial resistance
patterns different from those circulating

• Similar genetic type among agents isolated from distinct sources at
different times or locations

• Higher attack rates in those exposed in certain areas, such as inside
a building if released indoors, or lower rates in those inside a sealed
building if released outside

• Disease outbreaks of the same illness occurring in noncontiguous areas

• A disease outbreak with zoonotic impact

• Intelligence of a potential attack, claims by a terrorist or aggressor
of a release, and discovery of munitions or tampering

**[TEN STEPS IN THE MANAGEMENT OF]{.underline}**

**[BIOLOGICAL CASUALTIES ON THE BATTLEFIELD]{.underline}**

Military personnel on the modern battlefield face a wide range of
conventional and unconventional threats. Compared to conventional,
chemical, and nuclear weapon threats, biological weapons are, perhaps,
somewhat unique in their ability to cause confusion, disruption and
panic. It is useful for medical care providers to understand the factors
(Table 1) that account for this ability and for the difficulties they
would be expected to face in dealing with biological casualties.

+-----------------------------------------------------------------------+
| **Potential for massive numbers of casualties**                       |
|                                                                       |
| **Ability to produce lengthy illnesses requiring prolonged and        |
| extensive care**                                                      |
|                                                                       |
| **Ability of certain agents to spread via contagion**                 |
|                                                                       |
| **Paucity of adequate detection systems**                             |
|                                                                       |
| **Diminished role for self-aid & buddy aid, thereby increasing sense  |
| of helplessness**                                                     |
|                                                                       |
| **Presence of an incubation period, enabling victims to disperse      |
| widely**                                                              |
|                                                                       |
| **Ability to produce non-specific symptoms, complicating diagnosis**  |
|                                                                       |
| **Ability to mimic endemic infectious diseases, further complicating  |
| diagnosis**                                                           |
+-----------------------------------------------------------------------+

**Table 1. Characteristics of Biological Weapons and Warfare**

In light of these somewhat unique properties of biological weapons,
medical personnel will require a firm understanding of certain key
elements of biological defense in order to manage effectively the
consequences of a biological attack amidst the confusion expected on the
modern battlefield. Understanding the behavior, pathogenesis, modes of
transmission, diagnostic modalities, and available treatment options for
each of the potential agents thus becomes imperative. Acquiring such an
understanding is relatively straightforward once the identity of the
agent is known; many references (FM 8-9, FM 8-33, FM 8-284), including
this handbook, exist to assist medical personnel in agent-based therapy.
Proper and thorough evaluation and management of a potential biological
attack, before a causative agent is identified, however, is likely to be
complex and problematic. For this reason, we recommend a ten-step
process to guide medical personnel in such evaluation and management.

**I. Maintain an index of suspicion.** The health-care provider on the
modern battlefield must first possess a high index of suspicion
regarding the potential employment of biological weapons. This is due to
the fact that, with many of the biological warfare (BW) diseases, very
early treatment is mandatory if patients are to be salvaged. Anthrax,
botulism, plague, and smallpox are readily prevented if patients are
provided proper antibiotics, antisera, and/or immunization promptly
following exposure. Conversely, all of these diseases may prove fatal if
therapy or prophylaxis is delayed until classic symptoms develop.
Unfortunately, symptoms in the early, or prodromal, phase of illness are
non-specific, making diagnosis difficult. Moreover, many potential BW
diseases, such as Brucellosis, Q-fever, and Venezuelan Equine
Encephalitis (VEE), may never present as more than non-specific febrile
illnesses. Without a high index of suspicion, it is unlikely that the
battlefield provider, especially at lower echelons, removed from
sophisticated laboratory and preventive medicine resources, will
promptly arrive at a proper diagnosis and institute appropriate therapy.

**II. Protect Thyself.** Before medical personnel approach a potential
biological casualty, they must first take steps to protect themselves.
These steps may involve a combination of physical, chemical, and
immunologic forms of protection. On the battlefield, physical protection
typically consists of a protective mask. Designed primarily with
chemical vapor hazards in mind, the M-40 series mask certainly provides
adequate protection against all inhalational BW threats. In fact, a
HEPA-filter (or even a simple surgical) mask will afford adequate
protection against BW (although not against chemical) threats. Chemical
protection refers, in general, to the pre- and/or post-exposure
administration of antibiotics; such strategies are discussed on an
agent-specific basis elsewhere in this book. Immunologic protection
principally involves active immunization and, in the present climate,
applies mainly to protection against anthrax. Again, specific
immunization strategies are discussed throughout this book.

**III. Assess the Patient.** This initial assessment is somewhat
analogous to the primary survey of ATLS management. As such, airway
adequacy should be assessed and breathing and circulation problems
addressed before attention is given to specific management. The initial
assessment is conducted before decontamination is accomplished and
should thus be brief. Historical information of potential interest to
the clinician might include information about illnesses in other unit
members, the presence of unusual munitions, food and water procurement
sources, vector exposure, immunization history, travel history,
occupational duties, and MOPP status. Physical exam at this point should
concentrate on the pulmonary and neuromuscular systems, as well as
unusual dermatologic and vascular findings.

**IV. Decontaminate as Appropriate.** Decontamination plays a very
important role in the approach to chemical casualty management. The
incubation period of biological agents, however, makes it unlikely that
victims of a BW attack will present for medical care until days after an
attack. At this point, the need for decontamination is minimal or
non-existent. In those rare cases where decontamination is warranted,
simple soap and water bathing will usually suffice. Certainly, standard
military decontamination solutions (such as hypochlorite), typically
employed in cases of chemical agent contamination, would be effective
against all biological agents. In fact, even 0.1% bleach reliably kills
anthrax spores, the hardiest of biological agents. Routine use of
caustic substances, especially on human skin, however, is rarely
warranted following a biological attack. More information on
decontamination is included elsewhere in this text.

**V. Establish a Diagnosis.** With decontamination (where warranted)
accomplished, a more thorough attempt to establish a diagnosis can be
carried out. This attempt, somewhat analagous, to the secondary survey
used in the ATLS approach, should involve a combination of clinical,
epidemiologic, and laboratory examinations. The amount of expertise and
support available to the clinician will vary at each echelon of care. At
higher echelons, a full range of laboratory capabilities should enable
definitive diagnosis. At lower echelons, every attempt should be made to
obtain diagnostic specimens from representative patients and forward
these through laboratory channels. Nasal swabs (important for culture
and PCR, even if the clinician is unsure *which* organisms to assay
for), blood cultures, serum, sputum cultures, blood and urine for toxin
analysis, throat swabs, and environmental samples should be considered.

+-----------------------------------+-----------------------------------+
| **[Respiratory]{.underline}**     | **[Casualties]{.underline}**      |
|                                   |                                   |
| **[Rapid-Onset]{.underline}**     | **[Delayed-Onset]{.underline}**   |
|                                   |                                   |
| **Nerve Agents**                  | **Inhalational Anthrax**          |
|                                   |                                   |
| **Cyanide**                       | **Pneumonic Plague**              |
|                                   |                                   |
| **Mustard**                       | **Pneumonic Tularemia**           |
|                                   |                                   |
| **Lewisite**                      | **Q Fever**                       |
|                                   |                                   |
| **Phosgene**                      | **SEB Inhalation**                |
|                                   |                                   |
| **SEB Inhalation**                | **Ricin Inhalation**              |
|                                   |                                   |
|                                   | **Mustard**                       |
|                                   |                                   |
|                                   | **Lewisite**                      |
|                                   |                                   |
|                                   | **Phosgene**                      |
+-----------------------------------+-----------------------------------+
| **[Neurological]{.underline}**    | **[Casualties]{.underline}**      |
|                                   |                                   |
| **[Rapid-Onset]{.underline}**     | **[Delayed-Onset]{.underline}**   |
|                                   |                                   |
| **Nerve Agents**                  | **Botulism-peripheral symptoms**  |
|                                   |                                   |
| **Cyanide**                       | **VEE-CNS symptoms**              |
+-----------------------------------+-----------------------------------+

**Table 2. Diagnostic Matrix: Chemical & Biological Casualties.**

While awaiting laboratory confirmation, a diagnosis must be made on
clinical grounds. Access, at higher echelons, to infectious disease,
preventive medicine, and other specialists, can assist in this process.
At lower echelons, the clinician should, at the very least, be familiar
with the concept of syndromic diagnosis. Chemical and biological warfare
diseases can be generally divided into those that present "immediately"
with little or no incubation or latent period (principally the chemical
agents) and those with a considerable delay in presentation (principally
the biological agents). Moreover, BW diseases are likely to present as
one of a limited number of clinical syndromes. Plague, Tularemia, and
SEB disease all may present as pneumonia. Botulism and VEE may present
with peripheral and central neuromuscular findings, respectively. This
allows the construction of a simple diagnostic matrix as shown in Table
2. Even syndromic diagnosis, however, is complicated by the fact that
many BW diseases (VEE, Q-Fever, Brucellosis) may present simply as
undifferentiated febrile illnesses. Moreover, other diseases (Anthrax,
Plague, Tularemia, Smallpox) have undifferentiated febrile prodromes.

**VI. Render Prompt Treatment.** Unfortunately, it is precisely in the
prodromal phase of many diseases that therapy is most likely to be
effective. For this reason, empiric therapy of pneumonia or
undifferentiated febrile illness on the battlefield might be indicated
under certain circumstances. Table 3 is constructed by eliminating from
consideration those diseases for which definitive therapy is not
warranted, not available, or not critical. Empiric treatment of
respiratory casualties (patients with undifferentiated febrile illnesses
who might have prodromal anthrax, plague, or tularemia would be managed
in a similar manner) might then be entertained. Doxycycline, for
example, is effective against most strains of *B. anthracis, Y. pestis,*
and *F. tularensis,* as well as against *C. burnetii*, and the
*Brucellae*. Other tetracyclines and fluoroquinolones might also be
considered. Keep in mind that such therapy is, in no way, a substitute
for a careful and thorough diagnostic evaluation, when battlefield
conditions permit such an evaluation.

+-----------------------------------+-----------------------------------+
| **[Respiratory]{.underline}**     | **[Casualties]{.underline}**      |
|                                   |                                   |
| **[Rapid-Onset]{.underline}**     | **[Delayed-Onset]{.underline}**   |
|                                   |                                   |
| **Cyanide**                       | **Inhalational Anthrax**          |
|                                   |                                   |
|                                   | **Pneumonic Plague**              |
|                                   |                                   |
|                                   | **Pneumonic Tularemia**           |
+-----------------------------------+-----------------------------------+
| **[Neurological]{.underline}**    | **[Casualties]{.underline}**      |
|                                   |                                   |
| **[Rapid-Onset]{.underline}**     | **[Delayed-Onset]{.underline}**   |
|                                   |                                   |
| **Nerve Agents**                  | **Botulism**                      |
+-----------------------------------+-----------------------------------+

**Table 3. CW & BW Diseases Potentially Requiring Prompt Empiric
Therapy.**

**VII. Practice Good Infection Control.** Standard precautions provide
adequate protection against most infectious diseases, including those
potentially employed in BW. Anthrax, Tularemia, Brucellosis, Glanders,
Q-Fever, VEE, and the Toxin-Mediated diseases are not generally
contagious, and victims can be safely managed using standard
precautions. Such precautions should be familiar to all clinicians.
Under certain circumstances, however, one of three forms of
transmission-based precautions would be warranted. Smallpox victims
should, wherever possible, be managed using airborne precautions.
Pneumonic Plague warrants the use of droplet precautions, and certain
VHFs require contact precautions.

**VIII. Alert the Proper Authorities.** In any military context, the
command should immediately be apprised of casualties suspected due to
chemical or biological agents. The clinical laboratory should also be
notified. This will enable laboratory personnel to take proper
precautions when handling specimens and will also permit the optimal use
of various diagnostic modalities. Chemical Corps and Preventive Medicine
personnel should be contacted to assist in the delineation of
contaminated areas and the search for further victims.

**IX. Assist in the Epidemiologic Investigation.** All health care
providers require a basic understanding of epidemiologic principles.
Even under austere conditions, a rudimentary epidemiologic investigation
may assist in diagnosis and in the discovery of additional BW victims.
Clinicians should, at the very least, query patients about potential
exposures, ill unit members, food/water sources, unusual munitions or
spray devices, vector exposures, and develop a line listing of potential
cases. Such early discovery might, in turn, permit post-exposure
prophylaxis, thereby avoiding excess morbidity and mortality. Preventive
medicine officers, field sanitation personnel, epidemiology technicians,
environmental science officers, and veterinary officers are all
available to assist the clinician in conducting an epidemiologic
investigation.

**X. Maintain Proficiency and Spread the Gospel.** Fortunately, the
threat of BW has remained a theoretical one for most medical personnel.
Inability to practice casualty management, however, can lead to a rapid
loss of skills and knowledge. It is imperative that the medic maintains
proficiency in dealing with this low probability, but high consequence
problem. This can be done, in part, by availing oneself of several
resources. The OTSG (www.nbc-med.org) and USAMRIID
(www.usamriid.army.mil) Web Sites provide a wealth of information,
including the text of this handbook. Annual satellite television
broadcasts, sponsored by USAMRIID, provide in-depth discussion and
training in medical biodefense as well. A CD-ROM training aid is being
developed, and a new field manual (Army FM 8-284) summarizes BW disease
management recommendations. Finally, medical personnel, once aware of
the threat and trained to deal with it, must ensure that other personnel
in their units receive training as well. It is only through ongoing
training that you will be ready to deal with the threat posed by
biological weapons. By familiarizing yourself with the contents of this
handbook, you have taken a large step towards such readiness.

#### BACTERIAL AGENTS {#bacterial-agents .unnumbered}

###  {#section-9 .unnumbered}

Bacteria are unicellular organisms. They vary in shape and size from
spherical cells - cocci - with a diameter of 0.5-1.0 μm (micrometer), to
long rod-shaped organisms - bacilli - which may be from 1-5 μm in size.
Chains of bacilli may exceed 50 μm in length. The shape of the bacterial
cell is determined by the rigid cell wall. The interior of the cell
contains the nuclear material (DNA), cytoplasm, and cell membrane, that
are necessary for the life of the bacterium. Many bacteria also have
glycoproteins on their outer surfaces which aid in bacterial attachment
to cell surface receptors. Under special circumstances some types of
bacteria can transform into spores. The spore of the bacterial cell is
more resistant to cold, heat, drying, chemicals and radiation than the
vegetative bacterium itself. Spores are a dormant form of the bacterium
and, like the seeds of plants, they can germinate when conditions are
favorable.

The term rickettsia generally applies to very small, gram-negative
coccobacillary organisms of the genera *Rickettsia* and *Coxiella*.
Rickettsiae are unique from classical bacteria in their inability to
grow (with rare exceptions) in the absence of a living host cell, but
many are susceptible to treatment with antibiotics.

Bacteria generally cause disease in human beings and animals by one of
two mechanisms: by invading host tissues, and by producing poisons
(toxins). Many pathogenic bacteria utilize both mechanisms. The diseases
they produce often respond to specific therapy with antibiotics. It is
important to distinguish between the disease-causing organism and the
name of the disease it causes (in parentheses below). This manual covers
several of the bacteria or rickettsiae considered to be potential BW
threat agents: *Bacillus anthracis* (Anthrax), *Brucella* spp.
(Brucellosis), *Burkholderia mallei* (Glanders), *Burholderia
pseudomallei* (melioidosis), *Yersinia pestis* (Plague), *Francisella
tularensis* (Tularemia), and *Coxiella burnetii* (Q Fever).

#### ANTHRAX {#anthrax .unnumbered}

##### SUMMARY {#summary .unnumbered}

**Signs and Symptoms:** Incubation period is generally 1-6 days,
although longer periods have been noted. Fever, malaise, fatigue, cough
and mild chest discomfort progresses to severe respiratory distress with
dyspnea, diaphoresis, stridor, cyanosis, and shock. Death typically
occurs within 24-36 hours after onset of severe symptoms.

**Diagnosis:** Physical findings are non-specific. A widened mediastinum
may be seen on CXR in later stages of illness. The organism is
detectable by Gram stain of the blood and by blood culture late in the
course of illness.

**Treatment:** Although effectiveness may be limited after symptoms are
present, high dose antibiotic treatment with penicillin, ciprofloxacin,
or doxycycline should be undertaken. Supportive therapy may be
necessary.

**Prophylaxis:** Oral ciprofloxacin or doxycycline for known or imminent
exposure.

An FDA-licensed vaccine is available. Vaccine schedule is 0.5 ml SC at
0, 2, 4 weeks, then 6, 12, and 18 months (primary series), followed by
annual boosters.

**Isolation and Decontamination:** Standard precautions for healthcare
workers. After an invasive procedure or autopsy is performed, the
instruments and area used should be thoroughly disinfected with a
sporicidal agent (hypochlorite).

##### OVERVIEW {#overview .unnumbered}

*Bacillus anthracis,* the causative agent of Anthrax, is a
gram-positive, sporulating rod. The spores are the usual infective form.
Anthrax is primarily a zoonotic disease of herbivores, with cattle,
sheep, goats, and horses being the usual domesticated animal hosts, but
other animals may be infected. Humans generally contract the disease
when handling contaminated hair, wool, hides, flesh, blood and excreta
of infected animals and from manufactured products such as bone meal.
Infection is introduced through scratches or abrasions of the skin,
wounds, inhalation of spores, eating insufficiently cooked infected
meat, or by biting flies. The primary concern for intentional infection
by this organism is through inhalation after aerosol dissemination of
spores. All human populations are susceptible. The spores are very
stable and may remain viable for many years in soil and water. They
resist sunlight for varying periods.

##### HISTORY AND SIGNIFICANCE {#history-and-significance .unnumbered}

Anthrax spores were weaponized by the United States in the 1950\'s and
1960\'s before the old U.S. offensive program was terminated. Other
countries have weaponized this agent or are suspected of doing so.
Anthrax bacteria are easy to cultivate and spore production is readily
induced. Moreover, the spores are highly resistant to sunlight, heat and
disinfectants - properties which could be advantageous when choosing a
bacterial weapon. Iraq admitted to a United Nations inspection team in
August of 1991 that it had performed research on the offensive use of
*B. anthracis* prior to the Persian Gulf War, and in 1995 Iraq admitted
to weaponizing anthrax. A recent defector from the former Soviet
Union\'s biological weapons program revealed that the Soviets had
produced anthrax in ton quantities for use as a weapon. This agent could
be produced in either a wet or dried form, stabilized for weaponization
by an adversary and delivered as an aerosol cloud either from a line
source such as an aircraft flying upwind of friendly positions, or as a
point source from a spray device. Coverage of a large ground area could
also be theoretically facilitated by multiple spray bomblets
disseminated from a missile warhead at a predetermined height above the
ground.

##### CLINICAL FEATURES {#clinical-features .unnumbered}

Anthrax presents as three somewhat distinct clinical syndromes in
humans: cutaneous, inhalational, and gastrointestinal disease. The
cutaneous form (also referred to as a malignant pustule) occurs most
frequently on the hands and forearms of persons working with infected
livestock. It begins as a papule followed by formation of a fluid-filled
vesicle. The vesicle typically dries and forms a coal-black scab
(eschar), hence the term anthrax (from the Greek for coal). This local
infection can occasionally disseminate into a fatal systemic infection.
Gastrointestinal anthrax is rare in humans, and is contracted by the
ingestion of insufficiently cooked meat from infected animals. Endemic
inhalational anthrax, known as Woolsorters' disease, is also a rare
infection contracted by inhalation of the spores. It occurs mainly among
workers in an industrial setting handling infected hides, wool, and
furs. In man, the mortality of untreated cutaneous anthrax ranges up to
25 per cent; in inhalational and intestinal cases, the case fatality
rate is almost 100 percent.

##### DIAGNOSIS {#diagnosis .unnumbered}

After an incubation period of 1-6 days,\* presumably dependent upon the
dose and strain of inhaled organisms, the onset of inhalation anthrax is
gradual and nonspecific. Fever, malaise, and fatigue may be present,
sometimes in association with a nonproductive cough and mild chest
discomfort. These initial symptoms are often followed by a short period
of improvement (hours to 2-3 days), followed by the abrupt development
of severe respiratory distress with dyspnea, diaphoresis, stridor, and
cyanosis. Septicemia, shock and death usually follow within 24-36 hours
after the onset of respiratory distress. Physical findings are typically
non-specific, especially in the early phase of the disease. The chest
X-ray may reveal a widened mediastinum ± pleural effusions late in the
disease in about 55% of the cases, but typically is without infiltrates.
Pneumonia generally does not occur; therefore, organisms are not
typically seen in the sputum. *Bacillus anthracis* will be detectable by
Gram stain of the blood and by blood culture with routine media, but
often not until late in the course of the illness. Approximately 50% of
cases are accompanied by hemorrhagic meningitis, and therefore organisms
may also be identified in cerebrospinal fluid. Only vegetative
encapsulated bacilli are present during infection. Spores are not found
within the body unless it is open to ambient air. Studies of inhalation
anthrax in non-human primates (rhesus monkey) showed that bacilli and
toxin appear in the blood late on day 2 or early on day 3 post-exposure.
Toxin production parallels the appearance of bacilli in the blood and
tests are available to rapidly detect the toxin. Concurrently with the
appearance of anthrax, the WBC count becomes elevated and remains so
until death.

\*During an outbreak of inhalational anthrax in the Soviet Union in
1979, persons are reported to have become ill up to 6 weeks after an
aerosol release occurred.

##### MEDICAL MANAGEMENT {#medical-management-1 .unnumbered}

Almost all inhalational anthrax cases in which treatment was begun after
patients were significantly symptomatic have been fatal, regardless of
treatment. Penicillin has been regarded as the treatment of choice, with
2 million units given intravenously every 2 hours. Tetracyclines and
erythromycin have been recommended in penicillin allergic patients. The
vast majority of naturally occurring anthrax strains are sensitive *in
vitro* to penicillin. However, penicillin-resistant strains exist
naturally, and one has been recovered from a fatal human case. Moreover,
it might not be difficult for an adversary to induce resistance to
penicillin, tetracyclines, erythromycin, and many other antibiotics
through laboratory manipulation of organisms. All naturally occurring
strains tested to date have been sensitive to erythromycin,
chloramphenicol, gentamicin, and ciprofloxacin. In the absence of
antibiotic sensitivity data, empiric intravenous antibiotic treatment
should be instituted at the earliest signs of disease. Military policy
(FM 8-284) currently recommends ciprofloxacin (400 mg IV q 12 hrs) or
doxycycline (200 mg IV load, followed by 100 mg IV q 12 hrs) as initial
therapy, with penicillin (4 million U IV q 4 hours) as an alternative
once sensitivity data is available. Published recommendations from a
public health consensus panel recommends ciprofloxacin as initial
therapy. Therapy may then be tailored once antibiotic sensitivity is
available to penicillin G or doxycycline. Recommended treatment duration
is 60 days, and should be changed to oral therapy as clinical condition
improves. Supportive therapy for shock, fluid volume deficit, and
adequacy of airway may all be needed.

Standard Precautions are recommended for patient care. There is no
evidence of direct person-to-person spread of disease from inhalational
anthrax. After an invasive procedure or autopsy, the instruments and
area used should be thoroughly disinfected with a sporicidal agent.
Iodine can be used, but must be used at disinfectant strengths, as
antiseptic-strength iodophors are not usually sporicidal. Chlorine, in
the form of sodium or calcium hypochlorite, can also be used, but with
the caution that the activity of hypochlorites is greatly reduced in the
presence of organic material.

##### PROPHYLAXIS {#prophylaxis .unnumbered}

**Vaccine:** A licensed vaccine (Anthrax Vaccine Adsorbed) is derived
from sterile culture fluid supernatant taken from an attenuated strain.
Therefore, the vaccine does not contain live or dead organisms. The
vaccination series consists of six 0.5 ml doses SC at 0, 2, and 4 weeks,
then 6, 12 and 18 months, followed by yearly boosters. A human efficacy
trial in mill workers demonstrated protection against cutaneous anthrax.
There is insufficient data to know its efficacy against inhalational
anthrax in humans, although studies in rhesus monkeys indicate that good
protection can be afforded after only two doses (15 days apart) for up
to 2 years. However, it should be emphasized that the vaccine series
should be completed according to the licensed 6 dose primary series. As
with all vaccines, the degree of protection depends upon the magnitude
of the challenge dose; vaccine-induced protection could presumably be
overwhelmed by extremely high spore challenge. Current military policy
is to restart the primary vaccine series only if greater than two years
elapses between the first and second doses. For all other missed doses,
administer the missed dose ASAP and reset the timeline for the series
based on the most recent dose.

Contraindications for use of this vaccine include hypersensitivity
reaction to a previous dose of vaccine and age \< 18 or \> 65. Reasons
for temporary deferment of the vaccine include pregnancy, active
infection with fever, or a course of immune suppressing drugs such as
steroids. Reactogenicity is mild to moderate. Up to 30 percent of
recipients may experience mild discomfort at the inoculation site for up
to 72 hours (e.g., tenderness, erythema, edema, pruritus), fewer
experience moderate reactions, while less than 1 percent may experience
more severe local reactions, potentially limiting use of the arm for 1-2
days. Modest systemic reactions (e.g., myalgia, malaise, low-grade
fever) are uncommon, and severe systemic reactions such as anaphylaxis,
which precludes additional vaccination, are rare. The vaccine should be
stored between 2-6 ^o^C (refrigerator temperature, not frozen).

**Antibiotics:** Both Military doctrine and a public health consensus
panel recommend prophylaxis with ciprofloxacin (500 mg po bid) as the
first-line medication in a situation with anthrax as the presumptive
agent. Ciprofloxacin recently became the first medication approved by
the FDA for prophylaxis after exposure to a biological weapon (anthrax).
Alternatives are doxycycline (100 mg po bid) or amoxicillin (500mg po q
8 hours), if the strain is susceptible. Should an attack be confirmed as
anthrax, antibiotics should be continued for at least 4 weeks in all
those exposed, and until all those exposed have received three doses of
the vaccine. Those who have already received three doses within 6 months
of exposure should continue with their routine vaccine schedule. In the
absence of vaccine, chemoprophylaxis should continue for at least 60
days. Upon discontinuation of antibiotics, patients should be closely
observed. If clinical signs of anthrax occur, empiric therapy for
anthrax is indicated, pending etiologic diagnosis. Optimally, patients
should have medical care available upon discontinuation of antibiotics,
from a fixed medical care facility with intensive care capabilities and
infectious disease consultants.

**[BRUCELLOSIS]{.underline}**

##### SUMMARY {#summary-1 .unnumbered}

**Signs and Symptoms:** Illness, when manifest, typically presents with
fever, headache, myalgias, arthralgias, back pain, sweats, chills, and
generalized malaise. Other manifestations include depression, mental
status changes, and osteoarticular findings (i.e. Sacroiliitis,
vertebral osteomyelitis). Fatalities are uncommon.

**Diagnosis:** Diagnosis requires a high index of suspicion, since many
infections present as non-specific febrile illnesses or are
asymptomatic. Laboratory diagnosis can be made by blood culture with
prolonged incubation. Bone marrow cultures produce a higher yield.
Confirmation requires phage typing, oxidative metabolism, or genotyping
procedures. ELISA, followed by Western blot are available.

**Treatment:** Antibiotic therapy with doxycycline + rifampin or
doxycycline in combination with other medications for six weeks is
usually sufficient in most cases. More prolonged regimens may be
required for patients with complications of meningoencephalitis,
endocarditis, or osteomyelitis.

**Prophylaxis:** There is no human vaccine available against
brucellosis, although animal vaccines exist. Chemoprophylaxis is not
recommended after possible exposure to endemic disease. Treatment should
be considered for high-risk exposure to the veterinary vaccine,
inadvertent laboratory exposure, or confirmed biological warfare
exposure.

**Isolation and Decontamination:** Standard precautions are appropriate
for healthcare workers. Person-to-person transmission has been reported
via tissue transplantation and sexual contact. Environmental
decontamination can be accomplished with a 0.5% hypochlorite solution.

**OVERVIEW**

Brucellosis is one of the world's most important veterinary diseases,
and is caused by infection with one of six species of *Brucellae,* a
group of gram-negative cocco-baccillary facultative intracellular
pathogens. In animals, brucellosis primarily involves the reproductive
tract, causing septic abortion and orchitis, which, in turn, can result
in sterility. Consequently, brucellosis is a disease of great potential
economic impact in the animal husbandry industry. Four species (*B.
abortus, B. melitensis, B. suis*, and, rarely, *B. canis*) are
pathogenic in humans. Infections in abattoir and laboratory workers
suggest that the *Brucellae* are highly infectious via the aerosol
route. It is estimated that inhalation of only 10 to 100 bacteria is
sufficient to cause disease in man. Brucellosis has a low mortality rate
(5% of untreated cases), with rare deaths caused by endocarditis or
meningitis. Also, given that the disease has a relatively long and
variable incubation period (5-60 days), and that many naturally
occurring infections are asymptomatic, its usefulness as a weapon may be
diminished. Large aerosol doses, however, may shorten the incubation
period and increase the clinical attack rate, and the disease is
relatively prolonged, incapacitating, and disabling in its natural form.

**HISTORY AND SIGNIFICANCE**

Marston described the manifestations of disease caused by *B.
melitensis* ("Mediterranean gastric remittent fever") among British
soldiers on Malta during the Crimean War. Work by the Mediterranean
Fever Commission identified goats as the source, and restrictions on the
ingestion of unpasteurized goat milk products soon decreased the number
of brucellosis cases among military personnel.

In 1954, *Brucella suis* became the first agent weaponized by the United
States at Pine Bluff Arsenal when its offensive BW program was active.
Brucella weapons, along with the remainder of the U.S. biological
arsenal, were destroyed in 1969, when the offensive program was
disbanded.

Human brucellosis is now an uncommon disease in the United States, with
an annual incidence of 0.5 cases per 100,000 population. Most cases are
associated with the ingestion of unpasteurized dairy products, or with
abattoir and veterinary work. The disease is, however, highly endemic in
southwest Asia (annual incidence as high as 128 cases per 100,000 in
some areas of Kuwait), thus representing a hazard to military personnel
stationed in that theater.

**CLINICAL FEATURES**

Brucellosis, also known as "undulant fever", typically presents as a
nonspecific febrile illness resembling influenza. Fever, headache,
myalgias, arthralgias, back pain, sweats, chills, generalized weakness,
and malaise are common complaints. Cough and pleuritic chest pain occurs
in up to twenty percent of cases, but acute pneumonitis is unusual, and
pulmonary symptoms may not correlate with radiographic findings. The
chest x-ray is often normal, but may show lung abscesses, single or
miliary nodules, bronchopneumonia, enlarged hilar lymph nodes, and
pleural effusions. Gastrointestinal symptoms (anorexia, nausea,
vomiting, diarrhea and constipation) occur in up to 70 percent of adult
cases, but less frequently in children. Ileitis, colitis, and
granulomatous or mononuclear infiltrative hepatitis may occur, with
hepato- and splenomegaly present in 45-63 percent of cases.

Lumbar pain and tenderness can occur in up to 60% of brucellosis cases
and are sometimes due to various osteoarticular infections of the axial
skeleton. Vertebral osteomyelitis, intervertebral disc space infection,
paravertebral abscess, and sacroiliac infection occur in a minority of
cases, but may be a cause of chronic symptoms. Consequently, persistent
fever following therapy or the prolonged presence of significant
musculoskeletal complaints should prompt CT or MR imaging.
^99m^Technetium and ^67^Gallium scans are also reasonably sensitive
means for detecting sacroiliitis and other axial skeletal infections.
Joint involvement in brucellosis may vary from pain to joint immobility
and effusion. While the sacroiliac joints are most commonly involved,
peripheral joints (notably, hips, knees, and ankles) may also be
affected. Meningitis complicates a small minority of brucellosis cases,
and encephalitis, peripheral neuropathy, radiculoneuropathy and
meningovascular syndromes have also been observed in rare instances.
Behavioral disturbances and psychoses appear to occur out of proportion
to the height of fever, or to the amount of overt CNS disease. This
raises questions about an ill-defined neurotoxic component of
brucellosis.

**DIAGNOSIS**

Because most cases of brucellosis present as non-specific febrile
illnesses, diagnostic hallmarks are lacking and the disease is often
unsuspected. Maintenance of a high index of suspicion is thus critical
if one is to firmly establish a diagnosis of brucellosis. A history of
animal contact, consumption of unpasteurized dairy and goat-milk
products, or travel to areas where such consumption is common, should
prompt consideration of endemic brucellosis as a diagnosis. The
leukocyte count in brucellosis patients is usually normal but may be
low; anemia and thrombocytopenia may also occur. Blood and bone marrow
cultures during the acute febrile phase of illness yield the organism in
15-70% and 92% of cases, respectively. A biphasic culture method for
blood (Castaneda bottle) may improve the chances of isolation. Clinical
laboratories should always be alerted if a diagnosis of brucellosis is
suspected. This permits the use of selective isolation media and the
implementation of Biosafety Level-3 (BSL-3) safety precautions. A serum
agglutination test (SAT) is available to detect both IgM and IgG
antibodies; a titer of 1:160 or greater is indicative of active disease.
ELISA and PCR methods are becoming more widely utilized.

**MEDICAL MANAGEMENT**

Standard precautions are adequate in managing brucellosis patients, as
the disease is not generally transmissable from person-to-person. As
noted previously, BSL-3 practices should be used when handling suspected
brucella cultures in the laboratory because of the danger of inhalation
in this setting.

Oral antibiotic therapy alone is sufficient in most cases of
brucellosis. Exceptions involve uncommon cases of localized disease,
where surgical intervention may be required (e.g., valve replacement for
endocarditis). A combination of Doxycycline 200 mg/d PO + Rifampin 600
mg/d PO is generally recommended. Both drugs should be administered for
six weeks. Doxycycline 200 mg/d PO for six weeks in combination with two
weeks of Streptomycin (1 g/d IM) is an acceptable alternative. Regimens
involving Doxycycline + Gentamicin, TMP/SMX + Gentamicin, and
Ofloxacin + Rifampin have also been studied and shown effective.
Long-term triple-drug therapy with rifampin, a tetracycline, and an
aminoglycoside is recommended by some experts for patients with
meningoencephalitis or endocarditis.

**PROPHYLAXIS**

The risk of endemic brucellosis can be diminished by the avoidance of
unpasteurized goat-milk and dairy products, especially while travelling
in areas where veterinary brucellosis remains common. Live animal
vaccines are used widely, and have eliminated brucellosis from most
domestic animal herds in the United States, although no licensed human
brucellosis vaccine is available.

Chemoprophylaxis is not generally recommended following possible
exposure to endemic disease. A 3-6 week course of therapy (with one of
the regimens discussed above) should be considered following a high-risk
exposure to veterinary vaccine (such as a needle-stick injury),
inadvertent exposure in a laboratory, or exposure in a biological
warfare context.

#### GLANDERS AND MELIOIDOSIS {#glanders-and-melioidosis .unnumbered}

##### SUMMARY {#summary-2 .unnumbered}

**Signs and Symptoms:** Incubation period ranges from 10-14 days after
inhalation. Onset of symptoms may be abrupt or gradual. Inhalational
exposure produces fever (common in excess of 102 F.), rigors, sweats,
myalgias, headache, pleuritic chest pain, cervical adenopathy,
hepatosplenomegaly, and generalized papular / pustular eruptions. Acute
pulmonary disease can progress and result in bacteremia and acute
septicemic disease. Both diseases are almost always fatal without
treatment.

**Diagnosis:** Methylene blue or Wright stain of exudates may reveal
scant small bacilli with a safety-pin bipolar appearance. Standard
cultures can be used to identify both *B. mallei* and *B. pseudomallei*.
CXR may show miliary lesions, small multiple lung abscesses, or
infiltrates involving upper lungs, with consolidation and cavitation.
Leukocyte counts may be normal or elevated. Serologic tests can help
confirm diagnosis, but low titers or negative serology does not exclude
the diagnosis.

**Treatment:** Therapy will vary with the type and severity of the
clinical presentation. Patients with localized disease, may be managed
with oral antibiotics for a duration of 60-150 days. More severe illness
may require parenteral therapy and more prolonged treatment.

**Prophylaxis:** Currently, no pre-exposure or post-exposure prophylaxis
is available.

**Isolation and Decontamination:** Standard Precautions for healthcare
workers. Person-to-person airborne transmission is unlikely, although
secondary cases may occur through improper handling of infected
secretions. Contact precautions are indicated while caring for patients
with skin involvement. Environmental decontamination using a 0.5%
hypochlorite solution is effective.

#####  {#section-10 .unnumbered}

#####  {#section-11 .unnumbered}

#####  {#section-12 .unnumbered}

#####  {#section-13 .unnumbered}

#####  {#section-14 .unnumbered}

#####  {#section-15 .unnumbered}

#####  {#section-16 .unnumbered}

#####   {#section-17 .unnumbered}

##### OVERVIEW {#overview-1 .unnumbered}

The causative agents of Glanders and Melioidosis are *Burkholderia
mallei* and *Burkholderia pseudomallei,* respectively. Both are
gram-negative bacilli with a "safety-pin" appearance on microscopic
examination. Both pathogens affect domestic and wild animals, which,
like humans, acquire the diseases from inhalation or contaminated
injuries.

*B. mallei* is primarily noted for producing disease in horses, mules,
and donkeys. In the past man has seldom been infected, despite frequent
and often close contact with infected animals. This may be the result of
exposure to low concentrations of organisms from infected sites in ill
animals and because strains virulent for equids are often less virulent
for man. There are four basic forms of disease in horses and man. The
acute forms are more common in mules and donkeys, with death typically
occurring 3 to 4 weeks after illness onset. The chronic form of the
disease is more common in horses and causes generalized lymphadenopathy,
multiple skin nodules that ulcerate and drain, and induration,
enlargement, and nodularity of regional lymphatics on the extremities
and in other areas. The lymphatic thickening and induration has been
called farcy. Human cases have occurred primarily in veterinarians,
horse and donkey caretakers, and abattoir workers.

*B. pseudomallei* is widely distributed in many tropical and subtropical
regions. The disease is endemic in Southeast Asia and northern
Australia. In northeastern Thailand, *B. pseudomallei*, is one of the
most common causative agents of community-acquired septicemia.
Melioidosis presents in humans in several distinct forms, ranging from a
subclinical illness to an overwhelming septicemia, with a 90% mortality
rate and death within 24-48 hours after onset. Also, melioidosis can
reactivate years after primary infection and result in chronic and
life-threatening disease.

These organisms spread to man by invading the nasal, oral, and
conjunctival mucous membranes, by inhalation into the lungs, and by
invading abraded or lacerated skin. Aerosols from cultures have been
observed to be highly infectious to laboratory workers. Biosafety level
3 containment practices are required when working with these organisms
in the laboratory. Since aerosol spread is efficient, and there is no
available vaccine or reliable therapy, *B. mallei* and *B. pseudomallei*
have both been viewed as potential BW agents.

##### HISTORY AND SIGNIFICANCE {#history-and-significance-1 .unnumbered}

Despite the efficiency of spread in a laboratory setting, glanders has
only been a sporadic disease in man, and no epidemics of human disease
have been reported. There have been no naturally acquired cases of human
glanders in the United States in over 61 years. Sporadic cases continue
to occur in Asia, Africa, the Middle East and South America. During
World War I, glanders was believed to have been spread deliberately by
agents of the Central Powers to infect large numbers of Russian horses
and mules on the Eastern Front. This had an effect on troop and supply
convoys as well as on artillery movement, which were dependent on horses
and mules. Human cases in Russia increased with the infections during
and after WWI. The Japanese deliberately infected horses, civilians, and
prisoners of war with *B. mallei* at the Pinfang (China) Institute
during World War II. The United States studied this agent as a possible
BW weapon in 1943-44 but did not weaponize it. The former Soviet Union
is believed to have been interested in *B. mallei* as a potential BW
agent after World War II. The low transmission rates of *B. mallei* to
man from infected horses is exemplified by the fact that in China,
during World War II, thirty percent of tested horses were positive for
glanders, but human cases were rare. In Mongolia, 5-25% of tested
animals were reactive to *B. mallei*, but no human cases were seen. *B.
mallei* exists in nature only in infected susceptible hosts and is not
found in water, soil, or plants.

In contrast, melioidosis is widely distributed in the soil and water in
the tropics, and remains endemic in certain parts of the world, even to
this day. It is one of the few genuinely tropical diseases that are well
established in Southeast Asia and northern Australia. As a result of its
long incubation period, it could be unknowingly imported.

B. pseudomallei was also studied by the United States as a potential BW
agent, but was never weaponized. It has been reported that the former
Soviet Union was experimenting with B. pseudomallei as a BW agent.

##### CLINICAL FEATURES {#clinical-features-1 .unnumbered}

Both glanders and melioidosis may occur in an acute localized form, as
an acute pulmonary infection, or as an acute fulminant, rapidly fatal,
sepsis. Combinations of these syndromes may occur in human cases. Also,
melioidosis may remain asymptomatic after initial acquisition, and
remain quiescent for decades. However, these patients may present with
active melioidosis years later, often associated with an
immune-compromising state.

Aerosol infection produced by a BW weapon containing either *B. mallei*
or *B. pseudomallei* could produce any of these syndromes. The
incubation period ranges from 10- 14 days, depending on the inhaled dose
and agent virulence. The septicemic form begins suddenly with fever,
rigors, sweats, myalgias, pleuritic chest pain, granulomatous or
necrotizing lesions, generalized erythroderma, jaundice, photophobia,
lacrimation, and diarrhea. Physical examination may reveal fever,
tachycardia, cervical adenopathy and mild hepatomegaly or splenomegaly.
Blood cultures are usually negative until the patient is moribund. Mild
leukocytosis with a shift to the left or leukopenia may occur.

The pulmonary form may follow inhalation or arise by hematogenous
spread. Systemic symptoms as described for the septicemic form occur.
Chest radiographs may show miliary nodules (0.5-1.0 cm) and/or a
bilateral bronchopneumonia, segmental, or lobar pneumonia,
consolidation, and cavitating lung lesions

Acute infection of the oral, nasal and/ or conjunctival mucosa can cause
mucopurulent, blood-streaked discharge from the nose, associated with
septal and turbinate nodules and ulcerations. If systemic invasion
occurs from mucosal or cutaneous lesions then a papular and / or
pustular rash may occur that can be mistaken for smallpox (another
possible BW agent). Evidence of dissemination of these infections
includes the presence of skin pustules, abscesses of internal organs,
such as liver and spleen, and multiple pulmonary lesions. This form
carries a high mortality, and most patients develop rapidly progressive
septic shock.

The chronic form is unlikely to be present within 14 days after a BW
aerosol attack. It is characterized by cutaneous and intramuscular
abscesses on the legs and arms. These lesions are associated with
enlargement and induration of the regional lymph channels and nodes. The
chronic form may be asymptomatic, especially with melioidosis. There
have been cases associated with the development of osteomyelitis, brain
abscess, and meningitis.

##### Diagnosis {#diagnosis-1 .unnumbered}

Gram stain of lesion exudates reveals small gram negative, bipolar
bacteria. These stain irregularly with methylene blue or Wright's Stain.
The organisms can be cultured and identified with standard
bacteriological media. The addition of 1-5% glucose, 5 % glycerol, or
meat infusion nutrient agar may accelerate growth. Primary isolation
requires 48 hours at 37.5 ºC. For *B. mallei,* agglutination tests are
not positive for 7-10 days, and a high background titer in normal sera
(1:320 to 1:640) makes interpretation difficult. Complement fixation
tests are more specific and are considered positive if the titer is
equal to, or exceeds 1:20. For *B. pseudomallei,* a four-fold increase
in titer supports the diagnosis of melioidosis. A single titer above
1:160 with a compatible clinical picture suggests active infection.
Occurrence in the absence of animal contact and / or in an epidemic, is
presumptive evidence of a BW attack. Mortality will be high despite
antibiotic use. In the hamster 1 to 10 organisms administered by aerosol
is lethal

##### MEDICAL MANAGEMENT {#medical-management-2 .unnumbered}

Standard Precautions should be used to prevent person-to-person
transmission in proven or suspected cases. The recommended therapy will
vary with the type and severity of the clinical presentation. The
following oral regimens have been suggested for localized disease:
Amoxicillin / clavulanate 60 mg/kg/day in three divided doses;
Tetracycline 40 mg/kg/day in three divided doses; or Trimethoprim /
sulfa (TMP 4 mg/kg/day-sulfa 20 mg/kg/day) in two divided doses. The
duration of treatment should be for 60 - 150 days.

If the patient has localized disease with signs of mild toxicity, then a
combination of two of the oral regimens is recommended for a duration of
30 days, followed by monotherapy with either amoxicillin / clavulanate
or TMP / sulfa for 60 - 150 days. If extrapulmonary suppurative disease
is present, then therapy should continue for 6-12 months. Surgical
drainage of abscesses may be required.

For severe disease, parental therapy with Ceftazidime 120 mg/kg/day in
three divided doses combined with TMP/sulfa (TMP 8 mg/kg/day -- sulfa 40
mg/kg/day) in four divided doses for 2 weeks, followed by oral therapy
for 6 months.

Other antibiotics that have been effective in experimental infection in
hamsters include doxycycline, rifampin, and ciprofloxacin. The limited
number of infections in humans has precluded therapeutic evaluation of
most of the antibiotic agents; therefore, most antibiotic sensitivities
are based on animal and *in vitro* studies. Various isolates have
markedly different antibiotic sensitivities; therefore, each isolate
should be tested for its own resistance pattern.

##### PROPHYLAXIS {#prophylaxis-1 .unnumbered}

**Vaccine:** There is no vaccine available for human use.

**Antibiotics:** Post-exposure chemoprophylaxis may be tried with
TMP-SMX.

#### PLAGUE {#plague .unnumbered}

##### SUMMARY {#summary-3 .unnumbered}

**Signs and Symptoms:** Pneumonic plague begins after an incubation
period of 1-6 days, with high fever, chills, headache, malaise, followed
by cough (often with hemoptysis), progressing rapidly to dyspnea,
stridor, cyanosis, and death. Gastrointestinal symptoms are often
present. Death results from respiratory failure, circulatory collapse,
and a bleeding diathesis. Bubonic plague, featuring high fever, malaise,
and painful lymph nodes (buboes) may progress spontaneously to the
septicemic form (septic shock, thrombosis, DIC) or to the pneumonic
form.

**Diagnosis:** Suspect plague if large numbers of previously healthy
individuals develop fulminant Gram negative pneumonia, especially if
hemoptysis is present. Presumptive diagnosis can be made by Gram,
Wright, Giemsa or Wayson stain of blood, sputum, CSF, or lymph node
aspirates. Definitive diagnosis requires culture of the organism from
those sites. Immunodiagnosis is also helpful.

**Treatment:** Early administration of antibiotics is critical, as
pneumonic plague is invariably fatal if antibiotic therapy is delayed
more than 1 day after the onset of symptoms. Choose one of the
following: streptomycin, gentamicin, ciprofloxacin, or doxycycline for
10-14 days. Chloramphenicol is the drug of choice for plague meningitis.

**Prophylaxis:** For asymptomatic persons exposed to a plague aerosol or
to a patient with suspected pneumonic plague, give doxycycline 100 mg
orally twice daily for seven days or the duration of risk of exposure
plus one week. Alternative antibiotics include ciprofloxacin,
tetracycline, or chloramphenicol. No vaccine is currently available for
plague prophylaxis. The previously available licensed, killed vaccine
was effective against bubonic plague, but not against aerosol exposure.

**Isolation and Decontamination:** Use Standard Precautions for bubonic
plague, and Respiratory Droplet Precautions for suspected pneumonic
plague. *Y. pestis* can survive in the environment for varying periods,
but is susceptible to heat, disinfectants, and exposure to sunlight.
Soap and water is effective if decon is needed. Take measures to prevent
local disease cycles if vectors (fleas) and reservoirs (rodents) are
present.

##### OVERVIEW {#overview-2 .unnumbered}

*Yersinia pestis* is a rod-shaped, non-motile, non-sporulating,
gram-negative bacterium of the family *Enterobacteraceae*. It causes
plague, a zoonotic disease of rodents (e.g., rats, mice, ground
squirrels). Fleas that live on the rodents can transmit the bacteria to
humans, who then suffer from the bubonic form of plague. The bubonic
form may progress to the septicemic and/or pneumonic forms. Pneumonic
plague would be the predominant form after a purposeful aerosol
dissemination. All human populations are susceptible. Recovery from the
disease is followed by temporary immunity. The organism remains viable
in water, moist soil, and grains for several weeks. At near freezing
temperatures, it will remain alive from months to years but is killed by
15 minutes of exposure to 55°C. It also remains viable for some time in
dry sputum, flea feces, and buried bodies but is killed within several
hours of exposure to sunlight.

##### HISTORY AND SIGNIFICANCE {#history-and-significance-2 .unnumbered}

The United States worked with *Y. pestis* as a potential biowarfare
agent in the 1950\'s and 1960\'s before the old offensive biowarfare
program was terminated, and other countries are suspected of weaponizing
this organism. The former Soviet Union had more than 10 institutes and
thousands of scientists who worked with plague. During World War II,
Unit 731, of the Japanese Army, reportedly released plague-infected
fleas from aircraft over Chinese cities. This method was cumbersome and
unpredictable. The U.S. and Soviet Union developed the more reliable and
effective method of aerosolizing the organism. The interest in the
terrorist potential of plague was brought to light in 1995 when Larry
Wayne Harris was arrested in Ohio for the illicit procurement of a *Y.
pestis* culture through the mail. The contagious nature of pneumonic
plague makes it particularly dangerous as a biological weapon.

##### CLINICAL FEATURES {#clinical-features-2 .unnumbered}

Plague normally appears in three forms in man: bubonic, septicemic, and
pneumonic. The bubonic form begins after an incubation period of 2-10
days, with acute and fulminant onset of nonspecific symptoms, including
high fever, malaise, headache, myalgias, and sometimes nausea and
vomiting. Up to half of patients will have abdominal pain. Simultaneous
with or shortly after the onset of these nonspecific symptoms, the bubo
develops -- a swollen, very painful, infected lymph node. Buboes are
normally seen in the femoral or inguinal lymph nodes as the legs are the
most commonly flea-bitten part of the adult human body. The liver and
spleen are often tender and palpable. One quarter of patients will have
various types of skin lesions: a pustule, vesicle, eschar or papule
(containing leukocytes and bacteria) in the lymphatic drainage of the
bubo, and presumably representing the site of the inoculating flea bite.
Secondary septicemia is common, as greater than 80 percent of blood
cultures are positive for the organism in patients with bubonic plague.
However, only about a quarter of bubonic plague patients progress to
clinical septicemia.

In those that do progress to secondary septicemia, as well as those
presenting septicemic but without lymphadenopathy (primary septicemia),
the symptoms are similar to other Gram-negative septicemias: high fever,
chills, malaise, hypotension, nausea, vomiting, and diarrhea. However,
plague septicemia can also produce thromboses in the acral vessels, with
necrosis and gangrene, and DIC. Black necrotic appendages and more
proximal purpuric lesions caused by endotoxemia are often present.
Organisms can spread to the central nervous system, lungs, and
elsewhere. Plague meningitis occurs in about 6% of septicemic and
pneumonic cases.

Pneumonic plague is an infection of the lungs due to either inhalation
of the organisms (primary pneumonic plague), or spread to the lungs from
septicemia (secondary pneumonic plague). After an incubation period
varying from 1 to 6 days for primary pneumonic plague (usually 2-4 days,
and presumably dose-dependent), onset is acute and often fulminant. The
first signs of illness include high fever, chills, headache, malaise,
and myalgias, followed within 24 hours by a cough with bloody sputum.
Although bloody sputum is characteristic, it can sometimes be watery or,
less commonly, purulent. Gastrointestinal symptoms, including nausea,
vomiting, diarrhea, and abdominal pain, may be present. Rarely, a
cervical bubo might result from an inhalational exposure. The chest
X-ray findings are variable, but most commonly reveal bilateral
infiltrates, which may be patchy or consolidated. The pneumonia
progresses rapidly, resulting in dyspnea, stridor, and cyanosis. The
disease terminates with respiratory failure, and circulatory collapse.

Nonspecific laboratory findings include a leukocytosis, with a total WBC
count up to 20,000 cells with increased bands, and greater than 80
percent polymorphonuclear cells. One also often finds increased fibrin
split products in the blood indicative of a low-grade DIC. The BUN,
creatinine, ALT, AST, and bilirubin may also be elevated, consistent
with multiorgan failure.

In man, the mortality of untreated bubonic plague is approximately 60
percent (reduced to \<5% with prompt effective therapy), whereas in
untreated pneumonic plague the mortality rate is nearly 100 percent, and
survival is unlikely if treatment is delayed beyond 18 hours of
infection. In the U.S. in the past 50 years, 4 of the 7 pneumonic plague
patients (57%) died. Recent data from the ongoing Madagascar epidemic,
which began in 1989, corroborate that figure; the mortality associated
with respiratory involvement was 57%, while that for bubonic plague was
15%.

##### DIAGNOSIS {#diagnosis-2 .unnumbered}

Diagnosis is based primarily on clinical suspicion. The sudden
appearance of large numbers of previously healthy patients with severe,
rapidly progressive pneumonia with hemoptysis strongly suggests plague.
A presumptive diagnosis can be made microscopically by identification of
the coccobacillus in Gram, Wright, Giemsa, or Wayson\'s stained smears
from lymph node needle aspirate, sputum, blood, or cerebrospinal fluid
samples. When available, immunofluorescent staining is very useful.
Definitive diagnosis relies on culturing the organism from blood,
sputum, CSF, or bubo aspirates. The organism grows slowly at normal
incubation temperatures, and may be misidentified by automated systems
because of delayed biochemical reactions. It may be cultured on blood
agar, MacConkey agar or infusion broth. Most naturally occurring strains
of *Y. pestis* produce an F1-antigen *in vivo*, which can be detected in
serum samples by immunoassay. A four-fold rise in antibody titer in
patient serum is retrospectively diagnostic. PCR (using specific
primers), although not sufficiently developed and evaluated for routine
use, is a very sensitive and specific technique, currently able to
identify as few as 10 organisms per ml. Most clinical assays can be
performed in Biosafety Level 2 (BSL-2) labs, whereas procedures
producing aerosols or yielding significant quantities of organisms
require BSL-3 containment.

##### MEDICAL MANAGEMENT {#medical-management-3 .unnumbered}

Use Standard Precautions for bubonic plague patients. Suspected
pneumonic plague cases require strict isolation with Droplet Precautions
for at least 48 hours of antibiotic therapy, or until sputum cultures
are negative in confirmed cases. If competent vectors (fleas) and
reservoirs (rodents) are present, measures must be taken to prevent
local disease cycles. These might include, but are not limited to, use
of flea insecticides, rodent control measures (after or during flea
control), and flea barriers for patient care areas.

Streptomycin, gentamicin, doxycycline, and chloramphenicol are highly
effective, if begun early. Plague pneumonia is almost always fatal if
treatment is not initiated within 24 hours of the onset of symptoms.
Dosage regimens are as follows: streptomycin, 30 mg/kg/day IM in two
divided doses; gentamicin, 5mg/kg IM or IV once daily, or 2mg/kg loading
dose followed by 1.75 mg/kg IM or IV every 8 hours; doxycycline 200 mg
initially, followed by 100 mg every 12 hours. Duration of therapy is 10
to 14 days. While the patient is typically afebrile after 3 days, the
extra week of therapy prevents relapses. Results obtained from
laboratory animal, but not human, experience, indicate that quinolone
antibiotics, such as ciprofloxacin and ofloxacin, may also be effective.
Recommended dosage of ciprofloxacin is 400mg IV twice daily.
Chloramphenicol, 25 mg/kg IV loading dose followed by 15 mg/kg IV four
times daily x 10-14 days, is required for the treatment of plague
meningitis.

Usual supportive therapy includes IV crystalloids and hemodynamic
monitoring. Although low-grade DIC may occur, clinically significant
hemorrhage is uncommon, as is the need to treat with heparin. Endotoxic
shock is common, but pressor agents are rarely needed. Finally, buboes
rarely require any form of local care, but instead recede with systemic
antibiotic therapy. In fact, incision and drainage poses a risk to
others in contact with the patient; aspiration is recommended for
diagnostic purposes and may provide symptomatic relief.

##### PROPHYLAXIS {#prophylaxis-2 .unnumbered}

**Vaccine:** No vaccine is currently available for prophylaxis of
plague. A licensed, killed whole cell vaccine was available in the U.S.
from 1946 until November 1998. It offered protection against bubonic
plague, but was not effective against aerosolized *Y. pestis*.
Presently, an F1-V antigen (fusion protein) vaccine is in development at
USAMRIID. It protected mice for a year against an inhalational
challenge, and is now being tested in primates.

**Antibiotics:** Face-to-face contacts (within 2 meters) of patients
with pneumonic plague or persons possibly exposed to a plague aerosol in
a plague BW attack) should be given antibiotic prophylaxis for seven
days or the duration of risk of exposure plus seven days. If fever or
cough occurs in these individuals, treatment with antibiotics should be
started. Because of oral administration and relative lack of toxicity,
the choice of antibiotic for prophylaxis is doxycycline 100 mg orally
twice daily. Ciprofloxacin 500 mg orally twice daily has also shown to
be effective in preventing disease in exposed mice, and may be more
available in a wartime setting as it is also distributed in blister
packs for anthrax post-exposure prophylaxis. Tetracycline, 500 mg orally
four times daily, and chloramphenicol, 25 mg/kg orally four times daily,
are acceptable alternatives. Contacts of bubonic plague patients need
only be observed for symptoms for a week. If symptoms occur, start
treatment antibiotics.

#### Q FEVER {#q-fever .unnumbered}

##### SUMMARY {#summary-4 .unnumbered}

**Signs and Symptoms:** Fever, cough, and pleuritic chest pain may occur
as early as ten days after exposure. Patients are not generally
critically ill, and the illness lasts from 2 days to 2 weeks.

**Diagnosis:** Q fever is not a clinically distinct illness and may
resemble a viral illness or other types of atypical pneumonia. The
diagnosis is confirmed serologically.

**Treatment:** Q fever is generally a self-limited illness even without
treatment, but tetracycline or doxycycline should be given orally for 5
to 7 days to prevent complications of the disease. Q fever endocarditis
(rare) is much more difficult to treat.

**Prophylaxis:** Chemoprophylaxis begun too early during the incubation
period may delay but not prevent the onset of symptoms. Therefore,
tetracycline or doxycycline should be started 8-12 days post exposure
and continued for 5 days. This regimen has been shown to prevent
clinical disease. An inactivated whole cell IND vaccine is effective in
eliciting protection against exposure, but severe local reactions to
this vaccine may be seen in those who already possess immunity.
Therefore, an intradermal skin test is recommended to detect
pre-sensitized or immune individuals.

**Isolation and Decontamination:** Standard Precautions are recommended
for healthcare workers. Person-to-person transmission is rare. Patients
exposed to Q fever by aerosol do not present a risk for secondary
contamination or re-aerosolization of the organism. Decontamination is
accomplished with soap and water or a 0.5% chlorine solution on
personnel. The M291 skin decontamination kit will not neutralize the
organism.

##### OVERVIEW {#overview-3 .unnumbered}

The endemic form of Q fever is a zoonotic disease caused by the
rickettsia, *Coxiella burnetii*. Its natural reservoirs are sheep,
cattle, goats, dogs, cats and birds. The organism grows to especially
high concentrations in placental tissues. The infected animals do not
develop the disease, but do shed large numbers of the organisms in
placental tissues and body fluids including milk, urine, and feces.
Exposure to infected animals at parturition is an important risk factor
for endemic disease. Humans acquire the disease by inhalation of
aerosols contaminated with the organisms. Farmers and abattoir workers
are at greatest risk occupationally. A biological warfare attack with Q
fever would cause a disease similar to that occurring naturally. Q fever
is also a significant hazard in laboratory personnel who are working
with the organism.

##### HISTORY AND SIGNIFICANCE {#history-and-significance-3 .unnumbered}

Q fever was first described in Australia and called "Query fever"
because the causative agent was initially unknown. *Coxiella burnetii*,
discovered in 1937, is a rickettsial organism that is resistant to heat
and desiccation and highly infectious by the aerosol route. A single
inhaled organism may produce clinical illness. For all of these reasons,
Q fever could be used by an adversary as an incapacitating biological
warfare agent.

##### CLINICAL FEATURES {#clinical-features-3 .unnumbered}

Following the usual incubation period of 2-14 days, Q fever generally
occurs as a self-limiting febrile illness lasting 2 days to 2 weeks. The
incubation period varies according to the numbers of organisms inhaled,
with longer periods between exposure and illness with lower numbers of
inhaled organisms (up to forty days in some cases). The disease
generally presents as an acute non-differentiated febrile illness, with
headaches, fatigue, and myalgias as prominent symptoms. Physical
examination of the chest is usually normal. Pneumonia, manifested by an
abnormal chest x-ray, occurs in half of all patients, but only around
half of these, or 28 percent of patients, will have a cough (usually
non-productive) or rales. Pleuritic chest pain occurs in about
one-fourth of patients with Q fever pneumonia. Chest radiograph
abnormalities, when present, are patchy infiltrates that may resemble
viral or mycoplasma pneumonia. Rounded opacities and adenopathy have
also been described.

Approximately 33 percent of Q fever cases will develop acute hepatitis.
This can present with fever and abnormal liver function tests with the
absence of pulmonary signs and symptoms. Uncommon complications include
chronic hepatitis, culture-negative endocarditis, aseptic meningitis,
encephalitis and osteomyelitis. Most patients who develop endocarditis
have pre-existing valvular heart disease.

##### DIAGNOSIS {#diagnosis-3 .unnumbered}

**Differential Diagnosis:** Since Q fever usually presents as an
undifferentiated febrile illness, or a primary atypical pneumonia, it
may be difficult to distinguish from viral illnesses and must be
differentiated from pneumonia caused by *Mycoplasma pneumoniae,
Legionella pneumophila, Chlamydia psittaci*, and *Chlamydia pneumoniae*
(TWAR). More rapidly progressive forms of Q fever pneumonia may look
like bacterial pneumonias such as tularemia or plague. Significant
numbers of soldiers (from the same geographic area) presenting over a
one to two week period with a nonspecific febrile illness, and
associated pulmonary symptoms in about a quarter of cases, should
trigger the treating physicians to consider the possibility of an attack
with aerosolized Q fever. The diagnosis will often rest on the clinical
and epidemiologic picture in the setting of a possible biowarfare
attack.

**Laboratory Diagnosis:** A leukocytosis may be present in one third of
patients. Most patients with Q fever have a mild elevation of hepatic
transaminase levels. Identification of organisms by examination of the
sputum is not helpful. Isolation of the organism is impractical, as the
organism is difficult to culture and a significant hazard to laboratory
workers. Serological tests for Q fever include identification of
antibody to *C. burnetii* by indirect fluorescent antibody (IFA),
enzyme-linked immunosorbent assay (ELISA), and complement fixation.
Specific IgM antibodies may be detectable as early as the second week
after onset of illness. ELISA testing is available at USAMRIID. A single
serum specimen can be used to reliably diagnose acute Q fever with this
test as early as 1 1/2 - 2 weeks into the illness. The most commonly
available serologic test is the complement fixation test (CF) which is
relatively insensitive and may not be useful if sera have intrinsic
anti-complement activity.

##### MEDICAL MANAGEMENT {#medical-management-4 .unnumbered}

Standard Precautions are recommended for healthcare workers. Most cases
of acute Q fever will eventually resolve without antibiotic treatment,
but all suspected cases of Q fever should be treated to reduce the risk
of complications. Tetracycline 500 mg every 6 hr or doxycycline 100 mg
every 12 hr for 5-7 days will shorten the duration of illness, and fever
usually disappears within one to two days after treatment is begun.
Ciprofloxacin and other quinolones are active in vitro and should be
considered in patients unable to take tetracycline or doxycycline.
Successful treatment of Q fever endocarditis is much more difficult.
Tetracycline or doxycycline given in combination with
trimethoprim-sulfamethoxazole (TMP-SMX) or rifampin for 12 months or
longer has been successful in some cases. However, valve replacement is
often required to achieve a cure.

##### PROPHYLAXIS {#prophylaxis-3 .unnumbered}

**Vaccine**: A formalin-inactivated whole cell IND vaccine is available
for immunization of at-risk personnel on an investigational basis,
although a Q fever vaccine is licensed in Australia. Vaccination with a
single dose of this killed suspension of *C. burnetii* provides complete
protection against naturally occurring Q fever, and greater than 95
percent protection against aerosol exposure. Protection lasts for at
least 5 years. Administration of this vaccine in immune individuals may
cause severe local induration, sterile abscess formation, and even
necrosis at the inoculation site. This observation led to the
development of an intradermal skin test using 0.02 mg of specific
formalin-killed whole-cell vaccine to detect presensitized or immune
individuals.

####  Antibiotics: Chemoprophylaxis using Tetracycline 500 mg every 6 hours or doxycycline 100 mg every 12 hours for 5--7 days is effective if begun 8-12 days post exposure. Chemoprophylaxis is not effective and may only prolong the onset of disease if given immediately (1 to 7 days) after exposure.  {#antibiotics-chemoprophylaxis-using-tetracycline-500-mg-every-6-hours-or-doxycycline-100-mg-every-12-hours-for-57-days-is-effective-if-begun-8-12-days-post-exposure.-chemoprophylaxis-is-not-effective-and-may-only-prolong-the-onset-of-disease-if-given-immediately-1-to-7-days-after-exposure. .unnumbered}

#### TULAREMIA {#tularemia .unnumbered}

##### SUMMARY {#summary-5 .unnumbered}

**Signs and Symptoms:** Ulceroglandular tularemia presents with a local
ulcer and regional lymphadenopathy, fever, chills, headache and malaise.
Typhoidal tularemia presents with fever, headache, malaise, substernal
discomfort, prostration, weight loss and a non-productive cough.

**Diagnosis:** Clinical diagnosis. Physical findings are usually
non-specific. Chest x-ray may reveal a pneumonic process, mediastinal
lymphadenopathy or pleural effusion. Routine culture is possible but
difficult. The diagnosis can be established retrospectively by serology.

**Treatment:** Administration of antibiotics (streptomycin or
gentamicin) with early treatment is very effective.

**Prophylaxis:** A live, attenuated vaccine is available as an
investigational new drug. It is administered once by scarification. A
two-week course of tetracycline is effective as prophylaxis when given
after exposure.

**Isolation and Decontamination:** Standard Precautions for healthcare
workers. Organisms are relatively easy to render harmless by mild heat
(55 degrees Celsius for 10 minutes) and standard disinfectants.

##### OVERVIEW {#overview-4 .unnumbered}

*Francisella tularensis,* the causative agent of tularemia, is a small,
aerobic non-motile, gram-negative cocco-bacillus. Tularemia (also known
as rabbit fever and deer fly fever) is a zoonotic disease that humans
typically acquire after skin or mucous membrane contact with tissues or
body fluids of infected animals, or from bites of infected ticks,
deerflies, or mosquitoes. Less commonly, inhalation of contaminated
dusts or ingestion of contaminated foods or water may produce clinical
disease. Respiratory exposure by aerosol would typically cause typhoidal
or pneumonic tularemia. *F. tularensis* can remain viable for weeks in
water, soil, carcasses, hides, and for years in frozen rabbit meat. It
is resistant for months to temperatures of freezing and below. It is
easily killed by heat and disinfectants.

##### HISTORY AND SIGNIFICANCE {#history-and-significance-4 .unnumbered}

Tularemia was recognized in Japan in the early 1800's and in Russia in
1926. In the early 1900's, American workers investigating suspected
plague epidemics in San Francisco isolated the organism and named it
*Bacterium tularense* after Tulare County, California where the work was
performed. Dr. Edward Francis, USPHS, established the cause of deer-fly
fever as *Bacterium tularense* and subsequently devoted his life to
researching the organism and disease, hence, the organism was later
renamed *Francisella tularensis*

*Francisella tularensis* was weaponized by the United States in the
1950\'s and 1960\'s during the U.S. offensive biowarfare program, and
other countries are suspected to have weaponized this agent. This
organism could potentially be stabilized for weaponization by an
adversary and theoretically produced in either a wet or dried form, for
delivery against U.S. forces in a similar fashion to the other bacteria
discussed in this handbook.

##### CLINICAL FEATURES {#clinical-features-4 .unnumbered}

After an incubation period varying from 1-21 days (average 3-5 days),
presumably dependent upon the dose of organisms, onset is usually acute.
Tularemia typically appears in one of six forms in man depending upon
the route of inoculation: typhoidal, ulceroglandular, glandular,
oculoglandular, oropharyngeal, and pneumonic tularemia. In humans, as
few as 10 to 50 organisms will cause disease if inhaled or injected
intradermally, whereas approximately 10^8^ organisms are required with
oral challenge.

[Typhoidal tularemia]{.underline} (5-15 percent of naturally acquired
cases) occurs mainly after inhalation of infectious aerosols, but can
occur after intradermal or gastrointestinal challenge. *F. tularensis*
would presumably be most likely delivered by aerosol in a BW attack and
would primarily cause typhoidal tularemia. It manifests as fever,
prostration, and weight loss, but unlike most other forms of the
disease, presents without lymphadenopathy. Pneumonia may be severe and
fulminant and can be associated with any form of tularemia (30% of
ulceroglandular cases), but it is most common in typhoidal tularemia
(80% of cases). Respiratory symptoms, substernal discomfort, and a cough
(productive and non-productive) may also be present. Case fatality rates
following a BW attack may be greater than the 1-3 % seen with
appropriately treated natural disease. Case fatality rates are about 35%
in untreated naturally acquired typhoidal cases.

[Ulceroglandular tularemia]{.underline} (75-85 percent of cases) is most
often acquired through inoculation of the skin or mucous membranes with
blood or tissue fluids of infected animals. It is characterized by
fever, chills, headache, malaise, an ulcerated skin lesion, and painful
regional lymphadenopathy. The skin lesion is usually located on the
fingers or hand where contact occurs.

[Glandular tularemia]{.underline} (5-10 percent of cases) results in
fever and tender lymphadenopathy but no skin ulcer.

[Oculoglandular tularemia]{.underline} (1-2 percent of cases) occurs
after inoculation of the conjunctivae by contaminated hands, splattering
of infected tissue fluids, or by aerosols. Patients have unilateral,
painful, purulent conjunctivitis with preauricular or cervical
lymphadenopathy. Chemosis, periorbital edema, and small nodular lesions
or ulcerations of the palpebral conjunctiva are noted in some patients.

[Oropharyngeal tularemia]{.underline} refers to primary ulceroglandular
disease confined to the throat. It produces an acute exudative or
membranous pharyngotonsillitis with cervical lymphadenopathy.

[Pneumonic tularemia]{.underline} is a severe atypical pneumonia that
may be fulminant and with a high case fatality rate if untreated. It can
be primary following inhalation of organisms or secondary following
hematogenous / septicemic spread. It is seen in 30-80 percent of the
typhoidal cases and in 10-15 percent of the ulceroglandular cases.

The case fatality rate without treatment is approximately 5 percent for
the ulceroglandular form and 35 percent for the typhoidal form. All ages
are susceptible, and recovery is generally followed by permanent
immunity.

##### DIAGNOSIS {#diagnosis-4 .unnumbered}

A clue to the diagnosis of tularemia subsequent to a BW attack with *F.
tularensis* might be a large number of temporally clustered patients
presenting with similar systemic illnesses and a non-productive
pneumonia.

The clinical presentation of tularemia may be severe, yet non-specific.
Differential diagnoses include typhoidal syndromes (e.g., salmonella,
rickettsia, malaria) or pneumonic processes (e.g., plague, mycoplasma,
SEB).

Radiological evidence of pneumonia or mediastinal lymphadenopathy is
most common with typhoidal disease. In general, chest radiographs show
that approximately 50% of patients have pneumonia, and fewer than 1%
have hilar adenopathy without parenchymal involvement. Pleural effusions
are seen in 15% of patients with pneumonia. Interstitial patterns,
cavitary lesions, bronchopleural fistulae, and calcifications have been
reported in patients with tularemia pneumonia.

[Laboratory diagnosis]{.underline}. Initial laboratory evaluations are
generally nonspecific. Peripheral white blood cell count usually ranges
from 5,000 to 22,000 cells per microliter. Differential blood cell
counts are normal, with occasional lymphocytosis late in the disease.
Hematocrit, hemoglobin, and platelet levels are usually normal. Mild
elevations in lactic dehydrogenase, serum transaminases, and alkaline
phosphatase are common. Rhabdomyolysis may be associated with elevations
in serum creatine kinase and urinary myoglobin levels. Cerebrospinal
fluid is usually normal, although mild abnormalities in protein,
glucose, and blood cell count have been reported.

Tularemia can be diagnosed by recovery of the organism in culture from
blood, ulcers, conjunctival exudates, sputum, gastric washings, and
pharyngeal exudates. Recovery may even be possible after the institution
of appropriate antibiotic therapy. The organism grows poorly on standard
media but produces small, smooth, opaque colonies after 24 to 48 hours
on media containing cysteine or other sulfhydryl compounds (e.g.,
glucose cysteine blood agar, thioglycollate broth). Isolation represents
a clear hazard to laboratory personnel and culture should only be
attempted in BSL-3 containment.

Most diagnoses of tularemia are made serologically using bacterial
agglutination or enzyme-linked immunosorbent assay (ELISA). Antibodies
to *F. tularensis* appear within the first week of infection but levels
adequate to allow confidence in the specificity of the serologic
diagnosis (titer \> 1:160) do not appear until more than 2 weeks after
infection. Because cross-reactions can occur with *Brucella* spp.,
Proteus OX19, and Yersinia organisms and because antibodies may persist
for years after infection, diagnosis should be made only if a 4-fold or
greater increase in the tularemia tube agglutination or
microagglutination titer is seen during the course of the illness.
Titers are usually negative the first week of infection, positive the
second week in 50-70 percent of cases and reach a maximum in 4-8 weeks.

##### MEDICAL MANAGEMENT {#medical-management-5 .unnumbered}

Since there is no known human-to-human transmission, neither isolation
nor quarantine are required, since Standard Precautions are appropriate
for care of patients with draining lesions or pneumonia. Strict
adherence to the drainage/secretion recommendations of Standard
Precautions is required, especially for draining lesions, and for the
disinfection of soiled clothing, bedding, equipment, etc. Heat and
disinfectants easily inactivate the organism.

Appropriate therapy includes one of the following antibiotics:

• Gentamicin 3 - 5 mg/kg IV daily for 10 to 14 days

• Ciprofloxacin 400 mg IV every 12 hours, switch to oral ciprofloxacin
(500 mg every 12 hours) after the patient is clinically improved;
continue for completion of a 10- to 14-day course of therapy

• Ciprofloxacin 750 mg orally every 12 hours for 10 to 14 days

• Streptomycin 7.5 - 10 mg/kg IM every 12 hours for 10 to 14 days

Streptomycin has historically been the drug of choice for tularemia;
however, since it may not be readily available immediately after a
large-scale BW attack, gentamicin and other alternative drugs should be
considered first. Requests for streptomycin should be directed to the
Roerig Streptomycin Program at Pfizer Pharmaceuticals in New York
(800-254-4445). Another concern is that a fully virulent
streptomycin-resistant strain of *F. tularensis* was developed during
the 1950s and it is presumed that other countries have obtained it. The
strain was sensitive to gentamicin. Gentamicin offers the advantage of
providing broader coverage for gram-negative bacteria and may be useful
when the diagnosis of tularemia is considered but in doubt.

In a recent study of treatment in 12 children with ulceroglandular
tularemia, ciprofloxacin was satisfactory for outpatient treatment
(Pediatric Infectious Disease Journal, 2000; 19:449-453). Tetracycline
and chloramphenicol are also effective antibiotics;, however, they are
associated with significant relapse rates.

##### PROPHYLAXIS {#prophylaxis-4 .unnumbered}

**Vaccine:** An investigational live-attenuated vaccine (Live Vaccine
Strain - LVS), which is administered by scarification, has been given to
\>5,000 persons without significant adverse reactions and prevents
typhoidal and ameliorates ulceroglandular forms of laboratory-acquired
tularemia. Aerosol challenge tests in laboratory animals and human
volunteers have demonstrated significant protection. As with all
vaccines, the degree of protection depends upon the magnitude of the
challenge dose. Vaccine-induced protection could be overwhelmed by
extremely high doses of the tularemia bacteria.

**Immunoprophylaxis.** There is no passive immunoprophylaxis (i.e.,
immune globulin) available for pre- or post-exposure management of
tularemia.

**Pre-exposure prophylaxis:** Chemoprophylaxis given for anthrax or
plague (ciprofloxacin, doxycycline) may confer protection against
tularemia, based on *in vitro* susceptibilities.

**Post-exposure prophylaxis**. A 2-week course of antibiotics is
effective as post-exposure prophylaxis when given within 24 hours of
aerosol exposure from a BW attack, using one of the following regimens:

• Ciprofloxacin 500 mg orally every 12 hours for 2 weeks

• Doxycycline 100 mg orally every 12 hours for 2 weeks

• Tetracycline 500 mg orally every 6 hours for 2 weeks

Chemoprophylaxis is not recommended following potential natural
exposures (tick bite, rabbit or other animal exposures).

#### VIRAL AGENTS {#viral-agents .unnumbered}

Viruses are the simplest microorganisms and consist of a nucleocapsid
protein coat containing genetic material, either RNA or DNA. In some
cases, the viral particle is also surrounded by an outer lipid layer.
Viruses are much smaller than bacteria and vary in size from 0.02 μm to
0.2 μm (1 μm = 1/1000 mm). Viruses are intracellular parasites and lack
a system for their own metabolism; therefore, they are dependent on the
synthetic machinery of their host cells. This means that viruses, unlike
the bacteria, cannot be cultivated in synthetic nutritive solutions, but
require living cells in order to multiply. The host cells can be from
humans, animals, plants, or bacteria. Every virus requires its own
special type of host cell for multiplication, because a complicated
interaction occurs between the cell and virus. Virus-specific host cells
can be cultivated in synthetic nutrient solutions and then infected with
the virus in question. Another common way of cultivating viruses is to
grow them on chorioallantoic membranes (from fertilized eggs). The
cultivation of viruses is expensive, demanding, and time-consuming. A
virus typically brings about changes in the host cell that eventually
lead to cell death. This handbook covers three types of viruses which
could potentially be employed as BW agents: smallpox, alphaviruses
(e.g., VEE), and hemorrhagic fever viruses.

#### SMALLPOX {#smallpox .unnumbered}

##### SUMMARY {#summary-6 .unnumbered}

**Signs and Symptoms:** Clinical manifestations begin acutely with
malaise, fever, rigors, vomiting, headache, and backache. 2-3 days later
lesions appear which quickly progress from macules to papules, and
eventually to pustular vesicles. They are more abundant on the
extremities and face, and develop synchronously.

**Diagnosis:** Neither electron nor light microscopy are capable of
discriminating variola from vaccinia, monkeypox or cowpox. The new PCR
diagnostic techniques may be more accurate in discriminating between
variola and other *Orthopoxviruses*.

**Treatment:** At present there is no effective chemotherapy, and
treatment of a clinical case remains supportive.

**Prophylaxis:** Immediate vaccination or revaccination should be
undertaken for all personnel exposed.

**Isolation and Decontamination:** Droplet and Airborne Precautions for
a minimum of 17 days following exposure for all contacts. Patients
should be considered infectious until all scabs separate and quarantined
during this period. In the civilian setting strict quarantine of
asymptomatic contacts may prove to be impractical and impossible to
enforce. A reasonable alternative would be to require contacts to check
their temperatures daily. Any fever above 38 C (101 F) during the 17-day
period following exposure to a confirmed case would suggest the
development of smallpox. The contact should then be isolated
immediately, preferably at home, until smallpox is either confirmed or
ruled out and remain in isolation until all scabs separate.

##### OVERVIEW {#overview-5 .unnumbered}

Smallpox is caused by the Orthopox virus, variola, which occurs in at
least two strains, variola major and the milder disease, variola minor.
Despite the global eradication of smallpox and continued availability of
a vaccine, the potential weaponization of variola continues to pose a
military threat. This threat can be attributed to the aerosol
infectivity of the virus, the relative ease of large-scale production,
and an increasingly *Orthopoxvirus*-naive populace. Although the fully
developed cutaneous eruption of smallpox is unique, earlier stages of
the rash could be mistaken for varicella. Secondary spread of infection
constitutes a nosocomial hazard from the time of onset of a smallpox
patient\'s exanthem until scabs have separated. Quarantine with
respiratory isolation should be applied to secondary contacts for 17
days post-exposure. Vaccinia vaccination and vaccinia immune globulin
each possess some efficacy in post-exposure prophylaxis.

##### HISTORY AND SIGNIFICANCE {#history-and-significance-5 .unnumbered}

Endemic smallpox was declared eradicated in 1980 by the World Health
Organization (WHO). Although two WHO-approved repositories of variola
virus remain at the Centers for Disease Control and Prevention (CDC) in
Atlanta and the Institute for Viral Preparations in Moscow, the extent
of clandestine stockpiles in other parts of the world remains unknown.
In January 1996, WHO's governing board recommended that all stocks of
smallpox be destroyed by 30 June 1999. However, action on this was
delayed by the Clinton administration in May 1999 due to concerns over
the need for further study of the virus given its potential as a
biological warfare agent. The smallpox stockpiles are now scheduled for
destruction on 30 June 2002.

The United States stopped vaccinating its military population in 1989
and civilians in the early 1980s. These populations are now susceptible
to variola major, although recruits immunized in 1989 may retain some
degree of immunity. Variola may have been used by the British Army
against native Americans by giving them contaminated blankets from the
beds of smallpox victims during the eighteenth century. Japan considered
the use of smallpox as a BW weapon in World War II and it has been
considered as a possible threat agent against US forces for many years.
In addition, the former Soviet Union is reported to have produced and
stockpiled massive quantities of the virus for use as a biological
weapon. It is not known whether these stockpiles still exist in Russia.

##### CLINICAL FEATURES {#clinical-features-5 .unnumbered}

The incubation period of smallpox averaged 12 days, although it could
range from 7-19 days following exposure. Clinical manifestations begin
acutely with malaise, fever, rigors, vomiting, headache, and backache;
15% of patients developed delirium. Approximately 10% of light-skinned
patients exhibited an erythematous rash during this phase. Two to three
days later, an enanthem appears concomitantly with a discrete rash about
the face, hands and forearms.

Following eruptions on the lower extremities, the rash spread centrally
to the trunk over the next week. Lesions quickly progressed from macules
to papules, and eventually to pustular vesicles. Lesions were more
abundant on the extremities and face, and this centrifugal distribution
is an important diagnostic feature. In distinct contrast to varicella,
lesions on various segments of the body remain generally synchronous in
their stages of development. From 8 to 14 days after onset, the pustules
form scabs that leave depressed depigmented scars upon healing. Although
variola concentrations in the throat, conjunctiva, and urine diminish
with time, virus can be readily recovered from scabs throughout
convalescence. Therefore, patients should be isolated and considered
infectious until all scabs separate.

For the past century, two distinct types of smallpox were recognized.
Variola minor was distinguished by milder systemic toxicity and more
diminutive pox lesions, and caused 1% mortality in unvaccinated victims.
However, the prototypical disease variola major caused mortality of 3%
and 30% in the vaccinated and unvaccinated, respectively. Other clinical
forms associated with variola major, flat-type and hemorrhagic type
smallpox were notable for severe mortality. A naturally occurring
relative of variola, monkeypox, occurs in Africa, and is clinically
indistinguishable from smallpox with the exception of a lower case
fatality rate and notable enlargement of cervical and inguinal lymph
nodes.

##### DIAGNOSIS {#diagnosis-5 .unnumbered}

Smallpox must be distinguished from other vesicular exanthems, such as
chickenpox, erythema multiforme with bullae, or allergic contact
dermatitis. Particularly problematic to infection control measures would
be the failure to recognize relatively mild cases of smallpox in persons
with partial immunity. An additional threat to effective quarantine is
the fact that exposed persons may shed virus from the oropharynx without
ever manifesting disease. Therefore, quarantine and initiation of
medical countermeasures should be promptly followed by an accurate
diagnosis so as to avert panic.

The usual method of diagnosis is demonstration of characteristic virions
on electron microscopy of vesicular scrapings. Under light microscopy,
aggregations of variola virus particles, called Guarnieri bodies are
found. Another rapid but relatively insensitive test for Guarnieri
bodies in vesicular scrapings is Gispen\'s modified silver stain, in
which cytoplasmic inclusions appear black.

None of the above laboratory tests are capable of discriminating variola
from vaccinia, monkeypox or cowpox. This differentiation classically
required isolation of the virus and characterization of its growth on
chorioallantoic membrane. The development of polymerase chain reaction
diagnostic techniques promises a more accurate and less cumbersome
method of discriminating between variola and other *Orthopoxviruses*.

##### MEDICAL MANAGEMENT {#medical-management-6 .unnumbered}

Medical personnel must be prepared to recognize a vesicular exanthem in
possible biowarfare theaters as potentially variola, and to initiate
appropriate countermeasures. Any confirmed case of smallpox should be
considered an international emergency with immediate report made to
public health authorities. Droplet and Airborne Precautions for a
minimum of 17 days following exposure for *all* persons in direct
contact with the index case, especially the unvaccinated. In the
civilian setting strict quarantine of asymptomatic contacts may prove to
be impractical and impossible to enforce. A reasonable alternative would
be to require contacts to check their temperatures daily. Any fever
above 38 C (101 F) during the 17-day period following exposure to a
confirmed case would suggest the development of smallpox. The contact
should then be isolated immediately, preferably at home, until smallpox
is either confirmed or ruled out and remain in isolation until all scabs
separate. Patients should be considered infectious until all scabs
separate. Immediate vaccination or revaccination should also be
undertaken for all personnel exposed to either weaponized variola virus
or a clinical case of smallpox.

The potential for airborne spread to other than close contacts is
controversial. In general, close person-to-person contact is required
for transmission to reliably occur. Nevertheless, variola\'s potential
in low relative humidity for airborne dissemination was alarming in two
hospital outbreaks. Smallpox patients were infectious from the time of
onset of their eruptive exanthem, most commonly from days 3-6 after
onset of fever. Infectivity was markedly enhanced if the patient
manifested a cough. Indirect transmission via contaminated bedding or
other fomites was infrequent. Some close contacts harbored virus in
their throats without developing disease, and hence might have served as
a means of secondary transmission.

Vaccination with a verified clinical \"take\" (vesicle with scar
formation) within the past 3 years is considered to render a person
immune to smallpox. However, given the difficulties and uncertainties
under wartime conditions of verifying the adequacy of troops\' prior
vaccination, routine revaccination of all potentially exposed personnel
would seem prudent if there existed a significant prospect of smallpox
exposure.

Antivirals for use against smallpox are under investigation. Cidofovir
has been shown to have significant *in vitro* and *in vivo* activity in
experimental animals. Whether it would offer benefit superior to
immediate post-exposure vaccination in humans has not been determined.

##### PROPHYLAXIS {#prophylaxis-5 .unnumbered}

**Vaccine:** Smallpox vaccine (vaccinia virus) is most often
administered by intradermal inoculation with a bifurcated needle, a
process that became known as scarification because of the permanent scar
that resulted. Vaccination after exposure to weaponized smallpox or a
case of smallpox may prevent or ameliorate disease if given as soon as
possible and preferably within 7 days after exposure. A vesicle
typically appears at the vaccination site 5-7 days post-inoculation,
with surrounding erythema and induration. The lesion forms a scab and
gradually heals over the next 1-2 weeks.

Side effects include low-grade fever and axillary lymphadenopathy. The
attendant erythema and induration of the vaccination vesicle is
frequently misdiagnosed as bacterial superinfection. More severe
first-time vaccine reactions include secondary inoculation of the virus
to other sites such as the face, eyelid, or other persons (\~ 6/10,000
vaccinations), and generalized vaccinia, which is a systemic spread of
the virus to produce mucocutaneous lesions away from the primary
vaccination site (\~3/10,000 vaccinations).

Vaccination is *contraindicated* in the following conditions:
immunosuppression, HIV infection, history or evidence of eczema, or
current household, sexual, or other close physical contact with
person(s) possessing one of these conditions. In addition, vaccination
should not be performed during pregnancy. Despite these caveats, most
authorities state that, with the exception of significant impairment of
systemic immunity, there are no absolute contraindications to
*post-exposure* vaccination of a person who experiences *bona fide*
exposure to variola. However, concomitant VIG administration is
recommended for pregnant and eczematous persons in such circumstances.

**Passive Immunoprophylaxis:** Vaccinia Immune Globulin (VIG) is
generally indicated for treatment of complications to the smallpox
(vaccinia) vaccine, and should be available when administering vaccine.
Limited data suggests that vaccinia immune globulin may be of value in
post-exposure prophylaxis of smallpox when given within the first week
following exposure, and concurrently with vaccination. Vaccination alone
is recommended for those without contraindications to the vaccine. If
greater than one week has elapsed after exposure, administration of both
products, if available, is reasonable. The dose for prophylaxis or
treatment is 0.6 ml/kg intramuscularly. Due to the large volume (42 mls
in a 70 Kg person), the dose would be given in multiple sites over 24-36
hours.

#### VENEZUELAN EQUINE ENCEPHALITIS {#venezuelan-equine-encephalitis .unnumbered}

**SUMMARY**

**Signs and Symptoms:** Incubation period 1-6 days. Acute systemic
febrile illness with encephalitis developing in a small percentage (4%
children; \< 1% adults). Generalized malaise, spiking fevers, rigors,
severe headache, photophobia, and myalgias for 24-72 hours. Nausea,
vomiting, cough, sore throat, and diarrhea may follow. Full recovery
from malaise and fatigue takes 1-2 weeks. The incidence of CNS disease
and associated morbidity and mortality would be much higher after a BW
attack.

**Diagnosis:** Clinical and epidemiological diagnosis. Physical findings
non-specific. The white blood cell count may show a striking leukopenia
and lymphopenia. Virus isolation may be made from serum, and in some
cases throat swab specimens. Both neutralizing or IgG antibody in paired
sera or VEE specific IgM present in a single serum sample indicate
recent infection.

**Therapy:** Treatment is supportive only. Treat uncomplicated VEE
infections with analgesics to relieve headache and myalgia. Patients who
develop encephalitis may require anticonvulsants and intensive
supportive care to maintain fluid and electrolyte balance, ensure
adequate ventilation, and avoid complicating secondary bacterial
infections.

**Prophylaxis:** A live, attenuated vaccine is available as an
investigational new drug. A second, formalin-inactivated, killed vaccine
is available for boosting antibody titers in those initially receiving
the first vaccine. No post-exposure immunoprophylaxis. In experimental
animals, alpha-interferon and the interferon-inducer poly-ICLC have
proven highly effective as post-exposure prophylaxis. There are no human
clinical data.

**Isolation and Decontamination:** Patient isolation and quarantine is
not required. Standard Precautions augmented with vector control while
the patient is febrile. There is no evidence of direct human-to-human or
horse-to-human transmission. The virus can be destroyed by heat (80^o^C
for 30 min) and standard disinfectants.

**OVERVIEW**

The Venezuelan equine encephalitis (VEE) virus complex is a group of
eight mosquito-borne alphaviruses that are endemic in northern South
America and Trinidad and causes rare cases of human encephalitis in
Central America, Mexico, and Florida. These viruses can cause severe
diseases in humans and Equidae (horses, mules, burros and donkeys).
Natural infections are acquired by the bites of a wide variety of
mosquitoes. Equidae serve as amplifying hosts and source of mosquito
infection.

Western and Eastern Equine Encephalitis viruses are similar to the VEE
complex, are often difficult to distinguish clinically, and share
similar aspects of transmission and epidemiology. The human infective
dose for VEE is considered to be 10-100 organisms, which is one of the
principal reasons that VEE is considered a militarily effective BW
agent. Neither the population density of infected mosquitoes nor the
aerosol concentration of virus particles has to be great to allow
significant transmission of VEE in a BW attack. There is no evidence of
direct human-to-human or horse-to-human transmission. Natural aerosol
transmission is not known to occur. VEE particles are not considered
stable in the environment, and are thus not as persistent as the
bacteria responsible for Q fever, tularemia or anthrax. Heat and
standard disinfectants can easily kill the VEE virus complex.

**HISTORY AND SIGNIFICANCE**

Between 1969 and 1971, an epizootic of a \"highly pathogenic strain\" of
VEE emerged in Guatemala, moved through Mexico, and entered Texas in
June 1971. This strain was virulent in both equine species and humans.
In Mexico, there were 8,000-10,000 equine deaths, \"tens of thousands\"
of equine cases, and 17,000 human cases (no human deaths). Over 10,000
horses in Texas died. Once the Texas border was breached, a national
emergency was declared and resources were mobilized to vaccinate equines
in 20 states (95% of all horses and donkeys were vaccinated; over 3.2
million animals), establish equine quarantines, and control mosquito
populations with broad-scale insecticide use in the Rio Grande Valley
and along the Gulf Coast. A second VEE outbreak in 1995 in Venezuela and
Columbia involved over 75,000 human cases and over 20 deaths.

VEE is better characterized than EEE or WEE, primarily because it was
tested as a BW agent during the U.S. offensive program in the 1950\'s
and 1960\'s. Other countries have also been or are suspected to have
weaponized this agent. In compliance with President Nixon\'s National
Security Decision No. 35 of November 1969 to destroy the BW microbial
stockpile, all existing stocks of VEE in the U.S. were publicly
destroyed.

These viruses could theoretically be produced in large amounts in either
a wet or dried form by relatively unsophisticated and inexpensive
systems. This form of the VEE virus complex could be intentionally
disseminated as an aerosol and would be highly infectious. It could also
be spread by the purposeful dissemination of infected mosquitoes, which
can probably transmit the virus throughout their lives. The VEE complex
is relatively stable during the storage and manipulation procedures
necessary for weaponization.

In natural human epidemics, severe and often fatal encephalitis in
Equidae (30-90% mortality) always precedes disease in humans. However, a
biological warfare attack with virus intentionally disseminated as an
aerosol would most likely cause human disease as a primary event or
simultaneously with Equidae. During natural epidemics, illness or death
in wild or free ranging Equidae may not be recognized before the onset
of human disease, thus a natural epidemic could be confused with a BW
event, and data on onset of disease should be considered with caution. A
more reliable method for determining the likelihood of a BW event would
be the presence of VEE outside of its natural geographic range. A
biological warfare attack in a region populated by Equidae and
appropriate mosquito vectors could initiate an epizootic/epidemic.

**CLINICAL FEATURES**

Susceptibility is high (90-100%), and nearly 100% of those infected
develop overt illnesses. The overall case fatality rate for VEE is \<
1%, although it is somewhat higher in the very young or aged. Recovery
from an infection results in excellent short-term and long-term
immunity.

VEE is primarily an acute, incapacitating, febrile illness with
encephalitis developing in only a small percentage of the infected
population. Most VEE infections are mild (EEE and WEE are predominantly
encephalitis infections). After an incubation period from 1-6 days,
onset is usually sudden. The acute phase lasts 24-72 hours and is
manifested by generalized malaise, chills, spiking high fevers
(38^o^C-40.5^o^C), rigors, severe headache, photophobia, and myalgias in
the legs and lumbosacral area. Nausea, vomiting, cough, sore throat, and
diarrhea may follow. Physical signs include conjunctival injection,
erythematous pharynx and muscle tenderness. Patients would be
incapacitated by malaise and fatigue for 1-2 weeks before full recovery.

During natural epidemics, approximately 4% of infected children (\<15
years old) and less than 1% of adults will develop signs of severe CNS
infection (35% fatality for children and 10% for adults). Adults rarely
develop neurologic complications during natural infections. Experimental
aerosol challenges in animals suggest that the incidence of CNS disease
and associated morbidity and mortality would be much higher after a BW
attack, as the VEE virus would infect the olfactory nerve and spread
directly to the CNS. Mild CNS findings would include lethargy,
somnolence, or mild confusion, with or without nuchal rigidity.
Seizures, ataxia, paralysis, or coma follow more severe CNS involvement.
VEE infection during pregnancy may cause encephalitis in the fetus,
placental damage, abortion, or severe congenital neuroanatomical
anomalies.

**DIAGNOSIS**

Diagnosis of VEE is suspected on clinical and epidemiological grounds,
but confirmed by virus isolation, serology and PCR. A variety of
serological tests are applicable, including the IgM ELISA indirect FA,
hemagglutination inhibition, complement-fixation, and IgG. For persons
without prior known exposure to VEE complex viruses, a presumptive
diagnosis may be made by identifying IgM antibody in a single serum
sample taken 5-7 days after onset of illness. PCR procedures are
available for confirmation, but are generally available only as a rear
laboratory capability.

Samples suitable for performing diagnostic tests include blood culture
(only in appropriate BSL-3 containment), acute and convalescent sera,
and cerebrospinal fluid. Viremia during the acute phase of the illness
(but not during encephalitis) is generally high enough to allow
detection by antigen-capture enzyme-linked immunosorbent assay (ELISA).
Virus isolation is time consuming, but can be performed from serum and
throat swab specimens by inoculation of cell cultures or suckling mice
(a Gold Standard identification assay for VEE). VEE should be isolated
only in a BSL-3 laboratory.

The white blood cell count shows a striking leukopenia and lymphopenia.
In cases with encephalitis, the cerebrospinal fluid pressure may be
increased and contain up to 1,000 WBCs/mm^3^ (predominantly mononuclear
cells) and a mildly elevated protein concentration.

An outbreak of VEE may be difficult to distinguish from influenza on
clinical grounds. Clues to the diagnosis are the appearance of a small
proportion of neurological cases, or disease in equine animals. However,
these indicators may be absent in a BW attack. A BW aerosol attack could
lead to an epidemic of febrile meningoencephalitis featuring seizures
and coma. In a BW context, the differential diagnosis would include
other causes of aseptic meningitis and meningoencephalitis.

**MEDICAL MANAGEMENT**

No specific viral therapy exists; hence treatment is supportive only.
Patients with uncomplicated VEE infection may be treated with analgesics
to relieve headache and myalgia. Patients who develop encephalitis may
require anticonvulsants and intensive supportive care to maintain fluid
and electrolyte balance, ensure adequate ventilation, and avoid
complicating secondary bacterial infections. Patients should be treated
in a screened room or in quarters treated with a residual insecticide
for at least 5 days after onset, or until afebrile, as human cases may
be infectious for mosquitoes for at least 72 hours. Patient isolation
and quarantine is not required; sufficient contagion control is provided
by the implementation of Standard Precautions augmented with the need
for vector control while the patient is febrile. Patient-to-patient
transmission by means of respiratory droplet infection has not been
proven. The virus can be destroyed by heat (80C for 30 min) and
standard disinfectants.

**PROPHYLAXIS**

**Vaccine:** There are two IND human unlicensed VEE vaccines. The first
investigational vaccine (designated TC-83) was developed in the 1960\'s
and is a live, attenuated cell-culture-propagated vaccine produced by
the Salk Institute. This vaccine is not effective against all of the
serotypes in the VEE complex. It has been used to protect several
thousand persons against laboratory infections and is presently licensed
for use in Equidae (and was used in the 1970-71 Texas epizootic in
horses), but is an IND vaccine for humans. The vaccine is given as a
single 0.5 mL subcutaneous dose. Fever, malaise, and headache occur in
approximately 20 percent of vaccinees, and may be moderate to severe in
10 percent of those vaccinees to warrant bed rest for 1-2 days. Another
18 percent of vaccinees fail to develop detectable neutralizing
antibodies, but it is unknown whether they are susceptible to clinical
infection if challenged. Temporary contraindications for use include a
concurrent viral infection or pregnancy.

A second investigational (IND) vaccine (designated C-84) has been tested
but not licensed in humans and is prepared by formalin-inactivation of
the TC-83 strain. This vaccine is not used for primary immunization, but
is used to boost nonresponders to TC-83. Administer 0.5 mL
subcutaneously at 2-4 week intervals for up to 3 inoculations or until
an antibody response is measured. Periodic boosters are required. The
C-84 vaccine alone does not protect rodents against experimental aerosol
challenge. Therefore, C-83 is used only as a booster immunogen for the
TC-84 vaccine.

As with all vaccines, the degree of protection depends upon the
magnitude of the challenge dose; vaccine-induced protection could be
overwhelmed by extremely high doses of the pathogen. Research is
underway to produce a recombinant VEE vaccine.

**Immunoprophylaxis:** At present, there is no pre-exposure or
post-exposure immunoprophylaxis available.

**Chemoprophylaxis:** In experimental animals, alpha-interferon and the
interferon-inducer poly-ICLC have proven highly effective for
post-exposure chemoprophylaxis of VEE. There are no clinical data on
which to assess efficacy of these drugs in humans.

#### VIRAL HEMORRHAGIC FEVERS {#viral-hemorrhagic-fevers .unnumbered}

##### SUMMARY {#summary-7 .unnumbered}

**Signs and Symptoms:** VHFs are febrile illnesses which can feature
flushing of the face and chest, petechiae, bleeding, edema, hypotension,
and shock. Malaise, myalgias, headache, vomiting, and diarrhea may occur
in any of the hemorrhagic fevers.

**Diagnosis:** Definitive diagnosis rests on specific virologic
techniques. Significant numbers of military personnel with a hemorrhagic
fever syndrome should suggest the diagnosis of a viral hemorrhagic
fever.

**Treatment:** Intensive supportive care may be required. Antiviral
therapy with ribavirin may be useful in several of these infections
(Available only as IND under protocol). Convalescent plasma may be
effective in Argentine hemorrhagic fever (Available only as IND under
protocol).

**Prophylaxis:** The only licensed VHF vaccine is yellow fever vaccine.
Prophylactic ribavirin may be effective for Lassa fever, Rift Valley
fever, CCHF, and possibly HFRS (Available only as IND under protocol).

**Isolation and Decontamination:** Contact isolation, with the addition
of a surgical mask and eye protection for those coming within three feet
of the patient, is indicated for suspected or proven Lassa fever, CCHF,
or filovirus infections. Respiratory protection should be upgraded to
airborne isolation, including the use of a fit-tested HEPA filtered
respirator, a battery powered air purifying respirator, or a positive
pressure supplied air respirator, if patients with the above conditions
have prominent cough, vomiting, diarrhea, or hemorrhage. Decontamination
is accomplished with hypochlorite or phenolic disinfectants.

##### OVERVIEW {#overview-6 .unnumbered}

The viral hemorrhagic fevers are a diverse group of illnesses caused by
RNA viruses from four viral families. The *Arenaviridae* include the
etiologic agents of Argentine, Bolivian, and Venezuelan hemorrhagic
fevers, and Lassa fever. The *Bunyaviridae* include the members of the
*Hantavirus* genus, the Congo-Crimean hemorrhagic fever virus from the
*Nairovirus* genus, and the Rift Valley fever virus from the
*Phlebovirus* genus; the *Filoviridae* include Ebola and Marburg
viruses; and the *Flaviviridae* include dengue and yellow fever viruses.
These viruses are spread in a variety of ways; some may be transmitted
to humans through a respiratory portal of entry. Although evidence for
weaponization does not exist for many of these viruses, they are
included in this handbook because of their *potential* for aerosol
dissemination or weaponization, or likelihood for confusion with similar
agents that might be weaponized.

##### HISTORY AND SIGNIFICANCE {#history-and-significance-6 .unnumbered}

Because these viruses are so diverse and occur in different geographic
locations endemically, their full history is beyond the scope of this
handbook. However, there are some significant events that may provide
insight into their possible importance as biological threat agents.

***Arenaviridae:*** Argentine hemorrhagic fever (AHF), caused by the
Junin virus, was first described in 1955 in corn harvesters. From 300 to
600 cases per year occur in areas of the Argentine pampas. Bolivian,
Brazilian, and Venezuelan hemorrhagic fevers are caused by the related
Machupo, Guanarito, and Sabia viruses. Lassa virus causes disease in
West Africa. These viruses are transmitted from their rodent reservoirs
to humans by the inhalation of dusts contaminated with rodent excreta.

***Bunyaviridae:*** Congo-Crimean hemorrhagic fever (CCHF) is a
tick-borne disease that occurs in the Crimea and in parts of Africa,
Europe and Asia. It can also be spread by contact with infected animals,
and in healthcare settings. Rift Valley fever (RVF) is a mosquito-borne
disease that occurs in Africa. The hantaviruses are rodent-borne viruses
with a wide geographic distribution. Hantaan and closely related viruses
cause hemorrhagic fever with renal syndrome (HFRS), (also known as
Korean hemorrhagic fever or epidemic hemorrhagic fever). This is the
most common disease due to hantaviruses. It was described prior to WW II
in Manchuria along the Amur River, among United Nations troops during
the Korean conflict, and subsequently in Japan, China, and in the
Russian Far East. Severe disease also occurs in some Balkan states,
including Bosnia, Serbia and Greece. Nephropathia epidemica is a milder
disease that occurs in Scandinavia and other parts of Europe, and is
caused by strains carried by bank voles. In addition, newly described
hantaviruses cause Hantavirus Pulmonary Syndrome (HPS) in the Americas.
The hantaviruses are transmitted to humans by the inhalation of dusts
contaminated with rodent excreta.

***Filoviridae:*** Ebola hemorrhagic fever was first recognized in the
western equatorial province of the Sudan and the nearby region of Zaire
in 1976. A second outbreak occurred in Sudan in 1979, and in 1995 a
large outbreak (316 cases) developed in Kikwit, Zaire, from a single
index case. Subsequent epidemics have occurred in Gabon and the Ivory
Coast. The African strains cause severe disease and death. It is not
known why this disease appears infrequently. A related virus (Ebola
Reston) was isolated from monkeys imported into the United States from
the Philippines in 1989, and subsequently developed hemorrhagic fever.
While subclinical infections occurred among exposed animal handlers,
Ebola Reston has not been identified as a human pathogen. Marburg
epidemics have occurred on six occasions: five times in Africa, and once
in Europe. The first recognized outbreak occurred in Marburg, Germany,
and Yugoslavia, among people exposed to African green monkeys, and
resulted in 31 cases and 7 deaths. Filoviruses can be spread from human
to human by direct contact with infected blood, secretions, organs, or
semen. Ebola Reston apparently spread from monkey to monkey, and from
monkeys to humans by the respiratory route. The natural reservoirs of
the filoviruses are unknown.

***Flaviviridae:*** Yellow fever and dengue are two mosquito-borne
fevers that have great importance in the history of military campaigns
and military medicine. Tick-borne flaviruses include the agents of
Kyanasur Forest disease in India, and Omsk hemorrhagic fever in Siberia.

All of the VHF agents (except for dengue virus) are infectious by
aerosol in the laboratory. These viruses could conceivably be used by an
adversary as biological warfare agents, in view of their aerosol
infectivity, and, for some viruses, high lethality.

##### CLINICAL FEATURES {#clinical-features-6 .unnumbered}

The clinical syndrome that these viruses may cause is generally referred
to as viral hemorrhagic fever, or VHF. The target organ in the VHF
syndrome is the vascular bed; accordingly, the dominant clinical
features are usually due to microvascular damage and changes in vascular
permeability.

Not all infected patients develop VHF. There is both divergence and
uncertainty about which host factors and viral strain characteristics
might be responsible for the mechanisms of disease. For example, an
immunopathogenic mechanism has been identified for dengue hemorrhagic
fever, which usually occurs among patients previously infected with a
heterologous dengue serotype. Antibody directed against the previous
strain enhances uptake of dengue virus by circulating monocytes. These
cells express viral antigens on their surfaces. Lysis of the infected
monocytes by cytotoxic T-cell responses results in the release of
pro-inflammatory cytokines, pro-coagulants, and anticoagulants, which in
turn results in vascular injury and permeability, complement activation,
and a systemic coagulopathy.

DIC has been implicated in Rift Valley, Marburg and Ebola fevers, but in
most VHFs the etiology of the coagulopathy is multifactorial (e.g.,
hepatic damage, consumptive coagulopathy, and primary marrow injury to
megakaryocytes).

Common symptoms are fever, myalgia, and prostration. Physical
examination may reveal only conjunctival injection, mild hypotension,
flushing, and petechial hemorrhages. Full-blown VHF typically evolves to
shock and generalized mucous membrane hemorrhage, and often is
accompanied by evidence of pulmonary hematopoietic, and neurologic
involvement. Renal insufficiency is proportional to cardiovascular
compromise, except in HFRS, which features renal failure as an integral
part of the disease process.

Apart from epidemiologic and intelligence information, some distinctive
clinical features may suggest a specific etiologic agent. While hepatic
involvement is common among the VHFs, a clinical picture dominated by
jaundice and other features of hepatitis is only seen in some cases of
Rift Valley fever, Congo-Crimean, Marburg, and Ebola HFs, and yellow
fever. Kyanasur Forest disease and Omsk hemorrhagic fever are notable
for pulmonary involvement, and a biphasic illness with subsequent CNS
manifestations. Among the arenavirus infections, Lassa fever can cause
severe peripheral edema due to capillary leak, but hemorrhage is
uncommon, while hemorrhage is commonly caused by the South American
arenaviruses. Severe hemorrhage and nosocomial transmission are typical
for Congo-Crimean HF. Retinitis is commonly seen in Rift Valley fever,
and hearing loss is common among Lassa fever survivors.

Because of their worldwide occurrence, additional consideration should
be given to hantavirus infections. Classic HFRS has a severe course that
progresses sequentially from fever through hemorrhage, shock, renal
failure, and polyuria. Nephropathia endemica features prominent fever,
myalgia, abdominal pain, and oliguria, without shock or severe
hemorrhagic manifestations. North American cases of Hantavirus Pulmonary
Syndrome (HPS) due to the Sin Nombre virus lack hemorrhagic
manifestations and renal failure, but nevertheless carry a very high
mortality due to rapidly progressive and severe pulmonary capillary
leak, which presents as ARDS. These syndromes may overlap. Subclinical
or clinical pulmonary edema may occur in HFRS and nephropathia endemica,
while HFRS has complicated HPS due to South American hantaviruses and
the Bayou and Black Creek Canal viruses in North America.

Mortality may be substantial, ranging from 0.2% percent for nephropathia
endemica, to 50 to 90 percent among Ebola victims.

##### DIAGNOSIS {#diagnosis-6 .unnumbered}

A detailed travel history and a high index of suspicion are essential in
making the diagnosis of VHF. Patients with arenavirus or hantavirus
infections often recall having seen rodents during the presumed
incubation period, but since the viruses are spread to man by
aerosolized excreta or environmental contamination, actual contact with
the reservoir is not necessary. Large mosquito populations are common
during Rift Valley fever or flavivirus transmission, but a history of
mosquito bite is too common to be of diagnostic importance, whereas tick
bites or nosocomial exposure are of some significance in suspecting
Congo-Crimean HF. Large numbers of military personnel presenting with
VHF manifestations in the same geographic area over a short time period
should lead treating medical care providers to suspect either a natural
outbreak in an endemic setting, or possibly a biowarfare attack,
particularly if this type of disease does not occur naturally in the
local area.

VHF should be suspected in any patient presenting with a severe febrile
illness and evidence of vascular involvement (postural hypotension,
petechiae, easy bleeding, flushing of face and chest, non-dependent
edema) who has traveled to an area where the virus is known to occur, or
where intelligence information suggests a biological warfare threat.
Symptoms and signs suggesting additional organ system involvement are
common (headache, photophobia, pharyngitis, cough, nausea or vomiting,
diarrhea, constipation, abdominal pain, hyperesthesia, dizziness,
confusion, tremor), but usually do not dominate the picture with the
exceptions listed above under "Clinical Features." A positive tourniquet
test has been particularly useful in dengue hemorrhagic fever, but
should be sought in other hemorrhagic fevers as well.

The clinical laboratory can be very helpful. Thrombocytopenia
(exception: Lassa) and leukopenia (exceptions: Lassa, Hantaan, and some
severe CCHF cases) are the rule. Proteinuria and/or hematuria are
common, and their presence is the rule for Argentine HF, Bolivian HF,
and HFRS. High AST elevation correlates with severity of Lassa fever,
and jaundice is a poor prognostic sign in yellow fever.

In most geographic areas, the major item in the differential diagnosis
is malaria. It must be borne in mind that parasitemia in patients
partially immune to malaria does not prove that symptoms are due to
malaria. Other items in the differential may include typhoid fever,
nontyphoidal salmonellosis, leptospirosis, rickettsial infections,
shigellosis, relapsing fever, fulminant hepatitis, and meningococcemia.
Additional illnesses which could mimic VHF include acute leukemia, lupus
erythematosus, idiopathic or thrombotic thrombocytopenic purpura,
hemolytic uremic syndrome and the multiple causes of disseminated
intravascular coagulation.

Definitive diagnosis in an individual case rests on specific virologic
diagnosis. Most patients have readily detectable viremia at presentation
(exception: hantaviral infections). Rapid enzyme immunoassays can detect
viral antigens in acute sera from patients with Argentine HF, Lassa
fever, Rift Valley fever, Congo-Crimean HF, and yellow fever. Lassa- and
Hantaan-specific IgM often are detectable during the acute illness.
Diagnosis by virus cultivation and identification will require 3 to 10
days or longer. With the exception of dengue, specialized microbiologic
containment is required for safe handling of these viruses. Appropriate
precautions should be observed in collection, handling, shipping, and
processing of diagnostic samples. Both the Centers for Disease Control
and Prevention (CDC, Atlanta, Georgia) and the U.S. Army Medical
Research Institute of Infectious Diseases (USAMRIID, Frederick,
Maryland) have diagnostic laboratories functioning at the highest (BL-4
or P-4) containment level.

##### MEDICAL MANAGEMENT {#medical-management-7 .unnumbered}

General principles of supportive care apply to hemodynamic, hematologic,
pulmonary, and neurologic manifestations of VHF, regardless of the
specific etiologic agent. Only intensive care will save the most
severely ill patients. Health care providers employing vigorous fluid
resuscitation of hypotensive patients must be mindful of the propensity
of some VHFs (e.g., HFRS) for pulmonary capillary leak. Pressor agents
are frequently required. The use of intravascular devices and invasive
hemodynamic monitoring must be carefully considered in the context of
potential benefit versus the risk of hemorrhage. Restlessness,
confusion, myalgia, and hyperesthesia should be managed by conservative
measures, and the judicious use of sedatives and analgesics. Secondary
infections may occur as with any patient undergoing intensive care
utilizing invasive procedures and devices, such as intravenous lines and
indwelling catheters.

The management of clinical bleeding should follow the same principles as
for any patient with a systemic coagulopathy, assisted by coagulation
studies. Intramuscular injections, aspirin and other anticoagulant drugs
should be avoided.

The investigational antiviral drug ribavirin is available via
compassionate use protocols for therapy of Lassa fever, HFRS,
Congo-Crimean HF, and Rift Valley fever. Separate Phase III efficacy
trials have indicated that parenteral ribavirin reduces morbidity in
HFRS, and lowers both the morbidity and mortality of Lassa fever. In the
HFRS field trial, treatment was effective if begun within the first 4
days of fever, and continued for a 7 day course. A compassionate use
protocol, utilizing intravenous ribavirin as a treatment for Lassa
fever, is sponsored by the CDC. Doses are slightly different, and
continued for a 10 day course; treatment is most effective if begun
within 7 days of onset. The only significant side effect of ribavirin is
a modest anemia due to a reversible inhibition of erythropoiesis, and
mild hemolysis. Although ribavirin is teratogenic in laboratory animals,
the potential benefits must be weighed against the potential risks to
pregnant women with grave illness due to one of these VHFs. Safety in
infants and children has not been established. Ribavirin has poor *in
vitro* and *in vivo* activity against the filoviruses (Ebola and
Marburg) and the flaviviruses (dengue, yellow fever, Omsk HF and
Kyanasur Forest Disease).

Argentine HF responds to therapy with 2 or more units of convalescent
plasma containing adequate amounts of neutralizing antibody and given
within 8 days of onset.

This therapy is investigational, and available only under protocol.

##### PROPHYLAXIS {#prophylaxis-6 .unnumbered}

The only licensed vaccine available for any of the hemorrhagic fever
viruses is yellow fever vaccine, which is mandatory for travelers to
endemic areas of Africa and South America. Argentine hemorrhagic fever
vaccine is a live, attenuated, investigational vaccine developed at
USAMRIID, which has proved efficacious both in an animal model and in a
field trial in South America, and seems to protect against Bolivian
hemorrhagic fever as well. Both inactivated and live-attenuated Rift
Valley fever vaccines are currently under investigation. An
investigational vaccinia-vectored Hantaan vaccine is offered to
laboratory workers at USAMRIID. There are currently no vaccines for the
other VHF agents available for human use in the United States.

Persons with percutaneous or mucocutaneous exposure to blood, body
fluids, secretions, or excretions from a patient with suspected VHF
should immediately wash the affected skin surfaces with soap and water.
Mucous membranes should be irrigated with copious amounts of water or
saline.

Close personal contacts or medical personnel exposed to blood or
secretions from VHF patients (particularly Lassa fever, CCHF, and
filoviral diseases) should be monitored for symptoms, fever and other
signs during the established incubation period. A DoD compassionate use
protocol exists for prophylactic administration of oral ribavirin to
high risk contacts (direct exposure to body fluids) of Congo-Crimean HF
patients. A similar post-exposure prophylaxis strategy has been
suggested for high contacts of Lassa fever patients. Most patients will
tolerate this dose well, but patients should be under surveillance for
breakthrough disease (especially after drug cessation) or adverse drug
effects (principally anemia).

##### ISOLATION AND CONTAINMENT {#isolation-and-containment .unnumbered}

These viruses pose special challenges for hospital infection control.
With the exception of dengue (virus present, but no secondary infection
hazard) and hantaviruses (infectious virus not present in blood or
excreta at the time of clinical presentation), VHF patients generally
have significant quantities of virus in blood and often other
secretions. Special caution must be exercised in handling sharps,
needles, and other potential sources of parenteral exposure. Strict
adherence to standard precautions will prevent nosocomial transmission
of most VHFs.

Lassa, Congo-Crimean HF, Ebola, and Marburg viruses may be particularly
prone to aerosol nosocomial spread. Secondary infections among contacts
and medical personnel who were not parenterally exposed are well
documented. Sometimes this occurred when the acute hemorrhagic disease
(as seen in CCHF) mimicked a surgical emergency such as a bleeding
gastric ulcer, with subsequent exposure and secondary spread among
emergency and operating room personnel. Therefore, when one of these
diseases is suspected, additional management measures are indicated. The
patient should be hospitalized in a private room. An adjoining anteroom
for putting on and removing protective barriers, storage of supplies,
and decontamination of laboratory specimen containers, should be used if
available. A room with non-recirculated air under negative pressure is
advised for patients with significant cough, hemorrhage, or diarrhea. It
may be wise to place the patient in such a room initially, to avoid
having to transport the patient in the event of clinical deterioration.
All persons entering the room should wear gloves and gowns (contact
isolation). In addition, face shields or surgical masks and eye
protection are indicated for those coming within three feet of the
patient. Respiratory protection should be upgraded to airborne
isolation, including the use of a fit-tested HEPA filtered respirator, a
battery powered air purifying respirator, or a positive pressure
supplied air respirator, if patients with the above conditions have
prominent cough, vomiting, diarrhea, or hemorrhage. Caution should be
exercised in evaluating and treating the patient with suspected VHF.
Over-reaction on the part of health care providers is inappropriate and
detrimental to both patient and staff, but it is prudent to provide as
rigorous isolation measures as feasible.

Laboratory specimens should be double-bagged, and the exterior of the
outer bag decontaminated prior to transport to the laboratory. Excreta
and other contaminated materials should be autoclaved, or decontaminated
by the liberal application of hypochlorite or phenolic disinfectants.
Clinical laboratory personnel are also at risk for exposure, and should
employ a biosafety cabinet (if available) and barrier precautions when
handling specimens.

No carrier state has been observed for any VHF, but excretion of virus
in urine (e.g., Lassa fever) or semen (e.g., Argentine hemorrhagic
fever) may occur during convalescence. Should the patient die, there
should be minimal handling of the body, with sealing of the corpse in
leak-proof material for prompt burial or cremation.

#### BIOLOGICAL TOXINS {#biological-toxins .unnumbered}

Toxins are harmful substances produced by living organisms (animals,
plants, microbes). Features that distinguish them from chemical agents,
such as VX, cyanide, or mustard, include being not man-made,
non-volatile (no vapor hazard), usually not dermally active (mycotoxins
are the exception), and generally much more toxic per weight than
chemical agents. Their lack of volatility is very important and makes
them unlikely to produce either secondary or person-to-person exposures,
or a persistent environmental hazard.

A toxin's utility as an aerosol weapon is determined by its toxicity,
stability, and ease of production. The bacterial toxins, such as
botulinum toxins, are the most toxic substances by weight known
(Appendix I). Less toxic compounds, such as the mycotoxins, are
thousands of times less toxic than botulinum, and have limited aerosol
potential. The relationship between aerosol toxicity and the quantity of
toxin required for an effective open-air exposure is shown in Appendix
J, which demonstrates that for some agents such as the mycotoxins and
ricin, very large quantities (tons) would be needed for an effective
open-air attack. Stability limits the open-air potential of some toxins.
For example, botulinum and tetanus toxins are large molecular weight
proteins, and are easily denatured by environmental factors (heat,
desiccation, UV light), thus posing little downwind threat. Finally,
some toxins, such as saxitoxin, might be both stable and highly toxic,
but are so difficult to extract that they can only feasibly be produced
in minute quantities.

As with all biological weapons, potential to cause incapacitation as
well as lethality must be considered. Depending on the goals of an
adversary, incapacitating agents may be more effective than lethal
agents due to the overwhelming demand on the medical and evacuation
infrastructure, or the expected panic in the population. Several toxins
such as SEB, cause significant illness at doses much lower than that
required for lethality, and thus pose a significant incapacitating
threat.

This manual will cover four toxins considered to be among the most
likely to be used against U.S. military and civilian targets: botulinum
toxins, ricin, staphylococcal enterotoxin B (SEB), and T-2 mycotoxins.

#### BOTULINUM  {#botulinum .unnumbered}

####  {#section-18 .unnumbered}

##### SUMMARY {#summary-8 .unnumbered}

**Signs and Symptoms:** Usually begins with cranial nerve palsies,
including ptosis, blurred vision, diplopia, dry mouth and throat,
dysphagia, and dysphonia. This is followed by symmetrical descending
flaccid paralysis, with generalized weakness and progression to
respiratory failure. Symptoms begin as early as 12-36 hours after
inhalation, but may take several days after exposure to low doses of
toxin.

**Diagnosis:** Diagnosis is primarily a clinical one. Biowarfare attack
should be suspected if multiple casualties simultaneously present with
progressive descending flaccid paralysis. Lab confirmation can be
obtained by bioassay (mouse neutralization) of the patient's serum.
Other helpful labs include: ELISA or ECL for antigen in environmental
samples, PCR for bacterial DNA in environmental samples, or nerve
conduction studies and electromyography.

**Treatment:** Early administration of trivalent licensed antitoxin or
heptavalent antitoxin (IND product) may prevent or decrease progression
to respiratory failure and hasten recovery. Intubation and ventilatory
assistance for respiratory failure. Tracheostomy may be required.

**Prophylaxis:** Pentavalent toxoid vaccine (types A, B, C, D, and E) is
available as an IND product for those at high risk of exposure.

**Isolation and Decontamination:** Standard Precautions for healthcare
workers. Toxin is not dermally active and secondary aerosols are not a
hazard from patients. Decon with soap and water. Botulinum toxin is
inactivated by sunlight within 1-3 hours. Heat (80^O^C for 30 min.,
100^O^C for several minutes) and chlorine (\>99.7% inactivation by 3
mg/L FAC in 20 min.) also destroy the toxin.

##### OVERVIEW {#overview-7 .unnumbered}

The botulinum toxins are a group of seven related neurotoxins produced
by the spore-forming bacillus *Clostridium botulinum* and two other
*Clostridia* species. These toxins, types A through G, are the most
potent neurotoxins known; paradoxically, they have been used
therapeutically to treat spastic conditions (strabismus, blepharospasm,
torticollis, tetanus) and cosmetically to treat wrinkles. The spores are
ubiquitous; they germinate into vegetative bacteria that produce toxins
during anaerobic incubation. Industrial-scale fermentation can produce
large quantities of toxin for use as a BW agent. There are three
epidemiologic forms of naturally occurring botulismfood borne,
infantile, and wound. Botulinum could be delivered by aerosol or used to
contaminate food or water supplies. When inhaled, these toxins produce a
clinical picture very similar to food borne intoxication, although the
time to onset of paralytic symptoms after inhalation may actually be
longer than for food borne cases, and may vary by type and dose of
toxin. The clinical syndrome produced by these toxins is known as
\"botulism\".

##### HISTORY AND SIGNIFICANCE {#history-and-significance-7 .unnumbered}

Botulinum toxins have caused numerous cases of botulism when ingested in
improperly prepared or canned foods. Many deaths have occurred secondary
to such incidents. It is feasible to deliver botulinum toxins as an
aerosolized biological weapon, and several countries and terrorist
groups have weaponized them. Botulinum toxins were weaponized by the
U.S. in its old offensive BW program. Evidence obtained by the United
Nations in 1995 revealed that Iraq had filled and deployed over 100
munitions with nearly 10,000 liters of botulinum toxin. The Aum
Shinrikyo cult in Japan weaponized and attempted to disseminate
botulinum toxin on multiple occasions in Tokyo prior to their 1995 Sarin
attack in the Tokyo subway.

##### TOXIN CHARACTERISTICS {#toxin-characteristics .unnumbered}

The botulinum toxins are the most toxic compounds, per weight of agent,
known to man, requiring only 0.001 microgram per kilogram of body weight
to kill 50 percent of the animals studied. Botulinum toxin type A is
15,000 times more toxic by weight than VX and 100,000 times more toxic
than Sarin, two of the well-known organophosphate nerve agents.

Botulinum toxins are proteins with molecular weights of approximately
150,000 Daltons. Each of the seven distinct, but related neurotoxins, A
through G, is produced by a different strain of *Clostridia*. All seven
types act by the same mechanism. The toxins produce similar effects when
inhaled or ingested, although the time course may vary depending on the
route of exposure and the dose received. Although an aerosol attack is
the most likely scenario for the use of botulinum toxins, the agent
could be used to sabotage food supplies. Enemy special forces or
terrorists might use this method in certain scenarios to produce food
borne botulism in specific targets.

These large proteins are easily denatured by environmental conditions.
The toxins are detoxified in air within 12 hours. Sunlight inactivates
the toxins within 1-3 hours. Heat destroys the toxins in 30 minutes at
80^O^C and in several minutes at 100^O^C. In water, the toxins are
\>99.7% inactivated by 20 minutes' exposure to 3 mg/L free available
chlorine (FAC), similar to the military disinfection procedure; and 84%
inactivated by 20 minutes at 0.4% mg/L FAC, similar to municipal water
treatment procedures.

##### MECHANISM OF TOXICITY {#mechanism-of-toxicity .unnumbered}

Botulinum toxin consists of two polypeptide subunits (A and B chains).
The B subunit binds to receptors on the axons of motor neurons. The
toxin is taken into the axon, where the A chain exerts its cytotoxic
effect; it inactivates the axon, preventing release of acetylcholine and
blocking neuromuscular transmission (pre-synaptic inhibition). Recovery
follows only after the neuron develops a new axon, which can take
months. The presynaptic inhibition affects both cholinergic autonomic
(muscarinic) and motor (nicotinic) receptors. This interruption of
neurotransmission causes cranial nerve and skeletal muscle paralysis
seen in clinical botulism.

Unlike the situation with nerve agent intoxication, where there is too
much acetylcholine due to inhibition of acetylcholinesterase, the
problem in botulism is lack of the neurotransmitter in the synapse.
Thus, pharmacological measures such as atropine are not indicated in
botulism and would likely exacerbate symptoms (see Appendix H).

##### CLINICAL FEATURES {#clinical-features-7 .unnumbered}

The onset of symptoms of inhalation botulism usually occurs from 12 to
36 hours following exposure, but can vary according to the amount of
toxin absorbed, and could be reduced following a BW attack. Recent
primate studies indicate that the signs and symptoms may not appear for
several days when a low dose of the toxin is inhaled versus a shorter
time period following ingestion of toxin or inhalation of higher doses.

Cranial nerve palsies are prominent early, with eye symptoms such as
blurred vision due to mydriasis, diplopia, ptosis, and photophobia, in
addition to other cranial nerve signs such as dysarthria, dysphonia, and
dysphagia. Flaccid skeletal muscle paralysis follows, in a symmetrical,
descending, and progressive manner. Collapse of the upper airway may
occur due to weakness of the oropharyngeal musculature. As the
descending motor weakness involves the diaphragm and accessory muscles
of respiration, respiratory failure may occur abruptly. Progression from
onset of symptoms to respiratory failure has occurred in as little as 24
hours in cases of severe food borne botulism.

The autonomic effects of botulism are manifested by typical
anticholinergic signs and symptoms: dry mouth, ileus, constipation, and
urinary retention. Nausea and vomiting may occur as nonspecific sequelae
of an ileus. Dilated pupils (mydriasis) are seen in approximately 50
percent of cases.

Sensory symptoms usually do not occur. Botulinum toxins do not cross the
blood/brain barrier and do not cause CNS disease. However, the
psychological sequelae of botulism may be severe and require specific
intervention.

Physical examination usually reveals an afebrile, alert, and oriented
patient. Postural hypotension may be present. Mucous membranes may be
dry and crusted and the patient may complain of dry mouth or sore
throat. There may be difficulty with speaking and swallowing. Gag reflex
may be absent. Pupils may be dilated and even fixed. Ptosis and
extraocular muscle palsies may also be present. Variable degrees of
skeletal muscle weakness may be observed depending on the degree of
progression in an individual patient. Deep tendon reflexes may be
present or absent. With severe respiratory muscle paralysis, the patient
may become cyanotic or exhibit narcosis from CO2 retention.

##### DIAGNOSIS {#diagnosis-7 .unnumbered}

The occurrence of an epidemic of afebrile patients with progressive
symmetrical descending flaccid paralysis strongly suggests botulinum
intoxication. Foodborne outbreaks tend to occur in small clusters and
have never occurred in soldiers on military rations such as MRE's
(Meals, Ready to Eat). Higher numbers of cases in a theater of
operations should raise at least the consideration of a biological
warfare attack with aerosolized botulinum toxin.

Individual cases might be confused clinically with other neuromuscular
disorders such as Guillain-Barre syndrome, myasthenia gravis, or tick
paralysis. The edrophonium or Tensilon® test may be transiently positive
in botulism, so it may not distinguish botulinum intoxication from
myasthenia. The cerebrospinal fluid in botulism is normal and the
paralysis is generally symmetrical, which distinguishes it from
enteroviral myelitis. Mental status changes generally seen in viral
encephalitis should not occur with botulinum intoxication.

It may become necessary to distinguish nerve agent and/or atropine
poisoning from botulinum intoxication. Nerve agent poisoning produces
copious respiratory secretions and miotic pupils, whereas a decrease in
secretions is more likely in botulinum intoxication. Atropine overdose
is distinguished from botulism by its central nervous system excitation
(hallucinations and delirium) even though the mucous membranes are dry
and mydriasis is present. The clinical differences between botulinum
intoxication and nerve agent poisoning are depicted in Appendix H.

Laboratory testing is generally not critical to the diagnosis of
botulism. Mouse neutralization (bioassay) remains the most sensitive
test, and serum samples should be drawn and sent to a lab capable of
this test. PCR might detect *C. botulinum* genes in an environmental
sample. Detection of toxin in clinical or environmental samples is
sometimes possible using an ELISA or ECL test. Clinical samples can
include serum, gastric aspirates, stool, and respiratory secretions.
Survivors do not usually develop an antibody response due to the very
small amount of toxin necessary to produce clinical symptoms.

##### MEDICAL MANAGEMENT {#medical-management-8 .unnumbered}

Supportive care, including prompt respiratory support, can be
lifesaving. Respiratory failure due to paralysis of respiratory muscles
is the most serious effect and, generally, the cause of death. Reported
cases of botulism prior to 1950 had a mortality rate of 60%. With
tracheotomy or endotracheal intubation and ventilatory assistance,
fatalities are less than five percent today. Prevention of nosocomial
infections is a primary concern, along with hydration, nasogastric
suctioning for ileus, bowel and bladder care, and prevention of
decubitus ulcers and deep venous thromboses. Intensive and prolonged
nursing care may be required for recovery, which may take up to three
months for initial signs of improvement, and up to a year for complete
resolution of symptoms.

**Antitoxin:** Early administration of botulinum antitoxin is critical,
since the antitoxin can only neutralize the circulating toxin in
patients with symptoms that continue to progress. When symptom
progression ceases, no circulating toxin remains, and the antitoxin has
no effect. Antitoxin may be particularly effective in food-borne cases,
where presumably toxin continues to be absorbed through the gut wall.
Animal experiments show that after aerosol exposure, botulinum antitoxin
is very effective if given before the onset of clinical signs. If the
antitoxin is delayed until after the onset of symptoms, it does not
protect against respiratory failure.

Three different antitoxin preparations are available in the U.S. A
licensed trivalent (types A, B, E) equine antitoxin is available from
the Centers for Disease Control and Prevention for cases of food borne
botulism. This product has all the disadvantages of a horse serum
product, including the risks of anaphylaxis and serum sickness. A
monovalent human antiserum (type A) is available from the California
Department of Health Services for infant botulism. A \"despeciated\"
equine heptavalent antitoxin against all 7 serotypes has been prepared
by cleaving the Fc fragments from horse IgG molecules, leaving F(ab)~2~
fragments. This product was developed by USAMRIID, and is currently
available under IND status. It has been effective in animal studies.
However, 4% of horse antigens remain, so there is still a risk of
hypersensitivity reactions.

Use of the equine antitoxin requires skin testing for horse serum
sensitivity prior to administration. Skin testing is performed by
injecting 0.1 ml of a 1:10 dilution (in sterile physiological saline) of
antitoxin intradermally in the patient's forearm with a 26 or 27 gauge
needle. Monitor the injection site and observe the patient for allergic
reaction for 20 minutes. The skin test is positive if any of these
allergic reactions occur: hyperemic areola at the site of the injection
\> 0.5 cm; fever or chills; hypotension with decrease of blood pressure
\> 20 mm Hg for systolic and diastolic pressures; skin rash; respiratory
difficulty; nausea or vomiting; generalized itching. Do NOT administer
equine derived Botulinum F(ab')~2~ Antitoxin if the skin test is
positive. If no allergic symptoms are observed, the antitoxin is
administered as a single dose intravenously in a normal saline solution,
10 ml over 20 minutes.

With a positive skin test, desensitization can be attempted by
administering 0.01 - 0.1 ml of antitoxin subcutaneously, doubling the
previous dose every 20 minutes until 1.0 - 2.0 ml can be sustained
without any marked reaction. Preferably, desensitization should be
performed by an experienced allergist. Medical personnel administering
the antitoxin should be prepared to treat anaphylaxis with epinephrine,
intubation equipment, and IV access.

##### PROPHYLAXIS {#prophylaxis-7 .unnumbered}

**Vaccine:** A pentavalent toxoid of *Clostridium botulinum* toxin types
A, B, C, D, and E is available as an IND for pre-exposure prophylaxis.
It will likely remain under IND status since efficacy testing in humans
is not feasible. This product has been administered to several thousand
volunteers and occupationally at-risk workers, and induces serum
antitoxin levels that correspond to protective levels in experimental
animals. The currently recommended primary series of 0, 2, and 12 weeks,
followed by a 1 year booster induces protective antibody levels in
greater than 90 percent of vaccinees after one year. Adequate antibody
levels are transiently induced after three injections, but decline prior
to the one year booster.

Contraindications to the vaccine include sensitivities to alum,
formaldehyde, and thimerosal, or hypersensitivity to a previous dose.
Reactogenicity is mild, with two to four percent of vaccinees reporting
erythema, edema, or induration at the local site of injection which
peaks at 24 to 48 hours. The frequency of such local reactions increases
with subsequent inoculations; after the second and third doses, seven to
ten percent will have local reactions, with higher incidence (up to
twenty percent or so) after boosters. Severe local reactions are rare,
consisting of more extensive edema or induration. Systemic reactions are
reported in up to three percent, consisting of fever, malaise, headache,
and myalgia. Incapacitating reactions (local or systemic) are uncommon.
The vaccine should be stored at 2-8^O^C (not frozen).

The vaccine is recommended for selected individuals or groups judged at
high risk for exposure to botulinum toxin aerosols. There is no
indication at present for use of botulinum antitoxin as a prophylactic
modality except under extremely specialized circumstances.

Post-exposure prophylaxis, using the heptavalent antitoxin has been
demonstrated effective in animal studies; however, human data are not
available, so it is not recommended for this indication. The antitoxin
should be considered for this purpose only in extraordinary
circumstances.

#### RICIN {#ricin .unnumbered}

##### SUMMARY {#summary-9 .unnumbered}

**Signs and Symptoms:** Acute onset of fever, chest tightness, cough,
dyspnea, nausea, and arthralgias occurs 4 to 8 hours after inhalational
exposure. Airway necrosis and pulmonary capillary leak resulting in
pulmonary edema would likely occur within 18-24 hours, followed by
severe respiratory distress and death from hypoxemia in 36-72 hours.

**Diagnosis:** Acute lung injury in large numbers of geographically
clustered patients suggests exposure to aerosolized ricin. The rapid
time course to severe symptoms and death would be unusual for infectious
agents. Serum and respiratory secretions should be submitted for antigen
detection (ELISA). Acute and convalescent sera provide retrospective
diagnosis. Nonspecific laboratory and radiographic findings include
leukocytosis and bilateral interstitial infiltrates.

**Treatment:** Management is supportive and should include treatment for
pulmonary edema. Gastric lavage and cathartics are indicated for
ingestion, but charcoal is of little value for large molecules such as
ricin.

**Prophylaxis:** There is currently no vaccine or prophylactic antitoxin
available for human use, although immunization appears promising in
animal models. Use of the protective mask is currently the best
protection against inhalation.

**Isolation and Decontamination:** Standard Precautions for healthcare
workers. Ricin is non-volatile, and secondary aerosols are not expected
to be a danger to health care providers. Decontaminate with soap and
water. Hypochlorite solutions (0.1% sodium hypochlorite) can inactivate
ricin.

##### OVERVIEW {#overview-8 .unnumbered}

Ricin is a potent protein cytotoxin derived from the beans of the castor
plant (*Ricinus communis*). Castor beans are ubiquitous worldwide, and
the toxin is fairly easy to extract; Therefore, ricin is potentially
widely available. When inhaled as a small particle aerosol, this toxin
may produce pathologic changes within 8 hours and severe respiratory
symptoms followed by acute hypoxic respiratory failure in 36-72 hours.
When ingested, ricin causes severe gastrointestinal symptoms followed by
vascular collapse and death. This toxin may also cause disseminated
intravascular coagulation, microcirculatory failure and multiple organ
failure if given intravenously in laboratory animals.

##### HISTORY AND SIGNIFICANCE {#history-and-significance-8 .unnumbered}

Ricin's significance as a potential biological warfare toxin relates in
part to its wide availability. Worldwide, one million tons of castor
beans are processed annually in the production of castor oil; the waste
mash from this process is 5% ricin by weight. The toxin is also quite
stable and extremely toxic by several routes of exposure, including the
respiratory route. Ricin was apparently used in the assassination of
Bulgarian exile Georgi Markov in London in 1978. Markov was attacked
with a specially engineered weapon disguised as an umbrella, which
implanted a ricin-containing pellet into his body. This technique was
used in at least six other assassination attempts in the late 1970's and
early 1980's. In 1994 and 1995, four men from a tax-protest group known
as the "Minnesota Patriots Council," were convicted of possessing ricin
and conspiring to use it (by mixing it with the solvent DMSO) to murder
law enforcement officials. In 1995, a Kansas City oncologist, Deborah
Green, attempted to murder her husband by contaminating his food with
ricin. In 1997, a Wisconsin resident, Thomas Leahy, was arrested and
charged with possession with intent to use ricin as a weapon. Ricin has
a high terrorist potential due to its ready availability, relative ease
of extraction, and notoriety in the press.

##### TOXIN CHARACTERISTICS {#toxin-characteristics-1 .unnumbered}

Ricin is actually made up of two hemagglutinins and two toxins. The
toxins, RCL III and RCL IV, are dimers with molecular weights of about
66,000 daltons. The toxins are made up of two polypeptide chains, an A
chain and a B chain, which are joined by a disulfide bond. Ricin can be
produced relatively easily and inexpensively in large quantities in a
fairly low technology setting. Ricin can be prepared in liquid or
crystalline form, or it can be lyophilized to make a dry powder. It
could be disseminated as an aerosol, injected into a target, or used to
contaminate food or water on a small scale. Ricin is stable under
ambient conditions, but is detoxified by heat (80^O^C for 10 min., or
50^O^C for about an hour at pH 7.8) and chlorine (\>99.4% inactivation
by 100 mg/L FAC in 20 min.). Low chlorine concentrations, such as 10
mg/L FAC, as well as iodine at up to 16 mg/L, have no effect on ricin.
Ricin\'s toxicity is marginal when comparing its LD50 to other toxins,
such as botulinum and SEB (incapacitating dose). An enemy would need to
produce it in large quantities to cover a significant area on the
battlefield, thus potentially limiting large-scale use of ricin by an
adversary.

##### MECHANISM OF TOXICITY {#mechanism-of-toxicity-1 .unnumbered}

Ricin is very toxic to cells. It acts by inhibiting protein synthesis.
The B chain binds to cell surface receptors and the toxin-receptor
complex is taken into the cell; the A chain has endonuclease activity
and extremely low concentrations will inhibit DNA replication and
protein synthesis. In rodents, the histopathology of aerosol exposure is
characterized by necrosis of upper and lower respiratory epithelium,
causing tracheitis, bronchitis, bronchiolitis, and interstitial
pneumonia with perivascular and alveolar edema. There is a latent period
of 8 hours post-inhalation exposure before histologic lesions are
observed in animal models. In rodents, ricin is more toxic by the
aerosol route than by other routes of exposure.

##### CLINICAL FEATURES {#clinical-features-8 .unnumbered}

The clinical picture in intoxicated victims would depend on the route of
exposure. After aerosol exposure, signs and symptoms would depend on the
dose inhaled. Accidental sublethal aerosol exposures which occurred in
humans in the 1940's were characterized by acute onset of the following
symptoms in 4 to 8 hours: fever, chest tightness, cough, dyspnea,
nausea, and arthralgias. The onset of profuse sweating some hours later
was commonly the sign of termination of most of the symptoms. Although
lethal human aerosol exposures have not been described, the severe
pathophysiologic changes seen in the animal respiratory tract, including
necrosis and severe alveolar flooding, are probably sufficient to cause
death from ARDS and respiratory failure. Time to death in experimental
animals is dose dependent, occurring 36-72 hours post inhalation
exposure. Humans would be expected to develop severe lung inflammation
with progressive cough, dyspnea, cyanosis and pulmonary edema.

By other routes of exposure, ricin is not a direct lung irritant;
however, intravascular injection can cause minimal pulmonary
perivascular edema due to vascular endothelial injury. Ingestion causes
necrosis of the gastrointestinal epithelium, local hemorrhage, and
hepatic, splenic, and renal necrosis. Intramuscular injection causes
severe local necrosis of muscle and regional lymph nodes with moderate
visceral organ involvement.

##### DIAGNOSIS {#diagnosis-8 .unnumbered}

An attack with aerosolized ricin would be primarily diagnosed by the
clinical and epidemiological setting. Acute lung injury affecting a
large number of geographically clustered cases should raise suspicion of
an attack with a pulmonary irritant such as ricin, although other
pulmonary pathogens could present with similar signs and symptoms. Other
biological threats, such as SEB, Q fever, tularemia, plague, and some
chemical warfare agents like phosgene, need to be included in the
differential diagnosis. Ricin-induced pulmonary edema would be expected
to occur much later (1-3 days post exposure) compared to that induced by
SEB (about 12 hours post exposure) or phosgene (about 6 hours post
exposure). Ricin intoxication would be expected to progress despite
treatment with antibiotics, as opposed to an infectious process. There
would be no mediastinitis as seen with inhalation anthrax. Ricin
patients would not be expected to plateau clinically as occurs with SEB
intoxication.

Specific ELISA and ECL testing on serum and respiratory secretions, or
immunohistochemical stains of tissue may be used where available to
confirm the diagnosis. Ricin is an extremely immunogenic toxin, and
paired acute and convalescent sera should be obtained from survivors for
measurement of antibody response. PCR can detect castor bean DNA in most
ricin preparations. Additional supportive clinical or diagnostic
features after aerosol exposure to ricin may include the following:
bilateral infiltrates on chest radiographs, arterial hypoxemia,
neutrophilic leukocytosis, and a bronchial aspirate rich in protein
compared to plasma which is characteristic of high permeability
pulmonary edema.

##### MEDICAL MANAGEMENT {#medical-management-9 .unnumbered}

Management of ricin-intoxicated patients depends on the route of
exposure. Patients with pulmonary intoxication are managed by
appropriate respiratory support (oxygen, intubation, ventilation, PEEP,
and hemodynamic monitoring) and treatment for pulmonary edema, as
indicated. Gastrointestinal intoxication is best managed by vigorous
gastric lavage, followed by use of cathartics such as magnesium citrate.
Superactivated charcoal is of little value for large molecules such as
ricin. Volume replacement of GI fluid losses is important. In
percutaneous exposures, treatment would be primarily supportive.

##### PROPHYLAXIS {#prophylaxis-8 .unnumbered}

#### The protective mask is effective in preventing aerosol exposure. Although a vaccine is not currently available, candidate vaccines are under development which are immunogenic and confer protection against lethal aerosol exposures in animals. Pre-exposure Prophylaxis with such a vaccine is the most promising defense against a biological warfare attack with ricin.  {#the-protective-mask-is-effective-in-preventing-aerosol-exposure.-although-a-vaccine-is-not-currently-available-candidate-vaccines-are-under-development-which-are-immunogenic-and-confer-protection-against-lethal-aerosol-exposures-in-animals.-pre-exposure-prophylaxis-with-such-a-vaccine-is-the-most-promising-defense-against-a-biological-warfare-attack-with-ricin. .unnumbered}

#### STAPHYLOCOCCAL ENTEROTOXIN B {#staphylococcal-enterotoxin-b .unnumbered}

##### SUMMARY {#summary-10 .unnumbered}

**Signs and Symptoms:** Latent period of 3-12 hours after aerosol
exposure is followed by sudden onset of fever, chills, headache,
myalgia, and nonproductive cough. Some patients may develop shortness of
breath and retrosternal chest pain. Patients tend to plateau rapidly to
a fairly stable clinical state. Fever may last 2 to 5 days, and cough
may persist for up to 4 weeks. Patients may also present with nausea,
vomiting, and diarrhea if they swallow the toxin. Presumably, higher
exposure can lead to septic shock and death.

**Diagnosis:** Diagnosis is clinical. Patients present with a febrile
respiratory syndrome without CXR abnormalities. Large numbers of
patients presenting in a short period of time with typical symptoms and
signs of SEB pulmonary exposure would suggest an intentional attack with
this toxin.

**Treatment:** Treatment is limited to supportive care. Artificial
ventilation might be needed for very severe cases, and attention to
fluid management is important.

**Prophylaxis:** Use of protective mask. There is currently no human
vaccine available to prevent SEB intoxication.

**Isolation and Decontamination:** Standard Precautions for healthcare
workers. SEB is not dermally active and secondary aerosols are not a
hazard from patients. Decon with soap and water. Destroy any food that
may have been contaminated.

##### OVERVIEW {#overview-9 .unnumbered}

*Staphylococcus aureus* produces a number of exotoxins, one of which is
Staphylococcal enterotoxin B, or SEB. Such toxins are referred to as
exotoxins since they are excreted from the organism, and since they
normally exert their effects on the intestines they are called
enterotoxins. SEB is one of the pyrogenic toxins that commonly causes
food poisoning in humans after the toxin is produced in improperly
handled foodstuffs and subsequently ingested. SEB has a very broad
spectrum of biological activity. This toxin causes a markedly different
clinical syndrome when inhaled than it characteristically produces when
ingested. Significant morbidity is produced in individuals who are
exposed to SEB by either portal of entry to the body.

##### HISTORY AND SIGNIFICANCE {#history-and-significance-9 .unnumbered}

SEB is the second most common source of outbreaks of food poisoning.
Often these outbreaks occur in a setting such as a church picnic or
other community event, due to common source exposure in which
contaminated food is consumed. Although an aerosolized SEB toxin weapon
would not likely produce significant mortality, it could render 80
percent or more of exposed personnel clinically ill and unable to
perform their mission for 1-2 weeks. The demand on the medical and
logistical systems could be overwhelming. For these reasons, SEB was one
of the 7 biological agents stockpiled by the U.S. during its old
bioweapons program, which was terminated in 1969.

##### TOXIN CHARACTERISTICS {#toxin-characteristics-2 .unnumbered}

Staphylococcal enterotoxins are proteins of 23-29 kd molecular weight
(SEB is 28,494). They are extracellular products of coagulase-positive
staphylococci. Up to 50% of clinical isolates of *S. aureus* produce
exotoxins. They are produced in culture media and also in foods when
there is overgrowth of the staphylococcal organisms. Related toxins
include toxic shock syndrome toxin-1 (TSST-1) and exfoliative toxins.
SEB is one of at least seven antigenically distinct enterotoxins that
have been identified. These toxins are moderately stable; SEB is
inactivated after a few minutes at 100^O^C. SEB causes symptoms when
inhaled at very low doses in humans: a dose of several logs lower (at
least 100 times less) than the lethal dose by the inhaled route would be
sufficient to incapacitate 50 percent of those exposed. This toxin could
also be used to sabotage food or small volume water supplies.

##### MECHANISM OF TOXICITY {#mechanism-of-toxicity-2 .unnumbered}

Staphylococcal enterotoxins belong to a class of potent immune
stimulants known as bacterial superantigens. Superantigens bind to
monocytes at major histocompatibility complex type II receptors rather
than the usual antigen binding receptors. This leads to the direct
stimulation of large populations of T-helper cells while bypassing the
usual antigen processing and presentation. This induces a brisk cascade
of pro-inflammatory cytokines (such as tumor necrosis factor,
interferon, interleukin-1 and interleukin-2), with recruitment of other
immune effector cells, and relatively deficient activation of
counter-regulatory negative feedback loops. This results in an intense
inflammatory response that injures host tissues. Released cytokines are
thought to mediate many of the toxic effects of SEB.

##### CLINICAL FEATURES {#clinical-features-9 .unnumbered}

Symptoms of SEB intoxication begin after a latent period of 3-12 hours
after inhalation, or 4-10 hours after ingestion. Symptoms include
nonspecific flu-like symptoms (fever, chills, headache, myalgias), and
specific features dependent on the route of exposure. Oral exposure
results in predominantly gastrointestinal symptoms: nausea, vomiting,
and diarrhea. Inhalation exposures produce predominantly respiratory
symptoms: nonproductive cough, retrosternal chest pain, and dyspnea. GI
symptoms may accompany respiratory exposure due to inadvertent
swallowing of the toxin after normal mucocilliary clearance.

Respiratory pathology is due to the activation of pro-inflammatory
cytokine cascades in the lungs, leading to pulmonary capillary leak and
pulmonary edema. Severe cases may result in acute pulmonary edema and
respiratory failure.

The fever may last up to five days and range from 103 to 106 degrees F,
with variable degrees of chills and prostration. The cough may persist
up to four weeks, and patients may not be able to return to duty for two
weeks.

Physical examination in patients with SEB intoxication is often
unremarkable. Conjunctival injection may be present, and postural
hypotension may develop due to fluid losses. Chest examination is
unremarkable except in the unusual case where pulmonary edema develops.
The chest X-ray is also generally normal, but in severe cases increased
interstitial markings, atelectasis, and possibly overt pulmonary edema
or an ARDS picture may develop.

##### DIAGNOSIS {#diagnosis-9 .unnumbered}

Diagnosis of SEB intoxication is based on clinical and epidemiologic
features. Because the symptoms of SEB intoxication may be similar to
several respiratory pathogens such as influenza, adenovirus, and
mycoplasma, the diagnosis may initially be unclear. All of these might
present with fever, nonproductive cough, myalgia, and headache. SEB
attack would cause cases to present in large numbers over a very short
period of time, probably within a single 24-hour period. Naturally
occurring pneumonias or influenza would involve patients presenting over
a more prolonged interval of time. Naturally occurring staphylococcal
food poisoning cases would not present with pulmonary symptoms. SEB
intoxication tends to plateau rapidly to a fairly stable clinical state,
whereas inhalational anthrax, tularemia pneumonia, or pneumonic plague
would all continue to progress if left untreated. Tularemia and plague,
as well as Q fever, would be associated with infiltrates on chest
radiographs. Other diseases, including Hantavirus pulmonary syndrome,
Chlamydia pneumonia, and CW agent inhalation (mustard, phosgene), should
also be considered.

Laboratory confirmation of SEB intoxication includes antigen detection
(ELISA, ECL) on environmental and clinical samples, and gene
amplification (PCR -- to detect *Staphylococcal* genes) on environmental
samples. SEB may not be detectable in the serum by the time symptoms
occur; regardless, a serum specimen should be drawn as early as possible
after exposure. Data from rabbit studies clearly show that the presence
of SEB in the serum is transient; however, it accumulates in the urine
and can be detected for several hours post exposure. Therefore, urine
samples should also be obtained and tested for SEB. Respiratory
secretions and nasal swabs may demonstrate the toxin early (within 24
hours of exposure). Because most patients will develop a significant
antibody response to the toxin, acute and convalescent sera should be
drawn for retrospective diagnosis. Nonspecific findings include a
neutrophilic leukocytosis, an elevated erythrocyte sedimentation rate,
and chest x-ray abnormalities consistent with pulmonary edema.

##### MEDICAL MANAGEMENT {#medical-management-10 .unnumbered}

Currently, therapy is limited to supportive care. Close attention to
oxygenation and hydration is important, and in severe cases with
pulmonary edema, ventilation with positive end expiratory pressure,
vasopressors and diuretics might be necessary. Acetaminophen for fever,
and cough suppressants may make the patient more comfortable. The value
of steroids is unknown. Most patients would be expected to do quite well
after the initial acute phase of their illness, but generally would be
unfit for duty for one to two weeks. Severe cases risk death from
pulmonary edema and respiratory failure.

##### PROPHYLAXIS {#prophylaxis-9 .unnumbered}

Although there is currently no human vaccine for immunization against
SEB intoxication, several vaccine candidates are in development.
Preliminary animal studies have been encouraging. A vaccine candidate is
nearing transition to advanced development for safety and immunogenicity
testing in man. Experimentally, passive immunotherapy can reduce
mortality in animals, but only when given within 4-8 hours after
inhaling SEB. Because of the rapidity of SEB's binding with MHC
receptors (\<5 min. in vitro) active immunization is considered the most
practical defense. Interestingly, most people have detectable antibody
titers to SEB and SEC1, however, immunity acquired through natural
exposure to SEB does not provide complete protection from an aerosol
challenge (although it may reduce the emetic effect).

#### T-2 MYCOTOXINS  {#t-2-mycotoxins .unnumbered}

##### SUMMARY {#summary-11 .unnumbered}

**Signs and symptoms:** Exposure causes skin pain, pruritus, redness,
vesicles, necrosis and sloughing of the epidermis. Effects on the airway
include nose and throat pain, nasal discharge, itching and sneezing,
cough, dyspnea, wheezing, chest pain and hemoptysis. Toxin also produces
effects after ingestion or eye contact. Severe intoxication results in
prostration, weakness, ataxia, collapse, shock, and death.

**Diagnosis:** Should be suspected if an aerosol attack occurs in the
form of \"yellow rain\" with droplets of variously pigmented oily fluids
contaminating clothes and the environment. Confirmation requires testing
of blood, tissue and environmental samples.

**Treatment:** There is no specific antidote. Treatment is supportive.
Soap and water washing, even 4-6 hours after exposure can significantly
reduce dermal toxicity; washing within 1 hour may prevent toxicity
entirely. Superactivated charcoal should be given orally if the toxin is
swallowed.

**Prophylaxis:** The only defense is to prevent exposure by wearing a
protective mask and clothing (or topical skin protectant) during an
attack. No specific immunotherapy or chemotherapy is available for use
in the field.

**Isolation and Decontamination:** Outer clothing should be removed and
exposed skin decontaminated with soap and water. Eye exposure should be
treated with copious saline irrigation. Secondary aerosols are not a
hazard; however, contact with contaminated skin and clothing can produce
secondary dermal exposures. Contact Precautions are warranted until
decontamination is accomplished. Then, Standard Precautions are
recommended for healthcare workers. Environmental decontamination
requires the use of a hypochlorite solution under alkaline conditions
such as 1% sodium hypochlorite and 0.1M NaOH with 1 hour contact time.

##### OVERVIEW {#overview-10 .unnumbered}

The trichothecene (T-2) mycotoxins are a group of over 40 compounds
produced by fungi of the genus *Fusarium*, a common grain mold. They are
small molecular weight compounds, and are extremely stable in the
environment. They are the only class of toxin that is dermally active,
causing blisters within a relatively short time after exposure (minutes
to hours). Dermal, ocular, respiratory, and gastrointestinal exposures
would be expected after an attack with mycotoxins.

##### History AND SIGNIFICANCE {#history-and-significance-10 .unnumbered}

The potential for use as a BW toxin was demonstrated to the Russian
military shortly after World War II when flour contaminated with species
of *Fusarium* was unknowingly baked into bread that was ingested by
civilians. Some developed a protracted lethal illness called alimentary
toxic aleukia (ATA) characterized by initial symptoms of abdominal pain,
diarrhea, vomiting, prostration, and within days fever, chills, myalgias
and bone marrow depression with granulocytopenia and secondary sepsis.
Survival beyond this point allowed the development of painful
pharyngeal/laryngeal ulceration and diffuse bleeding into the skin
(petechiae and ecchymoses), melena, bloody diarrhea, hematuria,
hematemesis, epistaxis and vaginal bleeding. Pancytopenia, and
gastrointestinal ulceration and erosion were secondary to the ability of
these toxins to profoundly arrest bone marrow and mucosal protein
synthesis and cell cycle progression through DNA replication.

Mycotoxins allegedly were released from aircraft in the \"yellow rain\"
incidents in Laos (1975-81), Kampuchea (1979-81), and Afghanistan
(1979-81). It has been estimated that there were more than 6,300 deaths
in Laos, 1,000 in Kampuchea, and 3,042 in Afghanistan. The alleged
victims were usually unarmed civilians or guerrilla forces. These groups
were not protected with masks or chemical protective clothing and had
little or no capability of destroying the attacking enemy aircraft.
These attacks were alleged to have occurred in remote jungle areas,
which made confirmation of attacks and recovery of agent extremely
difficult. Some investigators have claimed that the "yellow clouds"
were, in fact, bee feces produced by swarms of migrating insects. Much
controversy has centered upon the veracity of eyewitness and victim
accounts, but there is evidence to make these allegations of BW agent
use in these areas possible.

##### TOXIN CHARACTERISTICS {#toxin-characteristics-3 .unnumbered}

The trichothecene mycotoxins are low molecular weight (250-500 daltons)
nonvolatile compounds produced by filamentous fungi (molds) of the
genera *Fusarium*, *Myrotecium, Trichoderma, Stachybotrys* and others.
The structures of approximately 150 trichothecene derivatives have been
described in the literature. These substances are relatively insoluble
in water but are highly soluble in ethanol, methanol and propylene
glycol. The trichothecenes are extremely stable to heat and ultraviolet
light inactivation. They retain their bioactivity even when autoclaved;
heating to 1500^o^ F for 30 minutes is required for inactivation.
Hypochlorite solution alone is does not effectively inactivate the
toxins. Rather, the addition of 0.1M NAOH to a 1% hypochlorite solution,
with 1 hour contact time is required. Soap and water effectively remove
this oily toxin from exposed skin or other surfaces.

##### MECHANISM OF TOXICITY {#mechanism-of-toxicity-3 .unnumbered}

The mycotoxins appear to have multiple mechanisms of action, many of
which are poorly understood. Their most notable effect stems from their
ability to rapidly inhibit protein and nucleic acid synthesis. Thus,
they are markedly cytotoxic to rapidly dividing cells such as in the
bone marrow, GI tract (mucosal epithelium), skin, and germ cells. Since
this imitates the hematopoietic and lymphoid effects of radiation
sickness, the mycotoxins are referred to as "radiomimetic agents." The
mycotoxins also alter cell membrane structure and function, inhibit
mitochondrial respiration, and inactivate certain enzymes.

##### CLINICAL FEATURES {#clinical-features-10 .unnumbered}

In a BW attack with trichothecenes, the toxin(s) can adhere to and
penetrate the skin, be inhaled, and can be ingested. In the alleged
yellow rain incidents, symptoms of exposure from all 3 routes coexisted.
Contaminated clothing can serve as a reservoir for further toxin
exposure. Early symptoms beginning within minutes of exposure include
burning skin pain, redness, tenderness, blistering, and progression to
skin necrosis with leathery blackening and sloughing of large areas of
skin. Upper respiratory exposure may result in nasal itching, pain,
sneezing, epistaxis, and rhinorrhea. Pulmonary/tracheobronchial toxicity
produces dyspnea, wheezing, and cough. Mouth and throat exposure causes
pain and blood tinged saliva and sputum. Anorexia, nausea, vomiting and
watery or bloody diarrhea with crampy abdominal pain occurs with
gastrointestinal toxicity. Eye pain, tearing, redness, foreign body
sensation and blurred vision may follow ocular exposure. Skin symptoms
occur in minutes to hours and eye symptoms in minutes. Systemic toxicity
can occur via any route of exposure, and results in weakness,
prostration, dizziness, ataxia, and loss of coordination. Tachycardia,
hypothermia, and hypotension follow in fatal cases. Death may occur in
minutes, hours or days. The most common symptoms are vomiting, diarrhea,
skin involvement with burning pain, redness and pruritus, rash or
blisters, bleeding, and dyspnea. A late effect of systemic absorption is
pancytopenia, predisposing to bleeding and sepsis.

##### Diagnosis {#diagnosis-10 .unnumbered}

Clinical and epidemiological findings provide clues to the diagnosis.
High attack rates, dead animals of multiple species, and physical
evidence such as yellow, red, green, or other pigmented oily liquid are
suggestive of mycotoxins. Rapid onset of symptoms in minutes to hours
supports a diagnosis of a chemical or toxin attack. Mustard and other
vesicant agents must be considered but they have an odor, are visible,
and can be rapidly detected by a field chemical test (M8 paper, M256
kit). Symptoms from mustard toxicity are also delayed for several hours.
Inhalation of staphylococcal enterotoxin B or ricin aerosols can cause
fever, cough, dyspnea, and wheezing but does not involve the skin.

Specific diagnosis of T-2 mycotoxins in the form of a rapid diagnostic
test is not presently available in the field. Serum and urine should be
collected and sent to a reference lab for antigen detection. The
mycotoxins and metabolites are eliminated in the urine and feces; 50-75%
is eliminated within 24 hours, however, metabolites can be detected as
late as 28 days after exposure. Pathologic specimens include blood,
urine, lung, liver, and stomach contents. Environmental and clinical
samples can be tested using a gas liquid chromatography-mass
spectrometry technique. This system can detect as little as 0.1-1.0 ppb
of T-2, which is sensitive enough to measure T-2 levels in the plasma of
toxin victims.

##### Medical Management {#medical-management-11 .unnumbered}

No specific antidote or therapeutic regimen is currently available. All
therapy is supportive. If a soldier is unprotected during an attack the
outer uniform should be removed within 4 hours and decontaminated by
exposure to 5% hypochlorite for 6-10 hours. The skin should be
thoroughly washed with soap and uncontaminated water if available. This
can reduce dermal toxicity, even if delayed 4-6 hours after exposure.
The M291 skin decontamination kit can also be used to remove
skin-adherent T-2. Standard burn care is indicated for cutaneous
involvement. Standard therapy for poison ingestion, including the use of
superactivated charcoal to absorb swallowed T-2, should be administered
to victims of an unprotected aerosol attack. Respiratory support may be
necessary. The eyes should be irrigated with normal saline or water to
remove toxin.

##### PROPHYLAXIS {#prophylaxis-10 .unnumbered}

Physical protection of the skin, mucous membranes, and airway (use of
chemical protective mask and clothing) are the only proven effective
methods of protection during an attack. Immunological (vaccines) and
chemoprotective pretreatments are being studied in animal models, but
are not available for field use by the warfighter. Topical skin
protectant may limit dermal exposure. Soap and water washing, even 1
hour after dermal exposure to T-2, effectively prevents dermal toxicity.

#### DETECTION {#detection .unnumbered}

Accurate intelligence is required to develop an effective defense
against biological warfare. Once an agent has been dispersed, detection
of the biological aerosol prior to its arrival over the target, in time
for personnel to don protective equipment, is the best way to minimize
or prevent casualties. However, interim systems for detecting biological
agents are just now being fielded in limited numbers. Until reliable
detectors are available in sufficient numbers, usually the first
indication of a biological attack in unprotected soldiers will be the
ill soldier.

Detector systems are evolving, and represent an area of intense interest
with the highest priorities within the research and development
community. Several systems are now being fielded. The Biological
Integrated Detection System (BIDS) is vehicle- mounted and concentrates
aerosol particles from environmental air, then subjects the particle
sample to both genetic and antibody-based detection schemes for selected
agents. The Long Range Biological Standoff Detection System (LRBSDS)
will provide a first time biological standoff detection capability to
provide early warning. It will employ infrared laser to detect aerosol
clouds at a standoff distance up to 30 kilometers. An improved version
is in development to extend the range to 100 km. This system will be
available for fixed-site applications or inserted into various transport
platforms such as fixed-wing or rotary aircraft. The Short-Range
Biological Standoff Detection System (SRBSDS) is in the research and
development phase. It will employ ultraviolet and laser-induced
fluorescence to detect biological aerosol clouds at distances up to 5
kilometers. The information will be used to provide early warning,
enhance contamination avoidance efforts, and cue other detection
efforts.

The principal difficulty in detecting biological agent aerosols stems
from differentiating the artificially generated BW cloud from the
background of organic matter normally present in the atmosphere.
Therefore, the aforementioned detection methods must be used in
conjunction with intelligence, physical protection, and medical
protection (vaccines and other chemoprophylactic measures) to provide
layered primary defenses against a biological attack.

#### PERSONAL PROTECTION {#personal-protection .unnumbered}

The currently fielded chemical protective equipment, which includes the
protective mask, battle dress overgarment (BDO), protective gloves, and
overboots will provide protection against a biological agent attack.

The M40 protective mask is available in three sizes, and when worn
correctly, will protect the face, eyes, and respiratory tract. The M40
utilizes a single screw-on filter element which involves two separate
but complementary mechanisms: 1) impaction and adsorption of agent
molecules onto ASC Whetlerite Carbon filtration media, and 2) static
electrical attraction of particles initially failing to contact the
filtration media. Proper maintenance and periodic replacement of the
crucial filter elements are of the utmost priority. The filter MUST be
replaced under these circumstances: the elements are immersed in water,
crushed, cut, or otherwise damaged; excessive breathing resistance is
encountered; the \"ALL CLEAR\" signal is given after exposure to a
biological agent; 30 days have elapsed in the combat theater of
operations (the filters must be replaced every 30 days); supply
bulletins indicate lot number expiration; or when ordered by the unit
commander. The filter element can only be changed in a non-contaminated
environment. Two styles of optical inserts for the protective mask are
available for soldiers requiring visual correction. The wire frame style
is considered to be the safer of the two and is more easily fitted into
the mask. A prong-type optical insert is also available. A drinking tube
on the mask allows the wearer to drink while in a contaminated
environment. Note that the wearer should disinfect the canteen and tube
by wiping with a 5 percent hypochlorite solution before use.

The battle dress overgarment suits come in eight sizes and are currently
available in both woodland and desert camouflage patterns. The suit may
be worn for 24 continuous hours in a contaminated environment, but once
contaminated, it must be replaced by using the MOPP-gear exchange
procedure described in the Soldier\'s Manual of Common Tasks. The
discarded BDO must be incinerated or buried. Chemical protective gloves
and overboots come in various sizes and are both made from butyl rubber.
They may be decontaminated and reissued. The gloves and overboots must
be visually inspected and decontaminated as needed after every 12 hours
of exposure in a contaminated environment. While the protective
equipment will protect against biological agents, it is important to
note that even standard uniform clothing of good quality affords a
reasonable protection against dermal exposure of surfaces covered.

Those casualties unable to continue wearing protective equipment should
be held and/or transported within casualty wraps designed to protect the
patient against further chemical-biological agent exposure. Addition of
a filter blower unit to provide overpressure enhances protection and
provides cooling.

Collective protection by the use of either a hardened or unhardened
shelter equipped with an air filtration unit providing overpressure can
offer protection for personnel in the biologically contaminated
environment. An airlock ensures that no contamination will be brought
into the shelter. In the absence of a dedicated structure, enhanced
protection can be afforded within most buildings by sealing cracks and
entry ports, and providing air filtration with high efficiency
particulate air (HEPA) filters within existing ventilation systems. The
key problem is that these shelters can be very limited in military
situations, very costly to produce and maintain, and difficult to
deploy. Personnel must be decontaminated prior to entering the
collective protection unit.

The most important route of exposure to biological agents is through
inhalation. Biological warfare (BW) agents are dispersed as aerosols by
one of two basic mechanisms: point or line source dissemination. Unlike
some chemical threats, aerosols of agents disseminated by line source
munitions (e.g., sprayed by low-flying aircraft or speedboats along the
coast) do not leave hazardous environmental residua (although anthrax
spores may persist and could pose a hazard near the dissemination line).
On the other hand, aerosols generated by point-source munitions (i.e.,
stationary aerosol generator, bomblets, etc.) are more apt to produce
ground contamination, but only in the immediate vicinity of
dissemination. Point-source munitions leave an obvious signature that
alerts the field commander that a biological warfare attack has
occurred. Because point-source munitions always leave an agent residue,
this evidence can be exploited for detection and identification
purposes.

Aerosol delivery systems for biological warfare agents most commonly
generate invisible clouds with particles or droplets of \< 10
micrometers (μm). They can remain suspended for extensive periods. The
major risk is pulmonary retention of inhaled particles. To a much lesser
extent, particles may adhere to an individual or his clothing, thus the
need for individual decontamination. The effective area covered varies
with many factors, including wind speed, humidity, and sunlight. In the
absence of an effective real-time alarm system or direct observation of
an attack, the first clue would be mass casualties fitting a clinical
pattern compatible with one of the biological agents. This may occur
hours or days after the attack.

Toxins may cause direct pulmonary toxicity or be absorbed and cause
systemic toxicity. Toxins are frequently as potent or more potent by
inhalation than by any other route. A unique clinical picture may
sometimes be seen which is not observed by other routes (e.g., pulmonary
edema after staphylococcal enterotoxin B (SEB) exposure). Mucous
membranes, including conjunctivae, are also vulnerable to many
biological warfare agents. Physical protection is then quite important
and the use of full-face masks equipped with small-particle filters,
like the chemical protective masks, assumes a high degree of importance.

Other routes for delivery of biological agents are thought to be less
important than inhalation, but are nonetheless potentially significant.
Contamination of food and water supplies, either purposefully or
incidentally after an aerosol biological warfare attack, represents a
hazard for infection or intoxication by ingestion. Assurance that food
and water supplies are free from contamination should be provided by
appropriate preventive medicine authorities in the event of an attack.

Intact skin provides an excellent barrier for most biological agents.
T-2 mycotoxins would be an exception because of their dermal activity.
However, mucous membranes and abraded, or otherwise damaged, integument
can allow for passage of some bacteria and toxins, and should be
protected in the event of an attack.

#### DECONTAMINATION {#decontamination .unnumbered}

Contamination is the introduction of an infectious agent on a body
surface, food or water, or other inanimate objects. Decontamination
involves either disinfection or sterilization to reduce microorganisms
to an acceptable level on contaminated articles, thus rendering them
suitable for use. Disinfection is the selective reduction of undesirable
microbes to a level below that required for transmission. Sterilization
is the killing of all organisms.

Decontamination methods have always played an important role in the
control of infectious diseases. However, we are often unable use the
most efficient means of rendering microbes harmless (e.g., toxic
chemical sterilization), as these methods may injure people and damage
materials which are to be decontaminated. BW agents can be
decontaminated by mechanical, chemical and physical methods:

1\) Mechanical decontamination involves measures to remove but not
necessarily neutralize an agent. An example is the filtering of drinking
water to remove certain water-borne pathogens (e.g. *Dracunculus
medinensis*), or in a BW context, the use of an air filter to remove
aerosolized anthrax spores, or water to wash agent from the skin.

2\) Chemical decontamination renders BW agents harmless by the use of
disinfectants that are usually in the form of a liquid, gas or aerosol.
Some disinfectants are harmful to humans, animals, the environment, and
materials.

3\) Physical means (heat, radiation) are other methods that can be
employed for decontamination of objects.

Dermal exposure to a suspected BW aerosol should be immediately treated
by soap and water decontamination. Careful washing with soap and water
removes nearly all of the agent from the skin surface. Hypochlorite
solution or other disinfectants are reserved for gross contamination
(i.e. following the spill of solid or liquid agent from a munition
directly onto the skin). In the absence of chemical or gross biological
contamination, these will confer no additional benefit, may be caustic,
and may predispose to colonization and resistant superinfection by
reducing the normal skin flora. Grossly contaminated skin surfaces
should be washed with a 0.5% sodium hypochlorite solution, if available,
with a contact time of 10 to 15 minutes.

Ampules of calcium hypochlorite (HTH) are currently fielded in the
Chemical Agent Decon Set for mixing hypochlorite solutions. The 0.5%
solution can be made by adding one 6-ounce container of calcium
hypochlorite to five gallons of water. The 5% solution can be made by
adding eight 6-ounce ampules of calcium hypochlorite to five gallons of
water. These solutions evaporate quickly at high temperatures so if they
are made in advance they should be stored in closed containers. Also the
chlorine solutions should be placed in distinctly marked containers
because it is very difficult to tell the difference between the 5%
chlorine solution and the 0.5% solution.

To mix a 0.5% sodium hypochlorite solution, take one part Clorox and
nine parts water (1:9) since standard stock Clorox is a 5.25% sodium
hypochlorite solution. The solution is then applied with a cloth or
swab. The solution should be made fresh daily with the pH in the
alkaline range.

Chlorine solution must NOT be used in (1) open body cavity wounds, as it
may lead to the formation of adhesions, or (2) brain and spinal cord
injuries. However, this solution may be instilled into non-cavity wounds
and then removed by suction to an appropriate disposal container. Within
about 5 minutes, this contaminated solution will be neutralized and
nonhazardous. Subsequent irrigation with saline or other surgical
solutions should be performed. Prevent the chlorine solution from being
sprayed into the eyes, as corneal opacities may result.

For decontamination of fabric clothing or equipment, a 5% hypochlorite
solution should be used. For decontamination of equipment, a contact
time of 30 minutes prior to normal cleaning is required. This is
corrosive to most metals and injurious to most fabrics, so rinse
thoroughly and oil metal surfaces after completion.

BW agents can be rendered harmless through such physical means as heat
and radiation. To render agents completely harmless, sterilize with dry
heat for two hours at 160 degrees centigrade. If autoclaving with steam
at 121 degrees centigrade and 1 atmosphere of overpressure (15 pounds
per square inch), the time may be reduced to 20 minutes, depending on
volume. Solar ultraviolet (UV) radiation has a disinfectant effect,
often in combination with drying. This is effective in certain
environmental conditions but hard to standardize for practical usage for
decontamination purposes.

The health hazards posed by environmental contamination by biological
agents differ from those posed by persistent or volatile chemical
agents. Aerosolized particles in the 1-5 µm size range will remain
suspended due to Brownian motion; suspended BW agents would be
eventually inactivated by solar ultraviolet light, desiccation, and
oxidation. Little, if any, environmental residues would occur. Possible
exceptions include residua near the dissemination line, or in the
immediate area surrounding a point-source munition. BW agents deposited
on the soil would be subject to degradation by environmental stressors,
and competing soil microflora. Simulant studies at Dugway Proving Ground
suggest that secondary reaerosolization would be difficult, and would
probably not pose a human health hazard. Environmental decontamination
of terrain is costly and difficult and should be avoided, if possible.
If grossly contaminated terrain, streets, or roads must be passed, the
use of dust-binding spray to minimize reaerosolization may be
considered. If it is necessary to decontaminate these surfaces,
chlorine-calcium or lye may be used. Otherwise, rely on the natural
processes which, especially outdoors, leads to the decontamination of
agent by drying and solar UV radiation. Rooms in fixed spaces are best
decontaminated with gases or liquids in aerosol form (e.g.,
formaldehyde). This is usually combined with surface disinfectants to
ensure complete decontamination.

**Appendix A: Glossary of Medical Terms**

Adapted from Stedman's Electronic Medical Dictionary,

Williams & Wilkins, Baltimore, MD, 1996 and

Principles and Practice of Infectious Diseases,

Mandell et al, Third Edition.

**Acetylcholine (ACH, Ach)** - The neurotransmitter substance at
cholinergic synapses, which causes cardiac inhibition, vasodilatation,
gastrointestinal peristalsis, and other parasympathetic effects. It is
liberated from preganglionic and postganglionic endings of
parasympathetic fibers and from preganglionic fibers of the sympathetic
as a result of nerve injuries, whereupon it acts as a transmitter on the
effector organ; it is hydrolyzed into choline and acetic acid by
acetylcholinesterase before a second impulse may be transmitted.

**Active immunization** -The act of artificially stimulating the body to
develop antibodies against infectious disease by the administration of
vaccines or toxoids.

**Adenopathy** - Swelling or morbid enlargement of the lymph nodes.

**Aleukia** - Absence or extremely decreased number of leukocytes in the
circulating blood.

**Analgesic** - 1. A compound capable of producing analgesia, i.e., one
that relieves pain by altering perception of nocioceptive stimuli
without producing anesthesia or loss of consciousness. 2. Characterized
by reduced response to painful stimuli.

**Anaphylaxis** - The term is commonly used to denote the immediate,
transient kind of immunologic (allergic) reaction characterized by
contraction of smooth muscle and dilation of capillaries due to release
of pharmacologically active substances (histamine, bradykinin,
serotonin, and slow-reacting substance), classically initiated by the
combination of antigen (allergen) with mast cell-fixed, cytophilic
antibody (chiefly IgE).

**Anticonvulsant** - An agent which prevents or arrests seizures.

**Antitoxin** - An antibody formed in response to and capable of
neutralizing a biological poison.; an animal serum containing
antitoxins.

**Arthralgia** - Severe pain in a joint, especially one not inflammatory
in character.

**AST** - Abbreviation for aspartate aminotransferase, a liver enzyme.

**Asthenia** - Weakness or debility.

**Ataxia** - An inability to coordinate muscle activity during voluntary
movement, so that smooth movements occur. Most often due to disorders of
the cerebellum or the posterior columns of the spinal cord; may involve
the limbs, head, or trunk.

**Atelectasis** - Absence of gas from a part or the whole of the lungs,
due to failure of expansion or resorption of gas from the alveoli.

**Atropine** - An anticholinergic, with diverse effects (tachycardia,
mydriasis, cycloplegia, constipation, urinary retention) attributable to
reversible competitive blockade of acetylcholine at muscarinic type
cholinergic receptors; used in the treatment of poisoning with
organophosphate insecticides or nerve gases.

**Bilirubin** - A red bile pigment formed from hemoglobin during normal
and abnormal destruction of erythrocytes. Excess bilirubin is associated
with jaundice.

**Blood agar** - A mixture of blood and nutrient agar, used for the
cultivation of many medically important microorganisms.

**Bronchiolitis** - Inflammation of the bronchioles, often associated
with bronchopneumonia.

**Bronchitis** - Inflammation of the mucous membrane of the bronchial
tubes.

**Brucella** - A genus of encapsulated, nonmotile bacteria (family
Brucellaceae) containing short, rod-shaped to coccoid, Gram-negative
cells. These organisms are parasitic, invading all animal tissues and
causing infection of the genital organs, the mammary gland, and the
respiratory and intestinal tracts, and are pathogenic for man and
various species of domestic animals. They do not produce gas from
carbohydrates.

**Bubo** - Inflammatory swelling of one or more lymph nodes, usually in
the groin; the confluent mass of nodes usually suppurates and drains
pus.

**Bulla, gen. and pl. bullae** - A large blister appearing as a
circumscribed area of separation of the epidermis from the subepidermal
structure (subepidermal *bulla*) or as a circumscribed area of
separation of epidermal cells (intraepidermal *bulla*) caused by the
presence of serum, or occasionally by an injected substance.

**Carbuncle** - Deep-seated pyogenic infection of the skin and
subcutaneous tissues, usually arising in several contiguous hair
follicles, with formation of connecting sinuses; often preceded or
accompanied by fever, malaise, and prostration.

**Cerebrospinal** - Relating to the brain and the spinal cord.

**Chemoprophylaxis** - Prevention of disease by the use of chemicals or
drugs.

**Cholinergic** - Relating to nerve cells or fibers that employ
acetylcholine as their neurotransmitter.

**CNS** - Abbreviation for central nervous system.

**Coagulopathy** - A disease affecting the coagulability of the blood.

**Coccobacillus** - A short, thick bacterial rod of the shape of an oval
or slightly elongated coccus.

**Conjunctiva, pl. conjunctivae** - The mucous membrane investing the
anterior surface of the eyeball and the posterior surface of the lids.

**CSF** - Abbreviation for cerebrospinal fluid.

**Cutaneous** - Relating to the skin.

**Cyanosis** - A dark bluish or purplish coloration of the skin and
mucous membrane due to deficient oxygenation of the blood, evident when
reduced hemoglobin in the blood exceeds 5 g per 100 ml.

**Diathesis** -The constitutional or inborn state disposing to a
disease, group of diseases, or metabolic or structural anomaly.

**Diplopia** -The condition in which a single object is perceived as two
objects.

**Distal** - Situated away from the center of the body, or from the
point of origin; specifically applied to the extremity or distant part
of a limb or organ.

**Dysarthria** - A disturbance of speech and language due to emotional
stress, to brain injury, or to paralysis, incoordination, or spasticity
of the muscles used for speaking.

**Dysphagia, dysphagy** - Difficulty in swallowing.

**Dysphonia** - Altered voice production.

**Dyspnea** - Shortness of breath, a subjective difficulty or distress
in breathing, usually associated with disease of the heart or lungs;
occurs normally during intense physical exertion or at high altitude.

**Ecchymosis** - A purplish patch caused by extravasation of blood into
the skin, differing from petechiae only in size (larger than 3 mm
diameter).

**Eczema** - Generic term for inflammatory conditions of the skin,
particularly with vesiculation in the acute stage, typically
erythematous, edematous, papular, and crusting; followed often by
lichenification and scaling and occasionally by duskiness of the
erythema and, infrequently, hyperpigmentation; often accompanied by
sensations of itching and burning.

**Edema** - An accumulation of an excessive amount of watery fluid in
cells, tissues, or serous cavities.

**Enanthem, enanthema** - A mucous membrane eruption, especially one
occurring in connection with one of the exanthemas.

**Encephalitis, pl. encephalitides** - Inflammation of the brain.

**Endotoxemia** - Presence in the blood of endotoxins.

**Endotracheal intubation** - Passage of a tube through the nose or
mouth into the trachea for maintenance of the airway during anesthesia
or for maintenance of an imperiled airway.

**Enterotoxin** - A cytotoxin specific for the cells of the intestinal
mucosa.

**Epistaxis** - Profuse bleeding from the nose.

**Epizootic** - 1. Denoting a temporal pattern of disease occurrence in
an animal population in which the disease occurs with a frequency
clearly in excess of the expected frequency in that population during a
given time interval. 2. An outbreak (epidemic) of disease in an animal
population; often with the implication that it may also affect human
populations.

**Erythema** - Redness of the skin due to capillary dilatation.

**Erythema multiforme** - An acute eruption of macules, papules, or
subdermal vesicles presenting a multiform appearance, the characteristic
lesion being the target or iris lesion over the dorsal aspect of the
hands and forearms; its origin may be allergic, seasonal, or from drug
sensitivity, and the eruption, although usually self-limited (e.g.,
multiforme minor), may be recurrent or may run a severe course,
sometimes with fatal termination (e.g., multiforme major or
Stevens-Johnson syndrome).

**Erythrocyte** - A mature red blood cell.

**Erythropoiesis** - The formation of red blood cells.

**Exanthema** - A skin eruption occurring as a symptom of an acute viral
or coccal disease, as in scarlet fever or measles.

**Extracellular** -Outside the cells.

**Extraocular** - Adjacent to but outside the eyeball.

**Fasciculation** - Involuntary contractions, or twitchings, of groups
(fasciculi) of muscle fibers, a coarser form of muscular contraction
than fibrillation.

**Febrile** - Denoting or relating to fever.

**Fomite** - Objects, such as clothing, towels, and utensils that
possibly harbor a disease agent and are capable of transmitting it.

**Formalin** - A 37% aqueous solution of formaldehyde.

**Fulminant hepatitis** - Severe, rapidly progressive loss of hepatic
function due to viral infection or other cause of inflammatory
destruction of liver tissue.

**Generalized vaccinia** - Secondary lesions of the skin following
vaccination which may occur in subjects with previously healthy skin but
are more common in the case of traumatized skin, especially in the case
of eczema (eczema vaccinatum). In the latter instance, generalized
vaccinia may result from mere contact with a vaccinated person.
Secondary vaccinial lesions may also occur following transfer of virus
from the vaccination to another site by means of the fingers
(autoinnoculation).

**Glanders** - A chronic debilitating disease of horses and other
equids, as well as some members of the cat family, caused by
*Pseudomonas mallei*; it is transmissible to humans. It attacks the
mucous membranes of the nostrils of the horse, producing an increased
and vitiated secretion and discharge of mucus, and enlargement and
induration of the glands of the lower jaw.

**Granulocytopenia** -Less than the normal number of granular leukocytes
in the blood.

**Guarnieri bodies** - Intracytoplasmic acidophilic inclusion body\'s
observed in epithelial cells in variola (smallpox) and vaccinia
infections, and which include aggregations of Paschen body\'s or virus
particles.

**Hemagglutination** - The agglutination of red blood cells; may be
immune as a result of specific antibody either for red blood cell
antigens per se or other antigens which coat the red blood cells, or may
be nonimmune as in hemagglutination caused by viruses or other microbes.

**Hemagglutinin** - A substance, antibody or other, that causes
hemagglutination.

**Hematemesis** - Vomiting of blood.

**Hemopoietic** - Pertaining to or related to the formation of blood
cells.

**Hematuria** - Any condition in which the urine contains blood or red
blood cells.

**Hemodynamic** - Relating to the physical aspects of the blood
circulation.

**Hemolysis** -Alteration, dissolution, or destruction of red blood
cells in such a manner that hemoglobin is liberated into the medium in
which the cells are suspended, e.g., by specific complement-fixing
antibodies, toxins, various chemical agents, tonicity, alteration of
temperature.

**Hemolytic Uremic Syndrome** - Hemolytic anemia and thrombocytopenia
occurring with acute renal failure.

**Hemoptysis** - The spitting of blood derived from the lungs or
bronchial tubes as a result of pulmonary or bronchial hemorrhage.

**Hepatic** - Relating to the liver.

**Heterologous** - 1. Pertaining to cytologic or histologic elements
occurring where they are not normally found. 2. Derived from an animal
of a different species, as the serum of a horse is heterologous for a
rabbit.

**Hyperemia** - The presence of an increased amount of blood in a part
or organ.

**Hyperesthesia** - Abnormal acuteness of sensitivity to touch, pain, or
other sensory stimuli.

**Hypotension** - Subnormal arterial blood pressure.

**Hypovolemia** - A decreased amount of blood in the body.

**Hypoxemia** - Subnormal oxygenation of arterial blood, short of
anoxia.

**Idiopathic** - Denoting a disease of unknown cause.

**Immunoassay** - Detection and assay of substances by serological
(immunological) methods; in most applications the substance in question
serves as antigen, both in antibody production and in measurement of
antibody by the test substance.

**In vitro** - In an artificial environment, referring to a process or
reaction occurring therein, as in a test tube or culture media.

**In vivo** - In the living body, referring to a process or reaction
occurring therein.

**Induration** - 1. The process of becoming extremely firm or hard, or
having such physical features. 2. A focus or region of indurated tissue.

**Inguinal** - Relating to the groin.

**Inoculation** - Introduction into the body of the causative organism
of a disease.

**Leukopenia** - The antithesis of leukocytosis; any situation in which
the total number of leukocytes in the circulating blood is less than
normal, the lower limit of which is generally regarded as 4000-5000 per
cu mm.

**Lumbosacral** - Relating to the lumbar vertebrae and the sacrum.

**Lumen, pl. lumina** - The space in the interior of a tubular
structure, such as an artery or the intestine.

**Lymphadenopathy** - Any disease process affecting a lymph node or
lymph nodes.

**Lymphopenia** - A reduction, relative or absolute, in the number of
lymphocytes in the circulating blood.

**Macula, pl. maculae** - 1. A small spot, perceptibly different in
color from the surrounding tissue. 2. A small, discolored patch or spot
on the skin, neither elevated above nor depressed below the skin\'s
surface.

**Mediastinitis** - Inflammation of the cellular tissue of the
mediastinum.

**Mediastinum** - The median partition of the thoracic cavity, covered
by the mediastinal pleura and containing all the thoracic viscera and
structures except the lungs.

**Megakaryocyte** - A large cell with a polyploid nucleus that is
usually multilobed; megakaryocytes are normally present in bone marrow,
not in the circulating blood, and give rise to blood platelets.

**Melena** - Passage of dark-colored, tarry stools, due to the presence
of blood altered by the intestinal juices.

**Meningism** - A condition in which the symptoms simulate a meningitis,
but in which no actual inflammation of these membranes is present.

**Meningococcemia** - Presence of meningococci (*N. meningitidis*) in
the circulating blood.

**Meninges** - Any membrane; specifically, one of the membranous
coverings of the brain and spinal cord.

**Microcyst** - A tiny cyst, frequently of such dimensions that a
magnifying lens or microscope is required for observation.

**Microscopy** - Investigation of minute objects by means of a
microscope.

**Moribund** - Dying; at the point of death.

**Mucocutaneous** - Relating to mucous membrane and skin; denoting the
line of junction of the two at the nasal, oral, vaginal, and anal
orifices.

**Myalgia** - Muscular pain.

**Mydriasis** - Dilation of the pupil.

**Narcosis** - General and nonspecific reversible depression of neuronal
excitability, produced by a number of physical and chemical agents,
usually resulting in stupor rather than in anesthesia.

**Necrosis** - Pathologic death of one or more cells, or of a portion of
tissue or organ, resulting from irreversible damage.

**Nephropathia epidemica** - A generally benign form of epidemic
hemorrhagic fever reported in Scandinavia.

**Neutrophilia** - An increase of neutrophilic leukocytes in blood or
tissues; also frequently used synonymously with leukocytosis, inasmuch
as the latter is generally the result of an increased number of
neutrophilic granulocytes in the circulating blood (or in the tissues,
or both).

**Nosocomial** - Denoting a new disorder (not the patient\'s original
condition) associated with being treated in a hospital, such as a
hospital-acquired infection.

**Oliguria** - Scanty urine production.

**Oropharynx** - The portion of the pharynx that lies posterior to the
mouth; it is continuous above with the nasopharynx via the pharyngeal
isthmus and below with the laryngopharynx.

**Osteomyelitis** - Inflammation of the bone marrow and adjacent bone.

**Pancytopenia** - Pronounced reduction in the number of erythrocytes,
all types of white blood cells, and the blood platelets in the
circulating blood.

**Pandemic** - Denoting a disease affecting or attacking the population
of an extensive region, country, continent; extensively epidemic.

**Papule** - A small, circumscribed, solid elevation on the skin.

**Parasitemia** -The presence of parasites in the circulating blood;
used especially with reference to malarial and other protozoan forms,
and microfilariae.

**Passive immunity** - Providing temporary protection from disease
through the administration of exogenously produced antibody (i.e.,
transplacental transmission of antibodies to the fetus or the injection
of immune globulin for specific preventive purposes).

**PCR** - see below for polymerase chain reaction.

**Percutaneous** - Denoting the passage of substances through unbroken
skin, for example, by needle puncture, including introduction of wires
and catheters.

**Perivascular** - Surrounding a blood or lymph vessel.

**Petechia, pl. petechiae** - Minute hemorrhagic spots, of pinpoint to
pinhead size, in the skin, which are not blanched by pressure.

**Pharyngeal** - Relating to the pharynx.

**Pharyngitis** - Inflammation of the mucous membrane and underlying
parts of the pharynx.

**Phosgene** - Carbonyl chloride; a colorless liquid below 8.2°C, but an
extremely poisonous gas at ordinary temperatures; it is an insidious
gas, since it is not immediately irritating, even when fatal
concentrations are inhaled.

**Photophobia** - Morbid dread and avoidance of light. Photosensitivity,
or pain in the eyes with exposure to light, can be a cause.

**Pleurisy** - Inflammation of the pleura.

**Polymerase chain reaction** - An in vitro method for enzymatically
synthesizing and amplifying defined sequences of DNA in molecular
biology. Can be used for improving DNA-based diagnostic procedures for
identifying unknown BW agents.

**Polymorphonuclear** - Having nuclei of varied forms; denoting a
variety of leukocyte.

**Polyuria** - Excessive excretion of urine.

**Presynaptic** - Pertaining to the area on the proximal side of a
synaptic cleft.

**Prophylaxis, pl. prophylaxes** - Prevention of disease or of a process
that can lead to disease.

**Prostration** - A marked loss of strength, as in exhaustion.

**Proteinuria** - Presence of urinary protein in concentrations greater
than 0.3 g in a 24-hour urine collection or in concentrations greater
than 1 g/l in a random urine collection on two or more occasions at
least 6 hours apart; specimens must be clean, voided midstream, or
obtained by catheterization.

**Pruritus** - Syn: itching.

**Ptosis, pl. ptoses** - In reference to the eyes, drooping of the
eyelids.

**Pulmonary edema** -Edema of the lungs.

**Pyrogenic** - Causing fever.

**Retinitis** - Inflammation of the retina.

**Retrosternal** - Posterior to the sternum.

**Rhinorrhea** - A discharge from the nasal mucous membrane.

**Sarin** - A nerve poison which is a very potent irreversible
cholinesterase inhibitor and a more toxic nerve gas than tabun or soman.

**Scarification** -The making of a number of superficial incisions in
the skin. It is the technique used to administer tularemia and smallpox
vaccines.

**Septic shock** - 1. shock associated with sepsis, usually associated
with abdominal and pelvic infection complicating trauma or operations;
2. shock associated with septicemia caused by Gram-negative bacteria.

**Sequela, pl. sequelae** - A condition following as a consequence of a
disease.

**Shigellosis** - Bacillary dysentery caused by bacteria of the genus
*Shigella*, often occurring in epidemic patterns.

**Soman** - An extremely potent cholinesterase inhibitor, similar to
sarin and tabun.

**Sterile abscess** - An abscess whose contents are not caused by
pyogenic bacteria.

**Stridor** - A high-pitched, noisy respiration, like the blowing of the
wind; a sign of respiratory obstruction, especially in the trachea or
larynx.

**Superantigen** - An antigen that interacts with the T cell receptor in
a domain outside of the antigen recognition site. This type of
interaction induces the activation of larger numbers of T cells compared
to antigens that are presented in the antigen recognition site.

**Superinfection** - A new infection in addition to one already present.

**Tachycardia** - Rapid beating of the heart, conventionally applied to
rates over 100 per minute.

**Teratogenicity** -The property or capability of producing fetal
malformation.

**Thrombocytopenia** - A condition in which there is an abnormally small
number of platelets in the circulating blood.

**Toxoid** - A modified bacterial toxin that has been rendered nontoxic
(commonly with formaldehyde) but retains the ability to stimulate the
formation of antitoxins (antibodies) and thus producing an active
immunity. Examples include Botulinum, tetanus, and diphtheria toxoids.

**Tracheitis** - Inflammation of the lining membrane of the trachea.

**Urticaria** - An eruption of itching wheals, usually of systemic
origin; it may be due to a state of hypersensitivity to foods or drugs,
foci of infection, physical agents (heat, cold, light, friction), or
psychic stimuli.

**Vaccine** - A suspension of attenuated live or killed microorganisms
(bacteria, viruses, or rickettsiae), or fractions thereof, administered
to induce immunity and thereby prevent infectious disease.

**Vaccinia** - An infection, primarily local and limited to the site of
inoculation, induced in man by inoculation with the vaccinia (coxpox)
virus in order to confer resistance to smallpox (variola). On about the
third day after vaccination, papules form at the site of inoculation
which become transformed into umbilicated vesicles and later pustules;
they then dry up, and the scab falls off on about the 21st day, leaving
a pitted scar; in some cases there are more or less marked
constitutional disturbances.

**Varicella** - An acute contagious disease, usually occurring in
children, caused by the varicella-zoster virus, a member of the family
*Herpesviridae*, and marked by a sparse eruption of papules, which
become vesicles and then pustules, like that of smallpox although less
severe and varying in stages, usually with mild constitutional symptoms;
incubation period is about 14 to 17 days. Syn: chickenpox

**Variola** - Syn: smallpox.

**Variolation** - The historical practice of inducing immunity against
smallpox by "scratching" the skin with the purulency from smallpox skin
pustules. The first inoculation for smallpox is said to have been done
in China about 1022 B.C.

**Viremia** - The presence of virus in the bloodstream.

**Virion** - The complete virus particle that is structurally intact and
infectious.

**Zoonosis** - An infection or infestation shared in nature by humans
and other animals that are the normal or usual host; a disease of humans
acquired from an animal source.

# Appendix B: Patient Isolation Precautions {#appendix-b-patient-isolation-precautions .unnumbered}

**Standard Precautions**

-   Wash hands after patient contact.

-   Wear gloves when touching blood, body fluids, secretions, excretions
    and contaminated items.

-   Wear a mask and eye protection, or a face shield during procedures
    likely to generate splashes or sprays of blood, body fluids,
    secretions or excretions

-   Handle used patient-care equipment and linen in a manner that
    prevents the transfer of microorganisms to people or equipment.

Use care when handling sharps and use a mouthpiece or other ventilation
device as an alternative to mouth-to-mouth resuscitation when practical.

[Standard precautions are employed in the care of ALL
patients]{.underline}

**Airborne Precautions**

Standard Precautions plus:

-   Place the patient in a private room that has monitored negative air
    pressure, a minimum of six air changes/hour, and appropriate
    filtration of air before it is discharged from the room.

-   Wear respiratory protection when entering the room.

-   Limit movement and transport of the patient. Place a mask on the
    patient if they need to be moved.

[Conventional Diseases requiring Airborne Precautions: Measles,
Varicella, Pulmonary Tuberculosis.]{.underline}

[Biothreat Diseases requiring Airborne Precautions:
Smallpox.]{.underline}

**Droplet Precautions**

Standard Precaution plus:

-   Place the patient in a private room or cohort them with someone with
    the same infection. If not feasible, maintain at least 3 feet
    between patients.

-   Wear a mask when working within 3 feet of the patient.

-   Limit movement and transport of the patient. Place a mask on the
    patient if they need to be moved.

## [Conventional Diseases requiring Droplet Precautions: Invasive *Haemophilus influenzae* and meningococcal disease, drug-resistant pneumococcal disease, diphtheria, pertussis, mycoplasma, GABHS, influenza, mumps, rubella, parvovirus.]{.underline} {#conventional-diseases-requiring-droplet-precautions-invasive-haemophilus-influenzae-and-meningococcal-disease-drug-resistant-pneumococcal-disease-diphtheria-pertussis-mycoplasma-gabhs-influenza-mumps-rubella-parvovirus. .unnumbered}

[Biothreat Diseases requiring Droplet precautions: Pneumonic
Plague.]{.underline}

# Appendix B: Patient Isolation Precautions (continued) {#appendix-b-patient-isolation-precautions-continued .unnumbered}

**Contact Precautions**

Standard Precautions plus:

-   Place the patient in a private room or cohort them with someone with
    the same infection if possible.

-   Wear gloves when entering the room. Change gloves after contact with
    infective material.

-   Wear a gown when entering the room if contact with patient is
    anticipated or if the patient has diarrhea, a colostomy or wound
    drainage not covered by a dressing.

-   Limit the movement or transport of the patient from the room.

-   Ensure that patient-care items, bedside equipment, and frequently
    touched surfaces receive daily cleaning.

-   Dedicate use of noncritical patient-care equipment (such as
    stethoscopes) to a single patient, or cohort of patients with the
    same pathogen. If not feasible, adequate disinfection between
    patients is necessary.

[Conventional Diseases requiring Contact Precautions: MRSA, VRE,
*Clostridium difficile*, RSV, parainfluenza, enteroviruses, enteric
infections in the incontinent host, skin infections (SSSS, HSV,
impetigo, lice, scabies), hemorrhagic conjunctivitis.]{.underline}

[Biothreat Diseases requiring Contact Precautions: Viral Hemorrhagic
Fevers.]{.underline}

For more information, see: Garner JS. Guideline for Infection Control
Practices in Hospitals. Infect Control Hosp Epidemiol 1996;17:53-80.

###### Appendix C: BW Agent Characteristics {#appendix-c-bw-agent-characteristics .unnumbered}

+------+-----+-------+------+--------+-------+------------+----------+
| **D  | *   | *     | **In | **Du   | *     | **P        | *        |
| isea | *Tr | *Infe | cuba | ration | *Leth | ersistence | *Vaccine |
| se** | ans | ctive | tion | of     | ality | of         | Ef       |
|      | mit | D     | Peri | Ill    | (ap   | Organism** | ficacy** |
|      | Man | ose** | od** | ness** | prox. |            |          |
|      | to  |       |      |        | case  |            | **       |
|      | Ma  | **(   |      |        | fat   |            | (aerosol |
|      | n** | Aeros |      |        | ality |            | exp      |
|      |     | ol)** |      |        | rat   |            | osure)** |
|      |     |       |      |        | es)** |            |          |
+------+-----+-------+------+--------+-------+------------+----------+
| **In | No  | 8,    | 1-6  | 3-5    | High  | Very       | 2 dose   |
| hala |     | 000-5 | days | days   |       | stable -   | efficacy |
| tion |     | 0,000 |      | (u     |       | spores     | against  |
| a    |     | s     |      | sually |       | remain     | up to    |
| nthr |     | pores |      | fatal  |       | viable for | 1,000    |
| ax** |     |       |      | if     |       | \> 40      | LD~50~   |
|      |     |       |      | untr   |       | years in   | in       |
|      |     |       |      | eated) |       | soil       | monkeys  |
+------+-----+-------+------+--------+-------+------------+----------+
| **B  | No  | 10    | 5-60 | Weeks  | \<5%  | Very       | No       |
| ruce |     | -100  | days | to     | untr  | stable     | vaccine  |
| llos |     | orga  |      | months | eated |            |          |
| is** |     | nisms | (usu |        |       |            |          |
|      |     |       | ally |        |       |            |          |
|      |     |       | 1-2  |        |       |            |          |
|      |     |       | mon  |        |       |            |          |
|      |     |       | ths) |        |       |            |          |
+------+-----+-------+------+--------+-------+------------+----------+
| **C  | R   | 1     | 4    | [\>]   | Low   | Unstable   | No data  |
| hole | are | 0-500 | h    | {.unde | with  | in         | on       |
| ra** |     | orga  | ours | rline} | treat | aerosols & | aerosol  |
|      |     | nisms | -    | 1 week | ment, | fresh      |          |
|      |     |       |      |        | high  | water;     |          |
|      |     |       | 5    |        | wi    | stable in  |          |
|      |     |       | days |        | thout | salt water |          |
|      |     |       | (usu |        |       |            |          |
|      |     |       | ally |        |       |            |          |
|      |     |       | 2-3  |        |       |            |          |
|      |     |       | d    |        |       |            |          |
|      |     |       | ays) |        |       |            |          |
+------+-----+-------+------+--------+-------+------------+----------+
| **Gl | Low | As    | 1    | Death  | \>    | Very       | No       |
| ande |     | sumed | 0-14 | in     | 50%   | stable     | vaccine  |
| rs** |     | low   | days | 7-10   |       |            |          |
|      |     |       | via  | days   |       |            |          |
|      |     |       | aer  | in     |       |            |          |
|      |     |       | osol | sept   |       |            |          |
|      |     |       |      | icemic |       |            |          |
|      |     |       |      | form   |       |            |          |
+------+-----+-------+------+--------+-------+------------+----------+
| **P  | H   | 10    | 2-3  | 1-6    | High  | For up to  | 3 doses  |
| neum | igh | 0-500 | days | days   | u     | 1 year in  | not      |
| onic |     | orga  |      |        | nless | soil; 270  | pr       |
| Plag |     | nisms |      | (u     | tr    | days in    | otective |
| ue** |     |       |      | sually | eated | live       | against  |
|      |     |       |      | fatal) | w     | tissue     | 118      |
|      |     |       |      |        | ithin |            | LD~50~   |
|      |     |       |      |        | 12-24 |            | in       |
|      |     |       |      |        | hours |            | monkeys  |
+------+-----+-------+------+--------+-------+------------+----------+
| *    | No  | 10-50 | 2-10 | [\>]   | Mod   | For months | 80%      |
| *Tul |     | orga  | days | {.unde | erate | in moist   | pr       |
| arem |     | nisms | (ave | rline} | if    | soil or    | otection |
| ia** |     |       | rage | 2      | untr  | other      | against  |
|      |     |       | 3-5) | weeks  | eated | media      |          |
|      |     |       |      |        |       |            | 1-10     |
|      |     |       |      |        |       |            | LD~50~   |
+------+-----+-------+------+--------+-------+------------+----------+
| **Q  | R   | 1-10  | 1    | 2-14   | Very  | For months | 94%      |
| Fev  | are | orga  | 0-40 | days   | low   | on wood    | pr       |
| er** |     | nisms | days |        |       | and sand   | otection |
|      |     |       |      |        |       |            | against  |
|      |     |       |      |        |       |            | 3,500    |
|      |     |       |      |        |       |            | LD~50~   |
|      |     |       |      |        |       |            | in       |
|      |     |       |      |        |       |            | guinea   |
|      |     |       |      |        |       |            | pigs     |
+------+-----+-------+------+--------+-------+------------+----------+
| **Sm | H   | As    | 7-17 | 4      | High  | Very       | Vaccine  |
| allp | igh | sumed | days | weeks  | to    | stable     | protects |
| ox** |     | low   | (ave |        | mod   |            | against  |
|      |     |       | rage |        | erate |            | large    |
|      |     | (1    | 12)  |        |       |            | doses in |
|      |     | 0-100 |      |        |       |            | primates |
|      |     | organ |      |        |       |            |          |
|      |     | isms) |      |        |       |            |          |
+------+-----+-------+------+--------+-------+------------+----------+
| **Ve | Low | 1     | 2-6  | Days   | Low   | Relatively | TC 83    |
| nezu |     | 0-100 | days | to     |       | unstable   | protects |
| elan |     | orga  |      | weeks  |       |            | against  |
| Eq   |     | nisms |      |        |       |            | 30-500   |
| uine |     |       |      |        |       |            | LD~50~   |
| En   |     |       |      |        |       |            | in       |
| ceph |     |       |      |        |       |            | hamsters |
| alit |     |       |      |        |       |            |          |
| is** |     |       |      |        |       |            |          |
+------+-----+-------+------+--------+-------+------------+----------+
| *    | Mo  | 1-10  | 4-21 | Death  | High  | Relatively | No       |
| *Vir | der | orga  | days | b      | for   | unstable - | vaccine  |
| al** | ate | nisms |      | etween | Zaire | depends on |          |
|      |     |       |      | 7-16   | st    | agent      |          |
| **H  |     |       |      | days   | rain, |            |          |
| emor |     |       |      |        | mod   |            |          |
| rhag |     |       |      |        | erate |            |          |
| ic** |     |       |      |        | with  |            |          |
|      |     |       |      |        | Sudan |            |          |
| **   |     |       |      |        |       |            |          |
| Feve |     |       |      |        |       |            |          |
| rs** |     |       |      |        |       |            |          |
+------+-----+-------+------+--------+-------+------------+----------+
| **Bo | No  | 0.001 | 1-5  | Death  | High  | For weeks  | 3 dose   |
| tuli |     | μg/kg | days | in     | wi    | in         | efficacy |
| sm** |     | is    |      | 24-72  | thout | nonmoving  | 100%     |
|      |     | L     |      | hours; | r     | water and  | against  |
|      |     | D~50~ |      | lasts  | espir | food       | 25-250   |
|      |     | for   |      | months | atory |            | LD~50~   |
|      |     | type  |      | if not | su    |            | in       |
|      |     | A     |      | lethal | pport |            | primates |
+------+-----+-------+------+--------+-------+------------+----------+
| **S  | No  | 0.03  | 3-12 | Hours  | \< 1% | Resistant  | No       |
| taph |     | μg/p  | h    |        |       | to         | vaccine  |
| Ent  |     | erson | ours |        |       | freezing   |          |
| erot |     | inca  | a    |        |       |            |          |
| oxin |     | pacit | fter |        |       |            |          |
| B**  |     | ation | in   |        |       |            |          |
|      |     |       | hala |        |       |            |          |
|      |     |       | tion |        |       |            |          |
+------+-----+-------+------+--------+-------+------------+----------+
| *    | No  | 3-5   | 1    | Days - | High  | Stable     | No       |
| *Ric |     | μg/kg | 8-24 | death  |       |            | vaccine  |
| in** |     | is    | h    | within |       |            |          |
|      |     | L     | ours | 10-12  |       |            |          |
|      |     | D~50~ |      | days   |       |            |          |
|      |     |       |      | for    |       |            |          |
|      |     | in    |      | ing    |       |            |          |
|      |     | mice  |      | estion |       |            |          |
+------+-----+-------+------+--------+-------+------------+----------+
| *    | No  | Mod   | 2-4  | Days   | Mod   | For years  | No       |
| *T-2 |     | erate | h    | to     | erate | at room    | vaccine  |
| Myco |     |       | ours | months |       | t          |          |
| toxi |     |       |      |        |       | emperature |          |
| ns** |     |       |      |        |       |            |          |
+------+-----+-------+------+--------+-------+------------+----------+

Appendix D: BW Agents - Vaccine, Therapeutics, and Prophylaxis

+------+-----------+---------------+------------+---------------------+
| **D  | **        | *             | **CHEMOP   | **COMMENTS**        |
| ISEA | VACCINE** | *CHEMOTHERAPY | ROPHYLAXIS |                     |
| SE** |           | (Rx)**        | (Px)**     |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
| **A  | **Bioport | **            | **Cip      | **Potential         |
| nthr | vaccine   | Ciprofloxacin | rofloxacin | alternates for Rx:  |
| ax** | (         | 400 mg IV q   | 500 mg PO  | gentamicin,         |
|      | licensed) | 12 h**        | bid x 4 wk | erythromycin, and   |
|      | 0.5 mL SC |               | If         | chloramphenicol**   |
|      | @ 0, 2, 4 | **or**        | unv        |                     |
|      | wk, 6,    |               | accinated, |                     |
|      | 12, 18 mo | **Doxycycline | begin      |                     |
|      | then      | 200 mg IV,    | initial    |                     |
|      | annual    | then 100 mg   | doses of   |                     |
|      | b         | IV q 12 h**   | vaccine**  |                     |
|      | oosters** |               |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           | **Penicillin  | **D        | **PCN for sensitive |
|      |           | 4 million     | oxycycline | organisms only**    |
|      |           | units IV q 4  | 100 mg PO  |                     |
|      |           | h**           | bid x 4 wk |                     |
|      |           |               | plus       |                     |
|      |           |               | vac        |                     |
|      |           |               | cination** |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
| **C  | **Wye     | **Oral        | **NA**     | **Vaccine not       |
| hole | th-Ayerst | rehydration   |            | recommended for     |
| ra** | Vaccine 2 | therapy       |            | routine protection  |
|      | doses 0.5 | during period |            | in endemic areas    |
|      | mL IM or  | of high fluid |            | (50% efficacy,      |
|      | SC @ 0,   | loss**        |            | short term)**       |
|      | 7-30      |               |            |                     |
|      | days,     |               |            |                     |
|      | then      |               |            |                     |
|      | boosters  |               |            |                     |
|      | Q 6       |               |            |                     |
|      | months**  |               |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           | *             |            | **Alternates for    |
|      |           | *Tetracycline |            | Rx: erythromycin,** |
|      |           | 500 mg q 6 h  |            |                     |
|      |           | x 3 d**       |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           | **Doxycycline |            | **trimethoprim and  |
|      |           | 300 mg once,  |            | sulfamethoxazole,   |
|      |           | or 100 mg q   |            | and furazolidone**  |
|      |           | 12 h x 3 d**  |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           | **            |            | **Quinolones for    |
|      |           | Ciprofloxacin |            | tetra/doxy          |
|      |           | 500 mg q 12 h |            | resistant strains** |
|      |           | x 3 d**       |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           | **Norfloxacin |            |                     |
|      |           | 400 mg q 12 h |            |                     |
|      |           | x 3 d**       |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
| **Q  | **IND     | *             | **Te       | **Currently testing |
| Fev  | 610 -     | *Tetracycline | tracycline | vaccine to          |
| er** | in        | 500 mg PO q 6 | 500 mg PO  | determine the       |
|      | activated | h x 5-7 d     | qid x 5 d  | necessity of skin   |
|      | whole     | continued at  | (start     | testing prior to    |
|      | cell      | least 2 d     | 8-12 d     | use.**              |
|      | vaccine   | after         | post-e     |                     |
|      | given as  | afebrile**    | xposure)** |                     |
|      | single    |               |            |                     |
|      | 0.5 ml    |               |            |                     |
|      | s.c.      |               |            |                     |
|      | in        |               |            |                     |
|      | jection** |               |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           | **Doxycycline | **D        |                     |
|      |           | 100 mg PO q   | oxycycline |                     |
|      |           | 12 h x 5-7 d  | 100 mg PO  |                     |
|      |           | continued at  | bid x 5 d  |                     |
|      |           | least 2 d     | (start     |                     |
|      |           | after         | 8-12 d     |                     |
|      |           | afebrile**    | post-e     |                     |
|      |           |               | xposure)** |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
| **Gl | **No      | **Antibiotic  | **Pos      | **No large          |
| ande | vaccine   | regimens vary | t-exposure | therapeutic human   |
| rs** | av        | depending on  | p          | trials have been    |
|      | ailable** | localization  | rophylaxis | conducted owing to  |
|      |           | and severity  | may be     | the rarity of       |
|      |           | of disease -  | tried with | naturally occurring |
|      |           | refer to      | TMP-SMX**  | disease.**          |
|      |           | text**        |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
| **   | **Greer   | *             | **D        | **Chloramphenicol   |
| Plag | in        | *Streptomycin | oxycycline | for plague          |
| ue** | activated | 30 mg/kg/d IM | 100 mg PO  | meningitis is       |
|      | vaccine   | in 2 divided  | bid x 7 d  | required**          |
|      | (FDA      | doses x 10 -- | or         |                     |
|      | licensed) | 14 d**        | duration   | **25 mg/kg IV, then |
|      | is no     |               | of         | 15 mg/kg qid x 14   |
|      | longer    | **or**        | exposure** | d**                 |
|      | ava       |               |            |                     |
|      | ilable.** | **Gentamicin  | **Cip      |                     |
|      |           | 5mg/kg IM or  | rofloxacin |                     |
|      |           | IV once daily | 500 mg PO  |                     |
|      |           | x 10 - 14 d** | bid x 7    |                     |
|      |           |               | d**        |                     |
|      |           | **or**        |            |                     |
|      |           |               |            |                     |
|      |           | **            |            |                     |
|      |           | Ciprofloxacin |            |                     |
|      |           | 400mg IV q 12 |            |                     |
|      |           | h until       |            |                     |
|      |           | clinically    |            |                     |
|      |           | improved then |            |                     |
|      |           | 750 mg PO bid |            |                     |
|      |           | for total of  |            |                     |
|      |           | 10 --14 d**   |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           | **Doxycycline | **Te       | **Alternate Rx:     |
|      |           | 200 mg IV     | tracycline | trimethoprim        |
|      |           | then 100 mg   | 500 mg PO  | -sulfamethoxazole** |
|      |           | IV bid, until | qid x 7    |                     |
|      |           | clinically    | d**        |                     |
|      |           | improved then |            |                     |
|      |           | 100mg PO bid  |            |                     |
|      |           | for total of  |            |                     |
|      |           | 10-14 d**     |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+

+------+-----------+---------------+------------+---------------------+
| **D  | **        | *             | **CHEMOP   | **COMMENTS**        |
| ISEA | VACCINE** | *CHEMOTHERAPY | ROPHYLAXIS |                     |
| SE** |           | (Rx)**        | (Px)**     |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
| **B  | **No      | **Doxycycline | **D        | **Trimethopr        |
| ruce | human     | 200 mg/d PO   | oxycycline | im-sulfamethoxazole |
| llos | vaccine   | plus rifampin | 200 mg/d   | may be substituted  |
| is** | av        | 600 mg/d PO x | PO plus    | for rifampin;       |
|      | ailable** | 6 wk**        | rifampin   | however, relapse    |
|      |           |               | 600 mg/d   | may reach 30%**     |
|      |           |               | PO x 6     |                     |
|      |           |               | wk**       |                     |
+------+-----------+---------------+------------+---------------------+
|      |           | **Ofloxacin   |            |                     |
|      |           | 400/rifampin  |            |                     |
|      |           | 600 mg/d PO x |            |                     |
|      |           | 6 wks**       |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
| *    | **IND -   | *             | **D        |                     |
| *Tul | Live      | *Streptomycin | oxycycline |                     |
| arem | a         | 7.5-10 mg/kg  | 100 mg PO  |                     |
| ia** | ttenuated | IM bid x      | bid x 14   |                     |
|      | vaccine:  | 10-14 d**     | d**        |                     |
|      | single    |               |            |                     |
|      | 0.1ml     |               |            |                     |
|      | dose by   |               |            |                     |
|      | scarif    |               |            |                     |
|      | ication** |               |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           | **Gentamicin  | **Te       |                     |
|      |           | 3-5 mg/kg/d   | tracycline |                     |
|      |           | IV x 10-14    | 500 mg PO  |                     |
|      |           | d**           | qid x**    |                     |
|      |           |               |            |                     |
|      |           |               | **14 d**   |                     |
+------+-----------+---------------+------------+---------------------+
|      |           | **            | **Cip      |                     |
|      |           | Ciprofloxacin | rofloxacin |                     |
|      |           | 400 mg IV q   | 500 mg PO  |                     |
|      |           | 12h until     | q 12 h for |                     |
|      |           | improved,     | 14 d**     |                     |
|      |           | then 500 mg   |            |                     |
|      |           | PO q 12 h for |            |                     |
|      |           | total of 10 - |            |                     |
|      |           | 14 d**        |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           | **            |            |                     |
|      |           | Ciprofloxacin |            |                     |
|      |           | 750 mg PO q   |            |                     |
|      |           | 12 h for 10 - |            |                     |
|      |           | 14 d**        |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
| **V  | **VEE DOD | **Supportive  | **NA**     | **TC-83 reactogenic |
| iral | TC-83     | therapy:      |            | in 20%**            |
| ence | live      | analgesics    |            |                     |
| phal | a         | and           |            | **No seroconversion |
| itid | ttenuated | an            |            | in 20%**            |
| es** | vaccine   | ticonvulsants |            |                     |
|      | (IND):    | prn**         |            | **Only effective    |
|      | 0.5 mL SC |               |            | against subtypes    |
|      | x1 dose** |               |            | 1A, 1B, and 1C**    |
+------+-----------+---------------+------------+---------------------+
|      | **VEE DOD |               |            | **C-84 vaccine used |
|      | C-84      |               |            | for non-responders  |
|      | (formalin |               |            | to TC-83**          |
|      | in        |               |            |                     |
|      | activated |               |            |                     |
|      | TC-83)    |               |            |                     |
|      | (IND):    |               |            |                     |
|      | 0.5 mL SC |               |            |                     |
|      | for up to |               |            |                     |
|      | 3 doses** |               |            |                     |
+------+-----------+---------------+------------+---------------------+
|      | **EEE     |               |            | **EEE and WEE       |
|      | in        |               |            | inactivated         |
|      | activated |               |            | vaccines are        |
|      | (IND):**  |               |            | poorly**            |
|      |           |               |            |                     |
|      | **0.5 mL  |               |            |                     |
|      | SC at 0 & |               |            |                     |
|      | 28 d**    |               |            |                     |
+------+-----------+---------------+------------+---------------------+
|      | **WEE     |               |            | **Immunogenic.      |
|      | in        |               |            | Multiple            |
|      | activated |               |            | immunizations are   |
|      | (IND):**  |               |            | required**          |
|      |           |               |            |                     |
|      | **0.5 mL  |               |            |                     |
|      | SC at 0,  |               |            |                     |
|      | 7, and 28 |               |            |                     |
|      | d**       |               |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
| **V  | **AHF     | **Ribavirin   | **NA**     | **Aggressive        |
| iral | Candid #1 | (CCHF/Lassa)  |            | supportive care and |
| Hem  | vaccine** | (IND)**       |            | management of       |
| orrh |           |               |            | hypotension very    |
| agic | **(x-p    | **30 mg/kg IV |            | important**         |
| Feve | rotection | initial dose; |            |                     |
| rs** | for BHF)  | then**        |            |                     |
|      | (IND)**   |               |            |                     |
|      |           | **16 mg/kg IV |            |                     |
|      |           | q 6 h x 4 d;  |            |                     |
|      |           | then**        |            |                     |
|      |           |               |            |                     |
|      |           | **8 mg/kg IV  |            |                     |
|      |           | q 8 h x 6 d** |            |                     |
+------+-----------+---------------+------------+---------------------+
|      | **RVF     | **Passive     |            |                     |
|      | in        | antibody for  |            |                     |
|      | activated | AHF, BHF,     |            |                     |
|      | vaccine   | Lassa fever,  |            |                     |
|      | (IND)**   | and CCHF**    |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
| **Sm | **Wyeth   | **No current  | **Vaccinia | **Pre and post      |
| allp | calf      | Rx other than | immune     | exposure            |
| ox** | lymph     | supportive;   | globulin   | vaccination         |
|      | vaccinia  | Cidofovir     | 0.6 mL/kg  | recommended if \> 3 |
|      | vaccine   | (effective in | IM (within | years since last    |
|      | (l        | vitro);       | 3 d of     | vaccine**           |
|      | icensed): | animal        | exposure,  |                     |
|      | 1 dose by | studies       | best       |                     |
|      | scarif    | ongoing**     | within 24  |                     |
|      | ication** |               | h)**       |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+

+------+-----------+---------------+------------+---------------------+
| **D  | **        | *             | **CHEMOP   | **COMMENTS**        |
| ISEA | VACCINE** | *CHEMOTHERAPY | ROPHYLAXIS |                     |
| SE** |           | (Rx)**        | (Px)**     |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
| **Bo | **DOD     | **DOD         | **NA**     | **Skin test for     |
| tuli | pe        | heptavalent   |            | hypersensitivity    |
| sm** | ntavalent | equine        |            | before equine       |
|      | toxoid    | despeciated   |            | antitoxin           |
|      | for       | antitoxin for |            | administration**    |
|      | serotypes | serotypes A-G |            |                     |
|      | A - E     | (IND): 1 vial |            |                     |
|      | (IND):    | (10 mL) IV**  |            |                     |
|      | 0.5 ml    |               |            |                     |
|      | deep SC @ |               |            |                     |
|      | 0, 2 & 12 |               |            |                     |
|      | wk, then  |               |            |                     |
|      | yearly    |               |            |                     |
|      | b         |               |            |                     |
|      | oosters** |               |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           | **CDC         | **NA**     |                     |
|      |           | trivalent     |            |                     |
|      |           | equine        |            |                     |
|      |           | antitoxin for |            |                     |
|      |           | serotypes A,  |            |                     |
|      |           | B, E          |            |                     |
|      |           | (licensed)**  |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
| **S  | **No      | **Ventilatory | **NA**     |                     |
| taph | vaccine   | support for   |            |                     |
| yloc | av        | inhalation    |            |                     |
| occu | ailable** | exposure**    |            |                     |
| sEnt |           |               |            |                     |
| erot |           |               |            |                     |
| oxin |           |               |            |                     |
| B**  |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
| *    | **No      | **Inhalation: | **NA**     |                     |
| *Ric | vaccine   | supportive    |            |                     |
| in** | av        | therapy**     |            |                     |
|      | ailable** |               |            |                     |
|      |           | **G-I :       |            |                     |
|      |           | gastric       |            |                     |
|      |           | lavage,       |            |                     |
|      |           | s             |            |                     |
|      |           | uperactivated |            |                     |
|      |           | charcoal,     |            |                     |
|      |           | cathartics**  |            |                     |
+------+-----------+---------------+------------+---------------------+
|      |           |               |            |                     |
+------+-----------+---------------+------------+---------------------+
| *    | **No      |               | **Decon    |                     |
| *T-2 | vaccine   |               | tamination |                     |
| Myco | av        |               | of         |                     |
| toxi | ailable** |               | clothing   |                     |
| ns** |           |               | and skin** |                     |
+------+-----------+---------------+------------+---------------------+

**Appendix E: Medical Sample Collection for Biological Threat Agents**

This guide helps determine which clinical samples to collect from
individuals exposed to aerosolized biological threat agents. Proper
collection of specimens is dependent on the time-frame following
exposure. Sample collection is described for "Early post-exposure",
"Clinical", and "Convalescent/ Terminal/ Postmortem" time-frames. These
time-frames are not rigid and will vary according to the concentration
of the agent used, the agent strain, and predisposing health factors of
the patient.

-   Early post-exposure: when it is known that an individual has been
    exposed to a bioagent aerosol; aggressively attempt to obtain
    samples as indicated

```{=html}
<!-- -->
```
-   Clinical: samples from those individuals presenting with clinical
    symptoms

```{=html}
<!-- -->
```
-   Convalescent/Terminal/Postmortem: samples taken during
    convalescence, the terminal stages of infection or toxicosis or
    postmortem during autopsy

[Shipping Samples]{.underline}: Most specimens sent rapidly (less than
24 h) to analytical labs require only blue or wet ice or refrigeration
at 2 to 8˚C. However, if the time span increases beyond 24 h, contact
the USAMRIID "Hot-Line" (1-888-USA-RIID) for other shipping requirements
such as shipment on dry-ice or in liquid nitrogen.

[Blood samples:]{.underline} Several choices are offered based on
availability of the blood collection tubes. Do not send blood in all the
tubes listed, but merely choose one. Tiger-top tubes that have been
centrifuged are preferred over red-top clot tubes with serum removed
from the clot, but the latter will suffice. Blood culture bottles are
also preferred over citrated blood for bacterial cultures.

[Pathology samples]{.underline}: routinely include liver, lung, spleen,
and regional or mesenteric lymph nodes. Additional samples requested are
as follows: brain tissue for encephalomyelitis cases (mortality is rare)
and the adrenal gland for Ebola (nice to have but not absolutely
required).

### Appendix E: Medical Sample Collection for Biological Threat Agents {#appendix-e-medical-sample-collection-for-biological-threat-agents .unnumbered}

###  *Bacteria and Rickettsia* {#bacteria-and-rickettsia .unnumbered}

####  {#section-19 .unnumbered}

+-----------------------+----------------------+----------------------+
| **[Early              | **[Convalescent/     | **[Terminal/Postm    |
| post-ex               | Cli                  | ortem]{.underline}** |
| posure]{.underline}** | nical]{.underline}** |                      |
+-----------------------+----------------------+----------------------+
| **Anthrax**           | [24 to 72            | [3 to 10             |
|                       | h]{.underline}       | days]{.underline}    |
| *Bacillus anthracis*  |                      |                      |
|                       | Serum (TT, RT) for   | Serum (TT, RT) for   |
| [0 -- 24              | toxin assays Blood   | toxin assays Blood   |
| h]{.underline}        | (E, C, H) for PCR.   | (BC, C) for culture. |
|                       | Blood (BC, C) for    | Pathology samples    |
| Nasal and throat      | culture              |                      |
| swabs, induced        |                      |                      |
| respiratory           |                      |                      |
| secretions for        |                      |                      |
| culture, FA, and PCR  |                      |                      |
+-----------------------+----------------------+----------------------+
| ## Plague {#          | [24 -- 72            | [\>6                 |
| plague-1 .unnumbered} | h]{.underline}       | days]{.underline}    |
|                       |                      |                      |
| *Yersinia pestis*     | Blood (BC, C) and    | Serum (TT, RT) for   |
|                       | bloody sputum for    | IgM later for IgG .  |
| [0 -- 24              | culture and FA (C),  | Pathology samples    |
| h]{.underline}        | F-1 Antigen assays   |                      |
|                       | (TT, RT), PCR (E, C, |                      |
| Nasal swabs, sputum,  | H)                   |                      |
| induced respiratory   |                      |                      |
| secretions for        |                      |                      |
| culture, FA, and PCR  |                      |                      |
+-----------------------+----------------------+----------------------+
| ## Tularemia {#tul    | [24 -- 72            | [\>6                 |
| aremia-1 .unnumbered} | h]{.underline}       | days]{.underline}    |
|                       |                      |                      |
| *Francisella          | # Blo                | Serum (TT, RT) for   |
| tularensis*           | od (BC, C) for cultu | IgM and later IgG,   |
|                       | re {#blood-bc-c-for- | agglutination        |
| [0 -- 24              | culture .unnumbered} | titers. Pathology    |
| h]{.underline}        |                      | Samples              |
|                       | #                    |                      |
| Nasal swabs, sputum,  |  Blood (E, C, H) for |                      |
| induced respiratory   |  PCR  {#blood-e-c-h- |                      |
| secretions for        | for-pcr .unnumbered} |                      |
| culture, FA and PCR   |                      |                      |
|                       | Sputum for FA & PCR  |                      |
+-----------------------+----------------------+----------------------+
| **Glanders**          | [24 -- 72            | [\>6                 |
|                       | h]{.underline}       | days]{.underline}    |
| *Burkholderia mallei* |                      |                      |
|                       | # Blood              | Blood (BC, C) and    |
| [0 -- 24              |  (BC, C) for culture | tissues for culture. |
| h]{.underline}        |  {#blood-bc-c-for-cu | Serum (TT, RT) for   |
|                       | lture-1 .unnumbered} | immunoassays.        |
| Nasal swabs, sputum,  |                      |                      |
| induced respiratory   | # B                  | Pathology samples.   |
| secretions for        | lood (E, C, H) for P |                      |
| culture and PCR.      | CR  {#blood-e-c-h-fo |                      |
|                       | r-pcr-1 .unnumbered} |                      |
|                       |                      |                      |
|                       | Sputum & drainage    |                      |
|                       | from skin lesions    |                      |
|                       | for PCR & culture.   |                      |
+-----------------------+----------------------+----------------------+
| BC: Blood culture     | E: EDTA (3-ml)       | TT: Tiger-top (5 --  |
| bottle                |                      | 10 ml)               |
|                       | H: Heparin (3-ml)    |                      |
| C: Citrated blood     |                      | RT: Red top if no TT |
| (3-ml)                |                      |                      |
+-----------------------+----------------------+----------------------+

### Appendix E: Medical Sample Collection for Biological Threat Agents {#appendix-e-medical-sample-collection-for-biological-threat-agents-1 .unnumbered}

###  *Bacteria and Rickettsia* {#bacteria-and-rickettsia-1 .unnumbered}

###  {#section-20 .unnumbered}

+----------------------+---+---------------------+---+---------------------+---+
| **[Early             |   | **[Convalescent/    |   | **[Terminal/Postmo  |   |
| post-exp             |   | Clin                |   | rtem]{.underline}** |   |
| osure]{.underline}** |   | ical]{.underline}** |   |                     |   |
+----------------------+---+---------------------+---+---------------------+---+
| **Brucellosis**      | [ |                     | [ |                     |   |
|                      | 2 |                     | \ |                     |   |
| *Brucella abortus*,  | 4 |                     | > |                     |   |
| *suis,* &            | - |                     | 6 |                     |   |
| *melitensis*         | - |                     | d |                     |   |
|                      | 7 |                     | a |                     |   |
| [0 -- 24             | 2 |                     | y |                     |   |
| h]{.underline}       | h |                     | s |                     |   |
|                      | ] |                     | ] |                     |   |
| Nasal swabs, sputum, | { |                     | { |                     |   |
| induced respiratory  | . |                     | . |                     |   |
| secretions for       | u |                     | u |                     |   |
| culture and PCR.     | n |                     | n |                     |   |
|                      | d |                     | d |                     |   |
|                      | e |                     | e |                     |   |
|                      | r |                     | r |                     |   |
|                      | l |                     | l |                     |   |
|                      | i |                     | i |                     |   |
|                      | n |                     | n |                     |   |
|                      | e |                     | e |                     |   |
|                      | } |                     | } |                     |   |
|                      |   |                     |   |                     |   |
|                      | # |                     | B |                     |   |
|                      |   |                     | l |                     |   |
|                      | B |                     | o |                     |   |
|                      | l |                     | o |                     |   |
|                      | o |                     | d |                     |   |
|                      | o |                     | ( |                     |   |
|                      | d |                     | B |                     |   |
|                      |   |                     | C |                     |   |
|                      | ( |                     | , |                     |   |
|                      | B |                     | C |                     |   |
|                      | C |                     | ) |                     |   |
|                      | , |                     | a |                     |   |
|                      |   |                     | n |                     |   |
|                      | C |                     | d |                     |   |
|                      | ) |                     | t |                     |   |
|                      |   |                     | i |                     |   |
|                      | f |                     | s |                     |   |
|                      | o |                     | s |                     |   |
|                      | r |                     | u |                     |   |
|                      |   |                     | e |                     |   |
|                      | c |                     | s |                     |   |
|                      | u |                     | f |                     |   |
|                      | l |                     | o |                     |   |
|                      | t |                     | r |                     |   |
|                      | u |                     | c |                     |   |
|                      | r |                     | u |                     |   |
|                      | e |                     | l |                     |   |
|                      | . |                     | t |                     |   |
|                      |   |                     | u |                     |   |
|                      | { |                     | r |                     |   |
|                      | # |                     | e |                     |   |
|                      | b |                     | . |                     |   |
|                      | l |                     | S |                     |   |
|                      | o |                     | e |                     |   |
|                      | o |                     | r |                     |   |
|                      | d |                     | u |                     |   |
|                      | - |                     | m |                     |   |
|                      | b |                     | ( |                     |   |
|                      | c |                     | T |                     |   |
|                      | - |                     | T |                     |   |
|                      | c |                     | , |                     |   |
|                      | - |                     | R |                     |   |
|                      | f |                     | T |                     |   |
|                      | o |                     | ) |                     |   |
|                      | r |                     | f |                     |   |
|                      | - |                     | o |                     |   |
|                      | c |                     | r |                     |   |
|                      | u |                     | i |                     |   |
|                      | l |                     | m |                     |   |
|                      | t |                     | m |                     |   |
|                      | u |                     | u |                     |   |
|                      | r |                     | n |                     |   |
|                      | e |                     | o |                     |   |
|                      | . |                     | a |                     |   |
|                      |   |                     | s |                     |   |
|                      | . |                     | s |                     |   |
|                      | u |                     | a |                     |   |
|                      | n |                     | y |                     |   |
|                      | n |                     | s |                     |   |
|                      | u |                     | . |                     |   |
|                      | m |                     |   |                     |   |
|                      | b |                     | P |                     |   |
|                      | e |                     | a |                     |   |
|                      | r |                     | t |                     |   |
|                      | e |                     | h |                     |   |
|                      | d |                     | o |                     |   |
|                      | } |                     | l |                     |   |
|                      |   |                     | o |                     |   |
|                      | B |                     | g |                     |   |
|                      | l |                     | y |                     |   |
|                      | o |                     | s |                     |   |
|                      | o |                     | a |                     |   |
|                      | d |                     | m |                     |   |
|                      | ( |                     | p |                     |   |
|                      | E |                     | l |                     |   |
|                      | , |                     | e |                     |   |
|                      | C |                     | s |                     |   |
|                      | , |                     |   |                     |   |
|                      | H |                     |   |                     |   |
|                      | ) |                     |   |                     |   |
|                      | f |                     |   |                     |   |
|                      | o |                     |   |                     |   |
|                      | r |                     |   |                     |   |
|                      | P |                     |   |                     |   |
|                      | C |                     |   |                     |   |
|                      | R |                     |   |                     |   |
|                      | . |                     |   |                     |   |
+----------------------+---+---------------------+---+---------------------+---+
| ## Q-Fever {#q-      | [ |                     | [ |                     |   |
| fever-1 .unnumbered} | 2 |                     | \ |                     |   |
|                      | t |                     | > |                     |   |
| ### *Coxiella bu     | o |                     | 6 |                     |   |
| rnetii* {#coxiella-b | 5 |                     | d |                     |   |
| urnetii .unnumbered} | d |                     | a |                     |   |
|                      | a |                     | y |                     |   |
| [0 -- 24             | y |                     | s |                     |   |
| h]{.underline}       | s |                     | ] |                     |   |
|                      | ] |                     | { |                     |   |
| Nasal swabs, sputum, | { |                     | . |                     |   |
| induced respiratory  | . |                     | u |                     |   |
| secretions for       | u |                     | n |                     |   |
| culture and PCR.     | n |                     | d |                     |   |
|                      | d |                     | e |                     |   |
|                      | e |                     | r |                     |   |
|                      | r |                     | l |                     |   |
|                      | l |                     | i |                     |   |
|                      | i |                     | n |                     |   |
|                      | n |                     | e |                     |   |
|                      | e |                     | } |                     |   |
|                      | } |                     |   |                     |   |
|                      |   |                     | B |                     |   |
|                      | # |                     | l |                     |   |
|                      |   |                     | o |                     |   |
|                      | B |                     | o |                     |   |
|                      | l |                     | d |                     |   |
|                      | o |                     | ( |                     |   |
|                      | o |                     | B |                     |   |
|                      | d |                     | C |                     |   |
|                      |   |                     | , |                     |   |
|                      | ( |                     | C |                     |   |
|                      | B |                     | ) |                     |   |
|                      | C |                     | f |                     |   |
|                      | , |                     | o |                     |   |
|                      |   |                     | r |                     |   |
|                      | C |                     | c |                     |   |
|                      | ) |                     | u |                     |   |
|                      |   |                     | l |                     |   |
|                      | f |                     | t |                     |   |
|                      | o |                     | u |                     |   |
|                      | r |                     | r |                     |   |
|                      |   |                     | e |                     |   |
|                      | c |                     | i |                     |   |
|                      | u |                     | n |                     |   |
|                      | l |                     | e |                     |   |
|                      | t |                     | g |                     |   |
|                      | u |                     | g |                     |   |
|                      | r |                     | s |                     |   |
|                      | e |                     | o |                     |   |
|                      |   |                     | r |                     |   |
|                      | i |                     | m |                     |   |
|                      | n |                     | o |                     |   |
|                      |   |                     | u |                     |   |
|                      | e |                     | s |                     |   |
|                      | g |                     | e |                     |   |
|                      | g |                     | i |                     |   |
|                      | s |                     | n |                     |   |
|                      |   |                     | o |                     |   |
|                      | o |                     | c |                     |   |
|                      | r |                     | u |                     |   |
|                      |   |                     | l |                     |   |
|                      | m |                     | a |                     |   |
|                      | o |                     | t |                     |   |
|                      | u |                     | i |                     |   |
|                      | s |                     | o |                     |   |
|                      | e |                     | n |                     |   |
|                      |   |                     |   |                     |   |
|                      | i |                     | P |                     |   |
|                      | n |                     | a |                     |   |
|                      | o |                     | t |                     |   |
|                      | c |                     | h |                     |   |
|                      | u |                     | o |                     |   |
|                      | l |                     | l |                     |   |
|                      | a |                     | o |                     |   |
|                      | t |                     | g |                     |   |
|                      | i |                     | y |                     |   |
|                      | o |                     | s |                     |   |
|                      | n |                     | a |                     |   |
|                      |   |                     | m |                     |   |
|                      | { |                     | p |                     |   |
|                      | # |                     | l |                     |   |
|                      | b |                     | e |                     |   |
|                      | l |                     | s |                     |   |
|                      | o |                     | . |                     |   |
|                      | o |                     |   |                     |   |
|                      | d |                     |   |                     |   |
|                      | - |                     |   |                     |   |
|                      | b |                     |   |                     |   |
|                      | c |                     |   |                     |   |
|                      | - |                     |   |                     |   |
|                      | c |                     |   |                     |   |
|                      | - |                     |   |                     |   |
|                      | f |                     |   |                     |   |
|                      | o |                     |   |                     |   |
|                      | r |                     |   |                     |   |
|                      | - |                     |   |                     |   |
|                      | c |                     |   |                     |   |
|                      | u |                     |   |                     |   |
|                      | l |                     |   |                     |   |
|                      | t |                     |   |                     |   |
|                      | u |                     |   |                     |   |
|                      | r |                     |   |                     |   |
|                      | e |                     |   |                     |   |
|                      | - |                     |   |                     |   |
|                      | i |                     |   |                     |   |
|                      | n |                     |   |                     |   |
|                      | - |                     |   |                     |   |
|                      | e |                     |   |                     |   |
|                      | g |                     |   |                     |   |
|                      | g |                     |   |                     |   |
|                      | s |                     |   |                     |   |
|                      | - |                     |   |                     |   |
|                      | o |                     |   |                     |   |
|                      | r |                     |   |                     |   |
|                      | - |                     |   |                     |   |
|                      | m |                     |   |                     |   |
|                      | o |                     |   |                     |   |
|                      | u |                     |   |                     |   |
|                      | s |                     |   |                     |   |
|                      | e |                     |   |                     |   |
|                      | - |                     |   |                     |   |
|                      | i |                     |   |                     |   |
|                      | n |                     |   |                     |   |
|                      | o |                     |   |                     |   |
|                      | c |                     |   |                     |   |
|                      | u |                     |   |                     |   |
|                      | l |                     |   |                     |   |
|                      | a |                     |   |                     |   |
|                      | t |                     |   |                     |   |
|                      | i |                     |   |                     |   |
|                      | o |                     |   |                     |   |
|                      | n |                     |   |                     |   |
|                      |   |                     |   |                     |   |
|                      | . |                     |   |                     |   |
|                      | u |                     |   |                     |   |
|                      | n |                     |   |                     |   |
|                      | n |                     |   |                     |   |
|                      | u |                     |   |                     |   |
|                      | m |                     |   |                     |   |
|                      | b |                     |   |                     |   |
|                      | e |                     |   |                     |   |
|                      | r |                     |   |                     |   |
|                      | e |                     |   |                     |   |
|                      | d |                     |   |                     |   |
|                      | } |                     |   |                     |   |
|                      |   |                     |   |                     |   |
|                      | # |                     |   |                     |   |
|                      |   |                     |   |                     |   |
|                      | B |                     |   |                     |   |
|                      | l |                     |   |                     |   |
|                      | o |                     |   |                     |   |
|                      | o |                     |   |                     |   |
|                      | d |                     |   |                     |   |
|                      |   |                     |   |                     |   |
|                      | ( |                     |   |                     |   |
|                      | E |                     |   |                     |   |
|                      | , |                     |   |                     |   |
|                      |   |                     |   |                     |   |
|                      | C |                     |   |                     |   |
|                      | , |                     |   |                     |   |
|                      |   |                     |   |                     |   |
|                      | H |                     |   |                     |   |
|                      | ) |                     |   |                     |   |
|                      |   |                     |   |                     |   |
|                      | f |                     |   |                     |   |
|                      | o |                     |   |                     |   |
|                      | r |                     |   |                     |   |
|                      |   |                     |   |                     |   |
|                      | P |                     |   |                     |   |
|                      | C |                     |   |                     |   |
|                      | R |                     |   |                     |   |
|                      | . |                     |   |                     |   |
|                      |   |                     |   |                     |   |
|                      |   |                     |   |                     |   |
|                      | { |                     |   |                     |   |
|                      | # |                     |   |                     |   |
|                      | b |                     |   |                     |   |
|                      | l |                     |   |                     |   |
|                      | o |                     |   |                     |   |
|                      | o |                     |   |                     |   |
|                      | d |                     |   |                     |   |
|                      | - |                     |   |                     |   |
|                      | e |                     |   |                     |   |
|                      | - |                     |   |                     |   |
|                      | c |                     |   |                     |   |
|                      | - |                     |   |                     |   |
|                      | h |                     |   |                     |   |
|                      | - |                     |   |                     |   |
|                      | f |                     |   |                     |   |
|                      | o |                     |   |                     |   |
|                      | r |                     |   |                     |   |
|                      | - |                     |   |                     |   |
|                      | p |                     |   |                     |   |
|                      | c |                     |   |                     |   |
|                      | r |                     |   |                     |   |
|                      | . |                     |   |                     |   |
|                      |   |                     |   |                     |   |
|                      | . |                     |   |                     |   |
|                      | u |                     |   |                     |   |
|                      | n |                     |   |                     |   |
|                      | n |                     |   |                     |   |
|                      | u |                     |   |                     |   |
|                      | m |                     |   |                     |   |
|                      | b |                     |   |                     |   |
|                      | e |                     |   |                     |   |
|                      | r |                     |   |                     |   |
|                      | e |                     |   |                     |   |
|                      | d |                     |   |                     |   |
|                      | } |                     |   |                     |   |
+----------------------+---+---------------------+---+---------------------+---+
| **Botulism**         | [ |                     | [ |                     |   |
|                      | 2 |                     | \ |                     |   |
| Botulinum toxin from | 4 |                     | > |                     |   |
| *Clostridium         | t |                     | 6 |                     |   |
| botulinum*           | o |                     | d |                     |   |
|                      | 7 |                     | a |                     |   |
| [0 -- 24             | 2 |                     | y |                     |   |
| h]{.underline}       | h |                     | s |                     |   |
|                      | ] |                     | ] |                     |   |
| Nasal swabs, induced | { |                     | { |                     |   |
| respiratory          | . |                     | . |                     |   |
| secretions for PCR   | u |                     | u |                     |   |
| (contaminating       | n |                     | n |                     |   |
| bacterial DNA) and   | d |                     | d |                     |   |
| toxin assays. Serum  | e |                     | e |                     |   |
| (TT, RT) for toxin   | r |                     | r |                     |   |
| assays               | l |                     | l |                     |   |
|                      | i |                     | i |                     |   |
|                      | n |                     | n |                     |   |
|                      | e |                     | e |                     |   |
|                      | } |                     | } |                     |   |
|                      |   |                     |   |                     |   |
|                      | N |                     | U |                     |   |
|                      | a |                     | s |                     |   |
|                      | s |                     | u |                     |   |
|                      | a |                     | a |                     |   |
|                      | l |                     | l |                     |   |
|                      | s |                     | l |                     |   |
|                      | w |                     | y |                     |   |
|                      | a |                     | n |                     |   |
|                      | b |                     | o |                     |   |
|                      | s |                     | I |                     |   |
|                      | , |                     | g |                     |   |
|                      | r |                     | M |                     |   |
|                      | e |                     | o |                     |   |
|                      | s |                     | r |                     |   |
|                      | p |                     | I |                     |   |
|                      | i |                     | g |                     |   |
|                      | r |                     | G |                     |   |
|                      | a |                     |   |                     |   |
|                      | t |                     | P |                     |   |
|                      | o |                     | a |                     |   |
|                      | r |                     | t |                     |   |
|                      | y |                     | h |                     |   |
|                      | s |                     | o |                     |   |
|                      | e |                     | l |                     |   |
|                      | c |                     | o |                     |   |
|                      | r |                     | g |                     |   |
|                      | e |                     | y |                     |   |
|                      | t |                     | s |                     |   |
|                      | i |                     | a |                     |   |
|                      | o |                     | m |                     |   |
|                      | n |                     | p |                     |   |
|                      | s |                     | l |                     |   |
|                      | f |                     | e |                     |   |
|                      | o |                     | s |                     |   |
|                      | r |                     | ( |                     |   |
|                      | P |                     | l |                     |   |
|                      | C |                     | i |                     |   |
|                      | R |                     | v |                     |   |
|                      | ( |                     | e |                     |   |
|                      | c |                     | r |                     |   |
|                      | o |                     | a |                     |   |
|                      | n |                     | n |                     |   |
|                      | t |                     | d |                     |   |
|                      | a |                     | s |                     |   |
|                      | m |                     | p |                     |   |
|                      | i |                     | l |                     |   |
|                      | n |                     | e |                     |   |
|                      | a |                     | e |                     |   |
|                      | t |                     | n |                     |   |
|                      | i |                     | f |                     |   |
|                      | n |                     | o |                     |   |
|                      | g |                     | r |                     |   |
|                      | b |                     | t |                     |   |
|                      | a |                     | o |                     |   |
|                      | c |                     | x |                     |   |
|                      | t |                     | i |                     |   |
|                      | e |                     | n |                     |   |
|                      | r |                     | d |                     |   |
|                      | i |                     | e |                     |   |
|                      | a |                     | t |                     |   |
|                      | l |                     | e |                     |   |
|                      | D |                     | c |                     |   |
|                      | N |                     | t |                     |   |
|                      | A |                     | i |                     |   |
|                      | ) |                     | o |                     |   |
|                      | a |                     | n |                     |   |
|                      | n |                     | ) |                     |   |
|                      | d |                     |   |                     |   |
|                      | t |                     |   |                     |   |
|                      | o |                     |   |                     |   |
|                      | x |                     |   |                     |   |
|                      | i |                     |   |                     |   |
|                      | n |                     |   |                     |   |
|                      | a |                     |   |                     |   |
|                      | s |                     |   |                     |   |
|                      | s |                     |   |                     |   |
|                      | a |                     |   |                     |   |
|                      | y |                     |   |                     |   |
|                      | s |                     |   |                     |   |
|                      | . |                     |   |                     |   |
+----------------------+---+---------------------+---+---------------------+---+
| BC: Blood culture    | E |                     | T |                     |   |
| bottle               | : |                     | T |                     |   |
|                      | E |                     | : |                     |   |
| C: Citrated blood    | D |                     | T |                     |   |
| (3-ml)               | T |                     | i |                     |   |
|                      | A |                     | g |                     |   |
|                      | ( |                     | e |                     |   |
|                      | 3 |                     | r |                     |   |
|                      | - |                     | - |                     |   |
|                      | m |                     | t |                     |   |
|                      | l |                     | o |                     |   |
|                      | ) |                     | p |                     |   |
|                      |   |                     | ( |                     |   |
|                      | H |                     | 5 |                     |   |
|                      | : |                     | - |                     |   |
|                      | H |                     | - |                     |   |
|                      | e |                     | 1 |                     |   |
|                      | p |                     | 0 |                     |   |
|                      | a |                     | m |                     |   |
|                      | r |                     | l |                     |   |
|                      | i |                     | ) |                     |   |
|                      | n |                     |   |                     |   |
|                      | ( |                     | R |                     |   |
|                      | 3 |                     | T |                     |   |
|                      | - |                     | : |                     |   |
|                      | m |                     | R |                     |   |
|                      | l |                     | e |                     |   |
|                      | ) |                     | d |                     |   |
|                      |   |                     | t |                     |   |
|                      |   |                     | o |                     |   |
|                      |   |                     | p |                     |   |
|                      |   |                     | i |                     |   |
|                      |   |                     | f |                     |   |
|                      |   |                     | n |                     |   |
|                      |   |                     | o |                     |   |
|                      |   |                     | T |                     |   |
|                      |   |                     | T |                     |   |
+----------------------+---+---------------------+---+---------------------+---+

### Appendix E: Medical Sample Collection for Biological Threat Agents {#appendix-e-medical-sample-collection-for-biological-threat-agents-2 .unnumbered}

###  *Bacteria and Rickettsia* {#bacteria-and-rickettsia-2 .unnumbered}

###  {#section-21 .unnumbered}

+-----------------------+---+---------------------+---+----------------------+---+
| **[Early              | * |                     |   | **[Terminal/Postm    |   |
| post-ex               | * |                     |   | ortem]{.underline}** |   |
| posure]{.underline}** | [ |                     |   |                      |   |
|                       | C |                     |   |                      |   |
|                       | o |                     |   |                      |   |
|                       | n |                     |   |                      |   |
|                       | v |                     |   |                      |   |
|                       | a |                     |   |                      |   |
|                       | l |                     |   |                      |   |
|                       | e |                     |   |                      |   |
|                       | s |                     |   |                      |   |
|                       | c |                     |   |                      |   |
|                       | e |                     |   |                      |   |
|                       | n |                     |   |                      |   |
|                       | t |                     |   |                      |   |
|                       | / |                     |   |                      |   |
|                       | C |                     |   |                      |   |
|                       | l |                     |   |                      |   |
|                       | i |                     |   |                      |   |
|                       | n |                     |   |                      |   |
|                       | i |                     |   |                      |   |
|                       | c |                     |   |                      |   |
|                       | a |                     |   |                      |   |
|                       | l |                     |   |                      |   |
|                       | ] |                     |   |                      |   |
|                       | { |                     |   |                      |   |
|                       | . |                     |   |                      |   |
|                       | u |                     |   |                      |   |
|                       | n |                     |   |                      |   |
|                       | d |                     |   |                      |   |
|                       | e |                     |   |                      |   |
|                       | r |                     |   |                      |   |
|                       | l |                     |   |                      |   |
|                       | i |                     |   |                      |   |
|                       | n |                     |   |                      |   |
|                       | e |                     |   |                      |   |
|                       | } |                     |   |                      |   |
|                       | * |                     |   |                      |   |
|                       | * |                     |   |                      |   |
+-----------------------+---+---------------------+---+----------------------+---+
| ##  {#se              |   | [36 to 48           | [ |                      |   |
| ction-22 .unnumbered} |   | h]{.underline}      | \ |                      |   |
|                       |   |                     | > |                      |   |
| ## Ricin Into         |   | Serum (TT, RT) for  | 6 |                      |   |
| xication {#ricin-into |   | toxin assay         | d |                      |   |
| xication .unnumbered} |   |                     | a |                      |   |
|                       |   | Tissues for         | y |                      |   |
| Ricin toxin from      |   | immunohisto-logical | s |                      |   |
| Castor beans          |   | stain in pathology  | ] |                      |   |
|                       |   | samples.            | { |                      |   |
| [0 -- 24              |   |                     | . |                      |   |
| h]{.underline}        |   |                     | u |                      |   |
|                       |   |                     | n |                      |   |
| Nasal swabs, induced  |   |                     | d |                      |   |
| respiratory           |   |                     | e |                      |   |
| secretions for PCR    |   |                     | r |                      |   |
| (contaminating castor |   |                     | l |                      |   |
| bean DNA) and toxin   |   |                     | i |                      |   |
| assays.               |   |                     | n |                      |   |
|                       |   |                     | e |                      |   |
| Serum (TT) for toxin  |   |                     | } |                      |   |
| assays                |   |                     |   |                      |   |
|                       |   |                     | S |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | m |                      |   |
|                       |   |                     | ( |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | , |                      |   |
|                       |   |                     | R |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | ) |                      |   |
|                       |   |                     | f |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | I |                      |   |
|                       |   |                     | g |                      |   |
|                       |   |                     | M |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | d |                      |   |
|                       |   |                     | I |                      |   |
|                       |   |                     | g |                      |   |
|                       |   |                     | G |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | v |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | v |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | s |                      |   |
+-----------------------+---+---------------------+---+----------------------+---+
| ## Staph enterotoxi   |   | [2 - 6              | [ |                      |   |
| cosis {#staph-enterot |   | h]{.underline}      | \ |                      |   |
| oxicosis .unnumbered} |   |                     | > |                      |   |
|                       |   | Urine for           | 6 |                      |   |
| *Staphylococcus*      |   | immunoassays Nasal  | d |                      |   |
| Enterotoxin B         |   | swabs, induced      | a |                      |   |
|                       |   | respiratory         | y |                      |   |
| [0 -- 3               |   | secretions for PCR  | s |                      |   |
| h]{.underline}        |   | (contaminating      | ] |                      |   |
|                       |   | bacterial DNA) and  | { |                      |   |
| Nasal swabs, induced  |   | toxin assays.       | . |                      |   |
| respiratory           |   |                     | u |                      |   |
| secretions for PCR    |   | Serum (TT, RT) for  | n |                      |   |
| (contaminating        |   | toxin assays        | d |                      |   |
| bacterial DNA) and    |   |                     | e |                      |   |
| toxin assays.         |   |                     | r |                      |   |
|                       |   |                     | l |                      |   |
| Serum (TT, RT) for    |   |                     | i |                      |   |
| toxin assays          |   |                     | n |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | } |                      |   |
|                       |   |                     |   |                      |   |
|                       |   |                     | S |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | m |                      |   |
|                       |   |                     | f |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | I |                      |   |
|                       |   |                     | g |                      |   |
|                       |   |                     | M |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | d |                      |   |
|                       |   |                     | I |                      |   |
|                       |   |                     | g |                      |   |
|                       |   |                     | G |                      |   |
+-----------------------+---+---------------------+---+----------------------+---+
| **T-2 toxicosis**     |   | [1 to 5             | [ |                      |   |
|                       |   | days]{.underline}   | \ |                      |   |
| [0 -- 24 h            |   |                     | > |                      |   |
| post                  |   | Serum (TT, RT),     | 6 |                      |   |
| exposure]{.underline} |   | tissue for toxin    | d |                      |   |
|                       |   | detection           | a |                      |   |
| Nasal & throat swabs, |   |                     | y |                      |   |
| induced respiratory   |   |                     | s |                      |   |
| secretions for        |   |                     | p |                      |   |
| immunoassays, HPLC/   |   |                     | o |                      |   |
| mass spectrometry     |   |                     | s |                      |   |
| (HPLC/MS).            |   |                     | t |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | x |                      |   |
|                       |   |                     | p |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | ] |                      |   |
|                       |   |                     | { |                      |   |
|                       |   |                     | . |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | d |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | } |                      |   |
|                       |   |                     |   |                      |   |
|                       |   |                     | U |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | f |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | d |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | c |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | f |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | x |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | m |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | b |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | s |                      |   |
+-----------------------+---+---------------------+---+----------------------+---+
| BC: Blood culture     |   | E: EDTA (3-ml)      | T |                      |   |
| bottle                |   |                     | T |                      |   |
|                       |   | H: Heparin (3-ml)   | : |                      |   |
| C: Citrated blood     |   |                     | T |                      |   |
| (3-ml)                |   |                     | i |                      |   |
|                       |   |                     | g |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | - |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | p |                      |   |
|                       |   |                     | ( |                      |   |
|                       |   |                     | 5 |                      |   |
|                       |   |                     | - |                      |   |
|                       |   |                     | - |                      |   |
|                       |   |                     | 1 |                      |   |
|                       |   |                     | 0 |                      |   |
|                       |   |                     | m |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | ) |                      |   |
|                       |   |                     |   |                      |   |
|                       |   |                     | R |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | : |                      |   |
|                       |   |                     | R |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | d |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | p |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | f |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | T |                      |   |
+-----------------------+---+---------------------+---+----------------------+---+

#####  {#section-23 .unnumbered}

### Appendix E: Medical Sample Collection for Biological Threat Agents {#appendix-e-medical-sample-collection-for-biological-threat-agents-3 .unnumbered}

###  *Bacteria and Rickettsia* {#bacteria-and-rickettsia-3 .unnumbered}

###  {#section-24 .unnumbered}

+-----------------------+---+---------------------+---+----------------------+---+
| **[Early              | * |                     |   | **[Terminal/Postm    |   |
| post-ex               | * |                     |   | ortem]{.underline}** |   |
| posure]{.underline}** | [ |                     |   |                      |   |
|                       | C |                     |   |                      |   |
|                       | o |                     |   |                      |   |
|                       | n |                     |   |                      |   |
|                       | v |                     |   |                      |   |
|                       | a |                     |   |                      |   |
|                       | l |                     |   |                      |   |
|                       | e |                     |   |                      |   |
|                       | s |                     |   |                      |   |
|                       | c |                     |   |                      |   |
|                       | e |                     |   |                      |   |
|                       | n |                     |   |                      |   |
|                       | t |                     |   |                      |   |
|                       | / |                     |   |                      |   |
|                       | C |                     |   |                      |   |
|                       | l |                     |   |                      |   |
|                       | i |                     |   |                      |   |
|                       | n |                     |   |                      |   |
|                       | i |                     |   |                      |   |
|                       | c |                     |   |                      |   |
|                       | a |                     |   |                      |   |
|                       | l |                     |   |                      |   |
|                       | ] |                     |   |                      |   |
|                       | { |                     |   |                      |   |
|                       | . |                     |   |                      |   |
|                       | u |                     |   |                      |   |
|                       | n |                     |   |                      |   |
|                       | d |                     |   |                      |   |
|                       | e |                     |   |                      |   |
|                       | r |                     |   |                      |   |
|                       | l |                     |   |                      |   |
|                       | i |                     |   |                      |   |
|                       | n |                     |   |                      |   |
|                       | e |                     |   |                      |   |
|                       | } |                     |   |                      |   |
|                       | * |                     |   |                      |   |
|                       | * |                     |   |                      |   |
+-----------------------+---+---------------------+---+----------------------+---+
| **Equine              |   | [24 to 72           | [ |                      |   |
| Encephalmyelitis**    |   | h]{.underline}      | \ |                      |   |
|                       |   |                     | > |                      |   |
| VEE, EEE and WEE      |   | Serum & Throat      | 6 |                      |   |
| viruses               |   | swabs for culture   | d |                      |   |
|                       |   | (TT, RT), RT-PCR    | a |                      |   |
| [0 -- 24              |   | (E, C, H, TT, RT)   | y |                      |   |
| h]{.underline}        |   | and Antigen ELISA   | s |                      |   |
|                       |   | (TT, RT), CSF,      | ] |                      |   |
| Nasal swabs & induced |   | Throat swabs up to  | { |                      |   |
| respiratory           |   | 5 days              | . |                      |   |
| secretions for RT-PCR |   |                     | u |                      |   |
| and viral culture     |   |                     | n |                      |   |
|                       |   |                     | d |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | } |                      |   |
|                       |   |                     |   |                      |   |
|                       |   |                     | S |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | m |                      |   |
|                       |   |                     | ( |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | , |                      |   |
|                       |   |                     | R |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | ) |                      |   |
|                       |   |                     | f |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | I |                      |   |
|                       |   |                     | g |                      |   |
|                       |   |                     | M |                      |   |
|                       |   |                     |   |                      |   |
|                       |   |                     | P |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | h |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | g |                      |   |
|                       |   |                     | y |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | m |                      |   |
|                       |   |                     | p |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | p |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | b |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | n |                      |   |
+-----------------------+---+---------------------+---+----------------------+---+
| ###  {#se             |   | [2 to 5             | [ |                      |   |
| ction-25 .unnumbered} |   | days]{.underline}   | \ |                      |   |
|                       |   |                     | > |                      |   |
| ### Ebola             |   | Serum (TT, RT) for  | 6 |                      |   |
|  {#ebola .unnumbered} |   | viral culture       | d |                      |   |
|                       |   |                     | a |                      |   |
| [0 -- 24              |   |                     | y |                      |   |
| h]{.underline}        |   |                     | s |                      |   |
|                       |   |                     | ] |                      |   |
| Nasal swabs & induced |   |                     | { |                      |   |
| respiratory           |   |                     | . |                      |   |
| secretions for RT-PCR |   |                     | u |                      |   |
| and viral culture     |   |                     | n |                      |   |
|                       |   |                     | d |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | } |                      |   |
|                       |   |                     |   |                      |   |
|                       |   |                     | S |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | m |                      |   |
|                       |   |                     | ( |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | , |                      |   |
|                       |   |                     | R |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | ) |                      |   |
|                       |   |                     | f |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | v |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | c |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | . |                      |   |
|                       |   |                     | P |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | h |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | g |                      |   |
|                       |   |                     | y |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | m |                      |   |
|                       |   |                     | p |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | p |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | d |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | g |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | d |                      |   |
|                       |   |                     | . |                      |   |
+-----------------------+---+---------------------+---+----------------------+---+
| **Pox (Small pox,     |   | [2 to 5             | [ |                      |   |
| monkey pox)**         |   | days]{.underline}   | \ |                      |   |
|                       |   |                     | > |                      |   |
| ## *O                 |   | Serum (TT, RT) for  | 6 |                      |   |
| rthopoxvirus* {#ortho |   | viral culture       | d |                      |   |
| poxvirus .unnumbered} |   |                     | a |                      |   |
|                       |   |                     | y |                      |   |
| [0 -- 24              |   |                     | s |                      |   |
| h]{.underline}        |   |                     | ] |                      |   |
|                       |   |                     | { |                      |   |
| Nasal swabs & induced |   |                     | . |                      |   |
| respiratory           |   |                     | u |                      |   |
| secretions for PCR    |   |                     | n |                      |   |
| and viral culture     |   |                     | d |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | } |                      |   |
|                       |   |                     |   |                      |   |
|                       |   |                     | S |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | m |                      |   |
|                       |   |                     | ( |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | , |                      |   |
|                       |   |                     | R |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | ) |                      |   |
|                       |   |                     | f |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | v |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | c |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | . |                      |   |
|                       |   |                     | D |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | g |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | f |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | m |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | k |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | / |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | c |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | p |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | g |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | f |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | m |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | c |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | c |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | p |                      |   |
|                       |   |                     | y |                      |   |
|                       |   |                     | , |                      |   |
|                       |   |                     | E |                      |   |
|                       |   |                     | M |                      |   |
|                       |   |                     | , |                      |   |
|                       |   |                     | v |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | c |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | u |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | , |                      |   |
|                       |   |                     | P |                      |   |
|                       |   |                     | C |                      |   |
|                       |   |                     | R |                      |   |
|                       |   |                     | . |                      |   |
|                       |   |                     | P |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | h |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | g |                      |   |
|                       |   |                     | y |                      |   |
|                       |   |                     | s |                      |   |
|                       |   |                     | a |                      |   |
|                       |   |                     | m |                      |   |
|                       |   |                     | p |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | s |                      |   |
+-----------------------+---+---------------------+---+----------------------+---+
| BC: Blood culture     |   | E: EDTA (3-ml)      | T |                      |   |
| bottle                |   |                     | T |                      |   |
|                       |   | H: Heparin (3-ml)   | : |                      |   |
| C: Citrated blood     |   |                     | T |                      |   |
| (3-ml)                |   |                     | i |                      |   |
|                       |   |                     | g |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | r |                      |   |
|                       |   |                     | - |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | p |                      |   |
|                       |   |                     | ( |                      |   |
|                       |   |                     | 5 |                      |   |
|                       |   |                     | - |                      |   |
|                       |   |                     | - |                      |   |
|                       |   |                     | 1 |                      |   |
|                       |   |                     | 0 |                      |   |
|                       |   |                     | m |                      |   |
|                       |   |                     | l |                      |   |
|                       |   |                     | ) |                      |   |
|                       |   |                     |   |                      |   |
|                       |   |                     | R |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | : |                      |   |
|                       |   |                     | R |                      |   |
|                       |   |                     | e |                      |   |
|                       |   |                     | d |                      |   |
|                       |   |                     | t |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | p |                      |   |
|                       |   |                     | i |                      |   |
|                       |   |                     | f |                      |   |
|                       |   |                     | n |                      |   |
|                       |   |                     | o |                      |   |
|                       |   |                     | T |                      |   |
|                       |   |                     | T |                      |   |
+-----------------------+---+---------------------+---+----------------------+---+

####  {#section-26 .unnumbered}

###  {#section-27 .unnumbered}

### Appendix F: Specimens for Laboratory Diagnosis {#appendix-f-specimens-for-laboratory-diagnosis .unnumbered}

+---------+-----+-----+--------+----------+---------+----+---------+
| #       | **F | **B | **S    | **Acute  | **      | *  | **      |
| #  {#se | ace | loo | mear** | &        | Stool** | *U | Other** |
| ction-2 | or  | d** |        | Conv     |         | ri |         |
| 8 .unnu | Na  |     |        | alescent |         | ne |         |
| mbered} | sal | **  |        | Sera**   |         | ** |         |
|         | Swa | Cul |        |          |         |    |         |
| #       | b** | tur |        |          |         |    |         |
| #  {#se |     | e** |        |          |         |    |         |
| ction-2 |     |     |        |          |         |    |         |
| 9 .unnu |     |     |        |          |         |    |         |
| mbered} |     |     |        |          |         |    |         |
|         |     |     |        |          |         |    |         |
| #       |     |     |        |          |         |    |         |
| # Agent |     |     |        |          |         |    |         |
|  {#agen |     |     |        |          |         |    |         |
| t .unnu |     |     |        |          |         |    |         |
| mbered} |     |     |        |          |         |    |         |
+---------+-----+-----+--------+----------+---------+----+---------+
| ##      | \+  | \+  | P      | \+       | \+      | \- | Cu      |
| ## Anth |     |     | leural |          |         |    | taneous |
| rax {#a |     |     | and CS |          | (24-48  |    | lesion  |
| nthrax- |     |     | Fluids |          | hrs     |    | as      |
| 1 .unnu |     |     |        |          | after   |    | pirates |
| mbered} |     |     | Media  |          | ex      |    |         |
|         |     |     | stinal |          | posure) |    |         |
+---------+-----+-----+--------+----------+---------+----+---------+
| #####   | \+  | \+  | \-     | \+       | \-      | \- | Bone    |
| ### Bre |     |     |        |          |         |    | marrow  |
| cellosi |     |     |        |          |         |    | and     |
| s {#bre |     |     |        |          |         |    | spinal  |
| cellosi |     |     |        |          |         |    | fluid   |
| s .unnu |     |     |        |          |         |    | cu      |
| mbered} |     |     |        |          |         |    | ltures; |
|         |     |     |        |          |         |    |         |
|         |     |     |        |          |         |    | t       |
|         |     |     |        |          |         |    | issues, |
|         |     |     |        |          |         |    | e       |
|         |     |     |        |          |         |    | xudates |
+---------+-----+-----+--------+----------+---------+----+---------+
| **Ch    | \-  | \-  | \-     | \+       | \+      |    |         |
| olera** |     |     |        |          |         |    |         |
+---------+-----+-----+--------+----------+---------+----+---------+
| **P     | \+  | \+  | Sputum | \+       | \-      | \- | Bubo    |
| lague** |     |     |        |          |         |    | as      |
|         |     |     |        |          |         |    | pirate, |
|         |     |     |        |          |         |    | CSF,    |
|         |     |     |        |          |         |    | sputum  |
+---------+-----+-----+--------+----------+---------+----+---------+
| **Tule  | \+  | \+  | \+^2^  | \+       | \-      | \- | Lesion  |
| remia** |     |     |        |          |         |    | sc      |
|         |     |     |        |          |         |    | raping, |
|         |     |     |        |          |         |    |         |
|         |     |     |        |          |         |    | Lymph   |
|         |     |     |        |          |         |    | nodes   |
+---------+-----+-----+--------+----------+---------+----+---------+
| **Q-    | \+  | 4   | L      | \+       |         |    | Lung,   |
| fever** |     |     | esions |          |         |    | spleen, |
|         |     |     |        |          |         |    | lymph   |
|         |     |     |        |          |         |    | nodes,  |
|         |     |     |        |          |         |    |         |
|         |     |     |        |          |         |    | Bone    |
|         |     |     |        |          |         |    | marrow  |
+---------+-----+-----+--------+----------+---------+----+---------+
| *       | \+  | 3   | \-     | \+       | \-      | \- | Liver   |
| *Congo- |     |     |        |          |         |    |         |
| Crimean |     |     |        |          |         |    |         |
| Hemo    |     |     |        |          |         |    |         |
| rrhagic |     |     |        |          |         |    |         |
| Fever** |     |     |        |          |         |    |         |
+---------+-----+-----+--------+----------+---------+----+---------+
| **VEE** | \+  | 3   | \-     | \+       | \-      |    | CSF     |
+---------+-----+-----+--------+----------+---------+----+---------+
| **Clos  | \+  |     | Wound  | \+       | \+      | \- |         |
| tridial |     |     | t      |          |         |    |         |
| T       |     |     | issues |          |         |    |         |
| oxins** |     |     |        |          |         |    |         |
+---------+-----+-----+--------+----------+---------+----+---------+
| **SEB   | \+  | \-  | \-     | \+       | \+      | \+ | Lung,   |
| Toxin** |     |     |        |          |         |    | kidney  |
+---------+-----+-----+--------+----------+---------+----+---------+
| **Ricin | \+  | \-  | \-     | \+       | \+      | \+ | Spleen, |
| Toxin** |     |     |        |          |         |    | lung,   |
|         |     |     |        |          |         |    | kidney  |
+---------+-----+-----+--------+----------+---------+----+---------+

^1^Within 18-24 hours

^2^Fluorescent antibody test on infected lymph node smears. Gram stain
has little value.

^3^Virus isolation from blood or throat swabs in appropriate
containment.

^4^*C. burnetii* can persist for days in blood and resists desiccation.
EDTA anticoagulated blood preferred. Culturing should not be done except
in BL3 containment.

###  {#section-30 .unnumbered}

### Appendix G: BW Agent Lab Identification {#appendix-g-bw-agent-lab-identification .unnumbered}

**[Immunoassays]{.underline}**

+--------------+-----------------+------------+---+------+---+----+------+
| #### Agen    | ##              | ####       |   | ###  | # | #  | ###  |
| t {#agent-1  | ## Gold Standar | Antigen De |   | # Ig | # | ## | # An |
| .unnumbered} | d {#gold-standa | tection {# |   | G {# | # | #  | imal |
|              | rd .unnumbered} | antigen-de |   | igg  | # | PC | s {# |
|              |                 | tection .u |   | .unn |   | R  | anim |
|              |                 | nnumbered} |   | umbe | I | {# | als  |
|              |                 |            |   | red} | g | pc | .unn |
|              |                 |            |   |      | M | r  | umbe |
|              |                 |            |   |      |   | .u | red} |
|              |                 |            |   |      | { | nn |      |
|              |                 |            |   |      | # | um |      |
|              |                 |            |   |      | i | be |      |
|              |                 |            |   |      | g | re |      |
|              |                 |            |   |      | m | d} |      |
|              |                 |            |   |      |   |    |      |
|              |                 |            |   |      | . |    |      |
|              |                 |            |   |      | u |    |      |
|              |                 |            |   |      | n |    |      |
|              |                 |            |   |      | n |    |      |
|              |                 |            |   |      | u |    |      |
|              |                 |            |   |      | m |    |      |
|              |                 |            |   |      | b |    |      |
|              |                 |            |   |      | e |    |      |
|              |                 |            |   |      | r |    |      |
|              |                 |            |   |      | e |    |      |
|              |                 |            |   |      | d |    |      |
|              |                 |            |   |      | } |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| Aflatoxins   | Mass            |            |   |      |   |    |      |
|              | spectrometry    |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| Arboviruses  | Virus           | X          |   | X    | X | X  | X    |
| (incl.       | isolation/FA,   |            |   |      |   |    |      |
| Alphaviruses | neutralization  |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| *Bacillus    | FA/Std.         | X (PA)     |   | X    | X | X  | X    |
| anthracis*   | Microbiology    |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| *Bacillus    | Std.            |            |   |      |   | X  |      |
| globigii*    | Microbiology    |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| *Bacillus    | Std.            |            |   |      |   | X  |      |
| th           | Microbiology    |            |   |      |   |    |      |
| uringiensis* |                 |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| Bot Toxins   | Mouse           | X (A,B,E   |   |      |   | X  | X    |
| (A-G)/*C.    | neutralization/ | Toxin)     |   |      |   |    |      |
| botulinum*   | standard        |            |   |      |   |    |      |
|              | microbiology    |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| *Brucella    | FA/Std.         | X          |   | X    | X | X  | X    |
| sp.*         | Microbiology    |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| *C.          | FA/eggs or cell | X          |   | X    | X | X  | X    |
| burnetii*    | Cx/serology     |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| *C.          | Std.            | X          |   | X    |   | X  |      |
| perfrin      | Micro./ELISA    |            |   |      |   |    |      |
| gens*/toxins | (alpha and      |            |   |      |   |    |      |
|              | enterotoxin     |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| *F.          | FA/Std.         | X          |   | X    | X | X  | X    |
| tularensis*  | Microbiology    |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| Filoviruses  | Virus           | X          |   | X    | X | X  | X    |
|              | isolation       |            |   |      |   |    |      |
|              | /neutralization |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| Hantaviruses | Virus           | X          |   | X    | X | X  | X    |
|              | isolation/      |            |   |      |   |    |      |
|              | FA              |            |   |      |   |    |      |
|              | /neutralization |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| Orthopox     | Virus           | X          |   | X    |   | X  | X    |
| Viruses      | isolation/      |            |   |      |   |    |      |
|              | FA              |            |   |      |   |    |      |
|              | /neutralization |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| Ricin Toxin  | ELISA           | X          |   | X    | X | X  | X    |
+--------------+-----------------+------------+---+------+---+----+------+
| Saxitoxin    | Bioassay        |            | ( |      |   |    | X    |
|              |                 |            | n |      |   |    |      |
|              |                 |            | e |      |   |    |      |
|              |                 |            | u |      |   |    |      |
|              |                 |            | t |      |   |    |      |
|              |                 |            | r |      |   |    |      |
|              |                 |            | a |      |   |    |      |
|              |                 |            | l |      |   |    |      |
|              |                 |            | i |      |   |    |      |
|              |                 |            | z |      |   |    |      |
|              |                 |            | i |      |   |    |      |
|              |                 |            | n |      |   |    |      |
|              |                 |            | g |      |   |    |      |
|              |                 |            | a |      |   |    |      |
|              |                 |            | n |      |   |    |      |
|              |                 |            | t |      |   |    |      |
|              |                 |            | i |      |   |    |      |
|              |                 |            | b |      |   |    |      |
|              |                 |            | o |      |   |    |      |
|              |                 |            | d |      |   |    |      |
|              |                 |            | i |      |   |    |      |
|              |                 |            | e |      |   |    |      |
|              |                 |            | s |      |   |    |      |
|              |                 |            | ) |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| SEA Toxin    | ELISA           | X          |   | X    |   | \* |      |
+--------------+-----------------+------------+---+------+---+----+------+
| SEB Toxin    | ELISA           | X          |   | X    |   | \* | X    |
+--------------+-----------------+------------+---+------+---+----+------+
| *Shigella    | Std.            | X          |   |      |   | X  |      |
| sp.*         | Microbiology    |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| T            | Bioassay        | X          | ( |      |   |    | X    |
| etrodotoxins |                 |            | n |      |   |    |      |
|              |                 |            | e |      |   |    |      |
|              |                 |            | u |      |   |    |      |
|              |                 |            | t |      |   |    |      |
|              |                 |            | r |      |   |    |      |
|              |                 |            | a |      |   |    |      |
|              |                 |            | l |      |   |    |      |
|              |                 |            | i |      |   |    |      |
|              |                 |            | z |      |   |    |      |
|              |                 |            | i |      |   |    |      |
|              |                 |            | n |      |   |    |      |
|              |                 |            | g |      |   |    |      |
|              |                 |            | a |      |   |    |      |
|              |                 |            | n |      |   |    |      |
|              |                 |            | t |      |   |    |      |
|              |                 |            | i |      |   |    |      |
|              |                 |            | b |      |   |    |      |
|              |                 |            | o |      |   |    |      |
|              |                 |            | d |      |   |    |      |
|              |                 |            | i |      |   |    |      |
|              |                 |            | e |      |   |    |      |
|              |                 |            | s |      |   |    |      |
|              |                 |            | ) |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| *Vibrio      | Std.            | X(toxin)   |   | X    | X | X  |      |
| cholerae*    | Microb          |            |   |      |   |    |      |
|              | iology/serology |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+
| *Yersinia    | FA/Std.         | X (F1)     |   | X    | X | X  | X    |
| pestis*      | Microbiology    |            |   |      |   |    |      |
+--------------+-----------------+------------+---+------+---+----+------+

[\_\_\_\_\_\_]{.underline}

\*Toxin gene detected

ELISA - enzyme-linked immunosorbent assays

FA - indirect or direct immunofluorescence assays

Std. Micro./serology - standard microbiological techniques available,
including electron microscopy

**Appendix H: Differential Diagnosis of Chemical Nerve Agent,**

> **Botulinum Toxin and SEB Intoxication following Inhalation Exposure**

+-----------------+-----------------+-----------------+-----------------+
|                 | **[Chemical     | **[Botulinum    | **[SEB          |
|                 | Nerve           | Toxin           | ]{.underline}** |
|                 | Agent           | ]{.underline}** |                 |
|                 | ]{.underline}** |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| ######## Tim    | Minutes         | Hours (12-24)   | Hours (1-6)     |
| e to Symptoms { |                 |                 |                 |
| #time-to-sympto |                 |                 |                 |
| ms .unnumbered} |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| **Nervous**     | Convulsions     | Progressive     | Headache        |
|                 |                 | paralysis       |                 |
|                 | Muscle          |                 | Muscle Aches    |
|                 | Twitching       |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| **C             | Slow heart rate | Normal rate     | Normal or Rapid |
| ardiovascular** |                 |                 | rate            |
+-----------------+-----------------+-----------------+-----------------+
| **Respiratory** | Difficult       | Normal, then    | Nonproductive   |
|                 | breathing       | progressive     | cough           |
|                 |                 | paralysis       |                 |
|                 | Airways         |                 | Severe case:    |
|                 | constriction    |                 | chest           |
|                 |                 |                 | pain/difficult  |
|                 |                 |                 | breathing       |
+-----------------+-----------------+-----------------+-----------------+
| **Gas           | Increased       | Decreased       | Nausea,         |
| trointestinal** | motility,       | motility        | vomiting and/or |
|                 |                 |                 | diarrhea        |
|                 | Pain, diarrhea  |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| **Ocular**      | Small pupils    | Droopy eyelids  | May see "red    |
|                 |                 |                 | eyes"           |
|                 |                 | Large pupils    |                 |
|                 |                 |                 | (conjuntival    |
|                 |                 |                 | injection)      |
+-----------------+-----------------+-----------------+-----------------+
| **Salivary**    | Profuse, watery | Normal          | May be slightly |
|                 |                 |                 | increased       |
|                 | Saliva          | Difficulty      | quantities of   |
|                 |                 | swallowing      | saliva          |
+-----------------+-----------------+-----------------+-----------------+
| **Death**       | Minutes         | 2-3 days        | Unlikely        |
+-----------------+-----------------+-----------------+-----------------+
| **Response to   | Yes             | No              | Atropine may    |
| Atropine/ 2-PAM |                 |                 | reduce          |
| Chloride**      |                 |                 | gastrointinal   |
|                 |                 |                 | symptoms        |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+

Appendix I: Comparative Lethality of Selected Toxins & Chemical

Agents in Laboratory Mice

**AGENT LD~50~ MOLECULAR SOURCE**

**(μg/kg) WEIGHT**

Botulinum toxin 0.001 150,000 Bacterium

Shiga toxin 0.002 55,000 Bacterium

Tetanus toxin 0.002 150,000 Bacterium

Abrin 0.04 65,000 Plant (Rosary Pea)

Diphtheria toxin 0.10 62,000 Bacterium

Maitotoxin 0.10 3,400 Marine Dinoflagellate

Palytoxin 0.15 2,700 Marine Soft Coral

Ciguatoxin 0.40 1,000 Marine Dinoflagellate

Textilotoxin 0.60 80,000 Elapid Snake

C. perfringens toxins 0.1 - 5.0 35-40,000 Bacterium

Batrachotoxin 2.0 539 Arrow-Poison Frog

Ricin 3.0 64,000 Plant (Castor Bean)

alpha-Conotoxin 5.0 1,500 Cone Snail

Taipoxin 5.0 46,000 Elapid Snake

Tetrodotoxin 8.0 319 Puffer Fish

alpha-Tityustoxin 9.0 8,000 Scorpion

Saxitoxin 10.0 (Inhal 2.0) 299 Marine Dinoflagellate

VX 15.0 267 Chemical Agent

SEB (Rhesus/Aerosol) 27.0 (ED~50~\~pg) 28,494 Bacterium

Anatoxin-A(s) 50.0 500 Blue-Green Algae

Microcystin 50.0 994 Blue-Green Algae

Soman (GD) 64.0 182 Chemical Agent

Sarin (GB) 100.0 140 Chemical Agent

Aconitine 100.0 647 Plant (Monkshood)

T-2 Toxin 1,210.0 466 Fungal Myotoxin

**Appendix J. Aerosol Toxicity in LD~50~ vs. Quantity of Toxin**

Aerosol toxicity in LD~50~ (see Appendix C) vs. quantity of toxin
required to provide a theoretically effective open-air exposure, under
ideal meteorological conditions, to an area 100 km^2^ . Ricin, saxitoxin
and botulinum toxins kill at the concentrations depicted. (Patrick and
Spertzel, 1992: Based on Cader K.L., BWL Tech Study #3, Mathematical
models for dosage and casualty resulting from single point and line
source release of aerosol near ground level, DTIC#AD3 10-361, Dec 1957)

**Appendix K: References and Emergency Response Contacts**

**Journals with Biological Weapon Theme issues:**

Annals of Emergency Medicine-August 1999

Emerging Infectious Diseases-July/August 1999

Journal of the American Medical Association-August 6, 1997

Journal of Public Health Management and Practice- July 2000

**Background/Overview**

Cieslak TJ, Eitzen EM. Bioterrorism: Agents of concern. J Public Health
Management Practice 2000;6:19-29

Cieslak TJ, Christopher GW, Kortepeter MG, Rowe JR, Pavlin JA, Culpepper
RC, Eitzen EM. Immunization against potential biological warfare agents.
Clin Infect Dis 2000 \[in press\].

Henretig FM, Cieslak TJ, Madsen JM, Eitzen EM, Flesiher GR. The
emergency department response to incidents of chemical and biological
terrorism. In: Textbook of Pediatric Emergency Medicine, Fleisher GR,
Ludwig S, eds. Lippincott, Williams, and Wilkins, Philadelphia, 2000,
pp. 1763-84.

Kortepeter MG, Parker GW. Potential Biological Weapons Threats. Emerging
Infectious Diseases 2000; 5(4): 523-527.

Macintyre AG, Christopher GW, Eitzen EM Jr., Gum R, Weir S, DeAtley C,
Tonat K, Barbera JA. Weapons of mass destruction events with
contaminated casualties: effective planning for health care facilities.
*JAMA* 2000:283;242-249.

McGovern TW, Christopher GW, Eitzen EM Jr. Cutaneous manifestations of
biological warfare and related threat agents. *Arch
Dermatol*;1999:135:311-322.

**Books:**

*Biological Weapons: Limiting the Threat*. Lederberg J (ed.).
Cambridge,Mass;The MIT Press:1999.

Institute of Medicine and National Research Council. *Chemical and
Biological Terrorism*. *Research and Development to Improve Civilian
Medical Response.* Washington, D.C.; National Academy Press;1999.

Ali J, Dwyer A, Eldridge J, Lewis FA, Patrick WC, Sidell, FR. *Jane's
Chemical-Biological Defense Guidebook*. Alexandria, Va; Jane's
Information Group; 1999.

Alibek K, with Handelman S. *Biohazard*. New York; Random House; 1999

Benenson, AS. Control of Communicable Diseases Manual (16th ed.)
American Public Health Association, Baltimore: United Book Press Co;
1995.

Falkenrath RA, Newman RD, Thayer BA. *America's Achilles' Heel. Nuclear,
Biological, and Chemical Terrorism and Covert Attack.* Cambridge, Mass;
The MIT Press, 1998.

Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and its
Eradication. Geneva, Switzerland: World Health Organization;1988.

Fields Virology (3d ed.), Fields BN, Knipe DM, Howley PM, et al (eds).
Philadelphia: Lippincott-Raven; 1996.

Guillemin J, Anthrax: The investigation of a deadly epidemic. Berkely
CA: Univeristy of California Press. 1999.

Hunter\'s Tropical Medicine (8th ed.). G. Thomas Strickland, (ed.).
2000: W.B. Saunders Co., Philadelphia.

Medical aspects of chemical and biological warfare. (TMM series. Part I,
Warfare, weaponry, and the casualty). Sidell FR, Takafuji ET, Franz DR
(eds.). Office of The Surgeon General at TMM Publications, Borden
Institute, Washington, D.C., 1997.

Medical Management of Biological Casualties Handbook (3rd ed.). Eitzen
E, Pavlin J, Cieslak T, Christopher G, Culpepper R (eds.).Fort Detrick,
Frederick, MD: U.S. Army Medical Research Institute of Infectious
Diseases; 1998.

Principles and Practice of Infectious Diseases (5th ed.). Mandell GL,
Bennett JE, Dolin R. 2000: Churchill Livingstone, Philadelphia.

Regis E. *The Biology of Doom*. New York; Henry Holt and Co.; 1999.

**Web Sources**

[Biolectures:]{.underline}

[www.nbc-med.org/SiteContent/MedRef/OnlineRef/GovDocs/BioWarfare]{.underline}

[www.nbc-med.org/SiteContent/MedRef/OnlineRef/GovDocs/Anthrax]{.underline}

[www.nbc-med.org/SiteContent/MedRef/OnlineRef/GovDocs/BioAgents.html]{.underline}

[www.nbc-med.org/SiteContent/MedRef/OnlineRef/GovDocs/SmallPox/index.htm]{.underline}

[www.nbc-med.org/SiteContent/MedRef/OnlineRef/GovDocs/Viral/index.htm]{.underline}

www.nbc-med.org. US Army Surgeon General's site on nuclear, biological,
chemical defense.

www.usamriid.army.mil. USAMRIID website

www.apic.org. Association of Professionals in Infection Control and
Epidemiology. Contains bioterrorism response plan

www.hopkins-biodefense.org Johns Hopkins University Center for Civilian
Biodefense

www.anthrax.osd.mil Anthrax Vaccine Implementation Program

www.bt.cdc.gov CDC\'s bioterrorism preparedness and response website

**Journal Articles:**

**Anthrax**

Abramova, F.A., Grinberg, L.M., Yampolskaya, O.V., Walker, D.H.,
*Pathology of Inhalational Anthrax in 42 Cases from the Sverdlovsk
Outbreak of 1979*. Proceedings of the National Academy of Sciences, USA
(1993), 90:2291-4.

Centers for Disease Control and Prevention. *Bioterrorism Alleging Use
of Anthrax and Interim Guidelines for Management-United States*, *1998*.
Morbidity and Mortality Weekly Report (1999), 48:69-74.

Cieslak TJ, Eitzen EM. Clinical and epidemiologic principles of anthrax.
Emerging Infect Dis 1999;5:-5.

Dixon TC, Meselson M, Guillemin J, Hanna PC. Anthrax. *New Engl J Med*
1999;341:815-826.

Friedlander AM, Welkos SLL, Pitt MLM, et al. Postexposure prophylaxis
against experimental inhalation anthrax. *J Infect Dis*
1993;167:1239-42.

Jackson, P.J., Hugh-Jones, M.E., Adair, D.M., et al. *Polymerase Chain
Reaction Analysis of Tissue Samples from the 1979 Sverdlovsk Anthrax
Victims: The Presence of Multiple Bacillus Anthracis Strains in
Different Victims.* Proceedings of the National Academy of Sciences, USA
(1998), 95:1224-9.

Garner, J.S., *Hospital Infection Control Practices Advisory Committee.
Guidelines for Isolation Precautions in Hospitals.* Infectious Control
Hospital, Epidemiology (1996), 17:53-80, and American Journal of
Infection Control (1996), 24:24-52

Meselson M, Guillemin JG, Hugh-Jones M, et al. The Sverdlovsk anthrax
outbreak of 1979. *Science*;1994:266:1202-1207.

Pile JC, Malone JD, Eitzen EM, Friedlander AM. Anthrax as a potential
biological warfare agent. *Arch Intern Med* 1998;158:429-34.

Pomerantsev, A.P., Staritsin, N.A., Mockov, Y.V., Marinin, L.I.,
*Expression of Cereolysine AB Genes in Bacillus anthracis Vaccine Strain
Ensures Protection Against Experimental Hemolytic Anthrax Infection.*
Vaccine (1997), 15:1846-1850.

**Brucellosis**

Mousa ARM, Elhag KM, Khogali M, Marafie AA. The nature of human
brucellosis in Kuwait: study of 379 cases. Rev Infect Dis 1988;10:211-7.

# Young EJ. An overview of human brucellosis. Clin Infect Dis 1995;21:283-90 {#young-ej.-an-overview-of-human-brucellosis.-clin-infect-dis-199521283-90 .unnumbered}

**Glanders/Melioidosis**

CDC. Laboratory-acquired human glanders - Marlyland, May 2000. MMWR
2000;49:532-535.

Chaowagul W, Suputtamongkol Y, Dance DAB, et al. Relapse in Melioidosis:
incidence and risk factors. J Infect Dis. 1993;168:1181-5.

Howe C, Miller WR. Human Glanders: report of six cases Ann Int Med 1947;
26: 93-115.

Leelarasamee A, Bovornkitti S. Melioidosis: review and update. Rev
Infect Dis. 1989;11(3): 413-23.

Misra VC, Mukesh S, Thakur V. Glanders: an appraisal and its control in
India. Indian Veterinary Medical Journal 1995;19(2):87-98.

**Plague**

Byrne, WR, Welkos, SL, Pitt, ML, et.al. Antibiotic Treatment of
Experimental Pneumonic Plague in Mice. *Antimicrobial Agents and
Chemotherapy*. 1998;42:675-681.

CDC. Prevention of Plague: Recommendations of the Advisory Committee on
Immunization Practices (ACIP). *MMWR* 1996;45:1-15.

Heath, DG, Anderson, GW, Mauro, JM, et.al. Protection Against
Experimental Bubonic and Pneumonic Plague by a Recombinant Capsular F1-V
Antigen Fusion Protein Vaccine. *Vaccine* 1998;16:1131-1137.

Inglesby, TV, Dennis, DT, Henderson, DA, et.al. Plague as a Biological
Weapon: Medical and Public Health Management. *JAMA* 2000;283:2281-2290.

Perry, RD and Fetherson, JD Yersinia pestis---Etiologic Agent of Plague.
*Clinical Microbiol Reviews* 1997;10:35-66.

**Smallpox**

Barquet N, Domingo P. Smallpox: The triumph over the most terrible of
the ministers of death. Ann Intern Med 1997;127;635-642.

\` Breman JG, Henderson DA. Poxvirus dilemmas-monkeypox, smallpox, and
biologic terrorism. N Engl J Med 1998;339:556-9.

CDC. Human monkeypox-Kasai Oriental, Zaire, 1996-1997. MMWR
1997;46:301-7.

CDC. Human Monkeypox-Kasai Oriental, Democratic Republic of Congo,
February 1996-October 1997. MMWR 1997;46:1168-71.

CDC. *Vaccinia (Smallpox)* *Vaccine: Recommendations of the ACIP*.
Morbidity and Mortality Weekly Report (1991), 40:RR-14 (Suppl).

Disseminated vaccinia in a military recruit with human immunodeficiency
virus (HIV) disease. N Engl J Med 1987;316:673-6.

Henderson DA. Edward Jenner's vaccine. Publ Health Rep 1997;112:117-121.

Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a biological
weapon. Medical and Public Health Management. JAMA 1999;281:2127-2137.

Kesson A, Ferguson JK, Rawlinson WD, Cunningham AL. Progressive vaccinia
treated with ribavirin and vacinia immune globulin. Clin Infect Dis
1997;25:911-4

McClain DJ, Harrison S, Yeager CL, et al. Immunologic responses to
vaccinia vaccines administered by different parenteral routes. J Infect
Dis 1997;175:756-63

Radetsky M. Smallpox: a history of its rise and fall. Pediatr Infect Dis
J 1999;18:85-93.

Vaccinia (smallpox) vaccine: recommendations of the Immunization
Practices +Advisory Committee (ACIP). MMWR 1991;40:RR-14 (Suppl)

**Viral Hemorrhagic Fevers**

Armstrong LR, Dembry LM, Rainey PM, Russi MB, et al. Management of a
Sabia virus-infected patient in a US Hospital. Infect Control Hosp
Epidemiol 1999;20:176-82.

Barry M, Russi M, Armstrong L, et al. Brief report: treatment of a
laboratory acquired Sabia virus infection. N Engl J Med 1995;333:294-6.

CDC. Management of patients with suspected viral hemorrhagic fever. MMWR
1988;37: S-3 (Suppl).

CDC. Update: Management of patients with suspected viral hemorrhagic
fever-United States. MMWR 1995;44:475-9.

CDC. Ebola virus infection in imported primates-Virginia, 1989. MMWR
1989;38:831-9.

CDC. Update: Filovirus infections among persons with occupational
exposure to nonhuman primates. MMWR 1990;39:266-7.

Christopher GW, Eitzen EM Jr. Air evacuation under high-level biosafety
containment: the Aeromedical Isolation Team. *Emerg Infect Dis*
1999;241-246. Available from: URL http: // www. cdc.
gov/ncidod/EID/vol5no2/ christopher.htm

Clausen L, Bothwell TH, Isaacson M, et al. Isolation and handling of
patients with dangerous infectious disease. S Afr Med J 1978;53:238-42.

Dalgard DW, Hardy, RJ, Pearson SL, et al. Combined simian hemorrhagic
fever and ebola virus infection in cynomolgus monkeys. Lab Anim Sci
1992;42:152-7.

Fisher-Hoch SP, Price ME, Craven RB, et al. Safe intensive-care
management of a severe case of Lassa fever with simple barrier nursing
techniques. Lancet 1985;2:1227-9.

Hill EE, McKee KT. Isolation and biocontainment of patients with highly
hazardous infectious diseases. J US Army Med Dept 1991;PB 8-91-1/2:10-4.

Holmes GP, McCormick JB, Trock SC, et al. Lassa fever in the United
States: investigation of a case and new guidelines for management. N Enl
J Med 1990;323:1120-3.

Jahrling PB, Geisbert TW, Dalgard DW, et al. Preliminary report:
isolation of Ebola virus from monkeys imported to USA. Lancet
1990;335:502-5.

Johnson KM, Monath TP. Imported Lassa fever-reexamining the algorithms.
New Engl J Med 1990;323:1139-40.

Peters CJ, Sanchez A, Rollin PE, Ksiazek TG, Murphy FA. Filoviridae:
Marburg and Ebola viruses. pp 1161-76, *Fields Virology* (3d ed.),
Fields BN, Knipe DM, Howley PM, et al (eds). Philadelphia:
Lippincott-Raven; 1996.

Trexler PC, RTD Emond, Evans B. Negative-pressure plastic isolator for
patients with dangerous infections. Brit Med J 1977; 559-61.

Wilson KE, Driscoll DM. Mobile high-containment isolation: a unique
patient care modality. Am J Infect Cont 1987;15:120-4.

**Toxins**

Burrows, WD and Renner, SE. Biological Warfare Agents as Threats to
Potable Water. *Environmental Health Perspectives*, 1999;107:975-984.

Franz, DR. Defense Against Toxin Weapons. 1997 Medical Research and
Materiel Command, pp. 1-49.

Franz, DR, Pitt, LM, Clayton, MA, et.al. Efficacy of Prophylactic and
Therapeutic Administration of Antitoxin for Inhalation Botulism.
*Botulinum and Tetanus Neurotoxins* \[Proc. Int. Conf.\] 1993;473-6.

Goldfrank, LR and Flomenbaum, NE. Botulism, in Goldfrank's Toxicologic
Emergencies, 6^th^ ed. Stamford, CT: Appleton and Lange, 1177-1189.

Parker, DT, Parker, AC, Ramachandran, CK. Joint CB Technical Data Source
Book, Volume VI. Toxin Agents, Part 3, Ricin. 1996 DPG/JCP-96/007.

Patrick, WC. Analysis of Botulinum Toxin, Type A, as a Biologicla
Warfare Threat. May 1998, pp.1-26 (unpublished monograph).

Rutala, WA and Weber, DJ. Uses of Inorganic Hypochlorite (Bleach) in
Health-Care Facilities. *Clinical Microbiology Reviews*,
1997;10:597-610.

**Federal Bureau of Investigation (FBI) Field Offices**

Revised FBI 1/5/99

  --------------- --------------------------------------- -------- --------------
  **FIELD         **STREET ADDRESS**                      **ZIP    **TELEPHONE
  OFFICE**                                                CODE**   No.**

  Albany, NY      200 McCarty Avenue                      12209    518/465-7551

  Albuquerque, NM 415 Silver Avenue, SW, Suite 300        87102    505/224-2000

  Anchorage, AK   101 East 6^th^ Avenue                   99501    907/258-5322

  Atlanta, GA     2635 Century Parkway, NE; Suite 400     30345    404/679-9000

  Baltimore, MD   7142 Ambassador Road                    21244    410/265-8080

  Birmingham, AL  2121 8^th^ Avenue, N., Room 1400        35203    205/326-6166

  Boston, MA      One Center Plaza, Suite 600             02108    617/742-5533

  Buffalo, NY     One FBI Plaza                           14202    716-856-7800

  Charlotte, NC   400 S. Tryon Street, Suite 900 Wachovia 28285    704/377-9200
                  Blvd                                             

  Chicago, IL     219 S. Dearborn Street, Room 905        60604    312/431-1333

  Cincinnati, OH  550 Main Street, Room 9000              45202    513/421-4310

  Cleveland, OH   1240 East 9^th^ Street, Room 3005       44199    216/522-1400

  Columbia, SC    151 Westpark Blvd.                      29210    803/551-1200

  Dallas, TX      1801 N. Lamar, Suite 300                75202    214/720-2200

  Denver, CO      1961 Stout Street, Room 1823, FOB       80294    303/629-7171

  Detroit, MI     477 Michigan Avenue, P.V. McNamara FOB, 48226    313/965-2323
                  26^th^ Floor                                     

  El Paso, TX     Suite 3000, 660 South Mesa Hills Drive  79912    915/832-5000

  Honolulu, HI    300 Ala Moana Blvd., Room 4-230,        96850    808/521-1411
                  Kalanianaole FOB                                 

  Houston, TX     2500 East T.C. Jester                   77008    713/693-5000

  Indianapolis,   575 N. Pennsylvania St., Room 679, FOB  46204    317/639-3301
  IN                                                               

  Jackson, MS     100 W. Capitol Street, Suite 1553, FOB  39269    601/948-5000

  Jacksonville,   7820 Arlington Expy, Suite 200          32211    904/721-1211
  FL                                                               

  Kansas City, MO 1300 Summit Street                      64105    816/221-6100

  Knoxville, TN   710 Locust Street, Suite 600            37902    423/544-0751

  Las Vegas, NV   John Lawrence Bailey Bldg., 700 E.      89104    702/385-1281
                  Charleston Blvd.                                 

  Little Rock, AR 10825 Financial Centre Pkwy., Suite 200 72211    501/221-9100

  Los Angeles, CA 11000 Wilshire Blvd., Suite 1700 FOB    90024    310/477-6565

  Louisville, KY  600 Martin Luther King Jr. Pl., Room    40202    502/583-3941
                  500                                              

  Memphis, TN     225 North Humphreys Blvd., Suite 3000,  38120    901/747-4300
                  Eagle Crest Bldg.                                

  Miami, FL       16320 NW 2^nd^ Avenue, N. Miami Beach   33169    305/944-9101

  Milwaukee, WI   330 E. Kilbourn Avenue, Suite 600       53202    414/276-4684

  Minneapolis, MN 111 Washington Avenue South, Buite 1100 55401    612/376-3200

  Mobile, AL      One St. Louis Street, 3^rd^ Floor, One  36602    334/438-3674
                  St. Louis Centre                                 

  New Haven, CT   150 Court Street, Room 535 FOB          06510    203/777-6311

  New Orleans, LA 1250 Poydras Street, Suite 2200         70113    504/522-4671

  New York City,  26 Federal Plaza, 23^rd^ Floor          10278    212/384-1000
  NY                                                               

  Newark, NJ      One Gateway Center, 22^nd^ Floor        07102    973/622-5613

  Norfolk, VA     150 Corporate Blvd.                     23502    757/455-0100

  Oklahoma City,  50 Penn Place, Suite 1600               73118    405/290-7770
  OK                                                               

  Omaha, NE       10755 Burt Street                       68114    402/493-8688

  Philadelphia,   600 Arch Street, 8^th^ Floor; William   19106    215/418-4000
  PA              J. Green, Jr., FOB                               

  Phoenix, AZ     201 E. Indianola Avenue, Suite 400      85012    602/279-5511

  Pittsburgh, PA  700 Grant Street, Suite 300 USPO        15219    412/471-2000

  Portland, OR    1500 S.W. 1^st^ Avenue, Suite 400;      97201    503/224-4181
                  Crown Plaza Bldg.                                

  Richmond, VA    111 Greencourt Road                     23228    804/261-1044

  Sacramento, CA  4500 Orange Grove Avenue                95841    916/481-9110

  Salt Lake City, 257 East 200 South, Suite 1200          84111    801/579-1400
  UT                                                               

  San Antonio. TX 615 E. Houston Street, Suite 200; US    78205    210/225-6741
                  Post Office & Courthouse Bldg.                   

  San Diego, CA   9797 Aero Drive                         92123    619/565-1255

  San Francisco,  450 Golden Gate Avenue, 13^th^ Floor    94102    415/553-7400
  CA                                                               

  San Juan, PR    150 Carlos Chardon, Room 526; U.S.      00918    787/754-6000
                  Federal Building, Hato Roy, PR                   

  Seattle, WA     915 Second Avenue, Room 710             98174    206/622-0460

  Springfield, IL 400 W. Monroe Street, Suite 400         62704    217/522-9675

  St. Louis, Mo   2222 Market Street                      63103    314/231-4324

  Tampa, FL       500 E. Zack Street, Suite 610 FOB       33602    813/273-4566

  Washington,     601 4^th^ Street, NW                    20535    202/278-2000
  D.C.                                                             
  --------------- --------------------------------------- -------- --------------

**Telephone Directory of State and Territorial Public Health Directors**

**Alabama**

Alabama Department of Public Health

State Health Officer

Phone No. (334) 206-5200

Fax No. (334) 206-2008

**Alaska**

Division of Public Health

Alaska Department of Health and Social Services

Director

Phone No. (907) 465-3090

Fax No. (907) 586-1877

**American Samoa**

Department of Health

American Samoa Government

Director

Phone No. (684) 633-4606

Fax No. (684) 633-5379

**Arizona**

Arizona Department of Health Services

Director

Phone No. (602) 542-1025

Fax No. (602) 542-1062

**Arkansas**

Arkansas Department of Health

Director

Phone No. (501) 661-2417

Fax No. (501) 671-1450

**California**

California Department of Health Services

State Health Officer

Phone No. (916) 657-1493

Fax No. (916) 657-3089

**Colorado**

Colorado Department of Public Health & Environment

Executive Director

Phone No. (303) 692-2011

Fax No. (303) 691-7702

**Connecticut**

Connecticut Department of Public Health

Commissioner

Phone No. (860) 509-7101

Fax No. (860) 509-7111

**Delaware**

Division of Public Health

Delaware Department of Health and Social Services

Director

Phone No. (302) 739-4700

Fax No. (302) 739-6659

**District of Columbia**

DC Department of Health

Acting Director

Phone No. (202) 645-5556

Fax No. (202) 645-0526

**Florida**

Florida Department of Health

Secretary and State Health Officer

Phone No. (850) 487-2945

Fax No. (850) 487-3729

**Georgia**

Division of Public Health

Georgia Department of Human Resources

Director

Phone No. (404) 657-2700

Fax No. (404) 657-2715

**Guam**

Department of Public Health & Social Services

Government of Guam

Director of Health

Phone No. (67l) 735-7102

Fax No. (671) 734-5910

**Hawaii**

Hawaii Department of Health

Director

Phone No. (808) 586-4410

Fax No. (808) 586-4444

**Idaho**

Division of Health

Idaho Department of Health and Welfare

Administrator

Phone No. (208) 334-5945

Fax No. (208) 334-6581

**Illinois**

Illinois Department of Public Health

Director of Public Health

Phone No. (217) 782-4977

Fax No. (217) 782-3987

**Indiana**

Indiana State Department of Health

State Health Commissioner

Phone No. (317) 233-7400

Fax No. (317) 233-7387

**Iowa**

Iowa Department of Public Health

Director of Public Health

Phone No. (515) 281-5605

Fax No. (515) 281-4958

**Kansas**

Kansas Department of Health and Environment

Director of Health

Phone No. (785) 296-1343

Fax No. (785) 296-1562

**Kentucky**

Kentucky Department for Public Health

Commissioner

Phone No. (502) 564-3970

Fax No. (502) 564-6533

**Louisiana**

Louisiana Department of Health and Hospitals

Asst Secretary and State Health Officer

Phone No. (504) 342-8093

Fax No. (504) 342-8098

**Maine**

Maine Bureau of Health

Maine Department of Human Services

Director

Phone No. (207) 287-3201

Fax No. (207) 287-4631

**Mariana Islands**

Department of Public Health & Environmental Services

Commonwealth of the Northern Mariana Islands

Secretary of Health and Environmental Services

Phone No. (670) 234-8950

Fax No. (670) 234-8930

**Marshall Islands**

Republic of the Marshall Islands

Majuro Hospital

Minister of Health & Environmental Services

Phone No. (692) 625-3355

Fax No. (692) 625-3432

**Maryland**

Maryland Dept of Health and Mental Hygiene

Secretary

Phone No. (410) 767-6505

Fax No. (410) 767-6489

**Massachusetts**

Massachusetts Department of Public Health

Commissioner

Phone No. (617) 624-5200

Fax No. (617) 624-5206

**Michigan**

Michigan Depart of Community Health

Chief Executive and Medical Officer

Phone No. (517) 335-8024

Fax No. (517) 335-9476

**Micronesia**

Department of Health Services

FSM National Government

Secretary of Health

Phone No. (691) 320-2619

Fax No. (691) 320-5263

**Minnesota**

Minnesota Department of Health

Commissioner of Health

Phone No. (651) 296-8401

Fax No. (651) 215-5801

**Mississippi**

Mississippi State Department of Health

State Health Officer and Chief Executive

Phone No. (601) 960-7634

Fax No. (601) 960-7931

**Missouri**

Missouri Department of Health

Director

Phone No. (573) 751-6001

Fax No. (573) 751-6041

**Montana**

Montana Dept of Public Health & Human Services, Director

Phone No. (406) 444-5622

Fax No. (406) 444-1970

**Nebraska**

Nebraska Health and Human Services System

Chief Medical Officer

Phone No. (402) 471-8399

Fax No. (402) 471-9449

**Nevada**

Division of Health

NV State Dept of Human Resources

State Health Officer

Phone No. (702) 687-3786

Fax No. (702) 687-3859

**New Hampshire**

New Hampshire Department of Health & Human Services

Medical Director

Phone No. (603) 271-4372

Fax No. (603) 271-4827

**New Jersey**

New Jersey Department of Health & Senior Services

Commissioner of Health

Phone No. (609) 292-7837

Fax No. (609) 292-0053

**New Mexico**

New Mexico Department of Health

Secretary

Phone No. (505) 827-2613

Fax No. (505) 827-2530

**New York**

New York State Department of Health

ESP-Corning Tower, 14th Floor

Albany, NY 12237

Commissioner of Health

Phone No. (518) 474-2011

Fax No. (518) 474-5450

**North Carolina**

NC Dept of Health and Human Services

State Health Director

Phone No. (919) 733-4392

Fax No. (919) 715-4645

**North Dakota**

North Dakota Department of Health

State Health Officer

Phone No. (701) 328-2372

Fax No. (701) 328-4727

**Ohio**

Ohio Department of Health

Director of Health

Phone No. (614) 466-2253

Fax No. (614) 644-0085

**Oklahoma**

Oklahoma State Department of Health

Commissioner of Health

Phone No. (405) 271-4200

Fax No. (405) 271-3431

**Oregon**

Oregon Health Division

Oregon Dept of Human Resources

Administrator

Phone No. (503) 731-4000

Fax No. (503) 731-4078

**Palau, Republic of**

Ministry of Health, Republic of Palau

Minister of Health

Phone No. (680) 488-2813

Fax No. (680) 488-1211

**Pennsylvania**

Pennsylvania Department of Health

Secretary of Health

Phone No. (717) 787-6436

Fax No. (717) 787-0191

**Puerto Rico**

Puerto Rico Department of Health

Secretary of Health

Phone No. (787) 274-7602

Fax No. (787) 250-6547

**Rhode Island**

Rhode Island Department of Health

Director of Health

Phone No. (401) 277-2231

Fax No. (401) 277-6548

**South Carolina**

SC Department of Health and Environmental Control

Commissioner

Phone No. (803) 734-4880

Fax No. (803) 734-4620

**South Dakota**

South Dakota State Dept of Health

Secretary of Health

Phone No. (605) 773-3361

Fax No. (605) 773-5683

**Tennessee**

Tennessee Department of Health

State Health Officer

Phone No. (615) 741-3111

Fax No. (615) 741-2491

**Texas**

Texas Department of Health

Commissioner of Health

Phone No. (512) 458-7375

Fax No. (512) 458-7477

**Utah**

# Utah Dept of Health, Director {#utah-dept-of-health-director .unnumbered}

Phone No. (801) 538-6111

Fax No. (801) 538-6306

**Vermont**

Vermont Department of Health

Commissioner

Phone No. (802) 863-7280

Fax No. (802) 865-7754

**Virgin Islands**

Virgin Islands Department of Health

Commissioner of Health

Phone No. (340) 774-0117; Fax No. (340) 777-4001

**Virginia**

Virginia Department of Health

State Health Commissioner

Phone No. (804) 786-3561

Fax No. (804) 786-4616

**Washington**

Washington State Department of Health

Acting Secretary of Health

Phone No. (360) 753-5871

Fax No. (360) 586-7424

**West Virginia**

# Bureau for Public Health {#bureau-for-public-health .unnumbered}

WV Department of Health & Human Resources

Commissioner of Health

Phone No. (304) 558-2971

Fax No. (304) 558-1035

**Wisconsin**

Division of Health

Wisconsin Department of Health and Family Services

Administrator

Phone No. (608) 266-1511

Fax No. (608) 267-2832

**Wyoming**

Wyoming Department of Health

Director

Phone No. (307) 777-7656

Fax No. (307) 777-7