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USAMRIID’s

MEDICAL MANAGEMENT

OF BIOLOGICAL CASUALTIES

HANDBOOK

Fourth Edition

February 2001

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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

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
3

USAMRIID’s

MEDICAL MANAGEMENT

OF BIOLOGICAL CASUALTIES

HANDBOOK

Fourth Edition

February 2001

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
4

PREFACE TO THE FOURTH EDITION

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

ACKNOWLEDGMENTS

 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 
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University of Texas at Austin; and Mr. D. Hampton Finger, Systems Administrator for 

The Institute for Advanced Technology. 

DISCLAIMER

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.
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EXECUTIVE ORDER 13139:

IMPROVING HEALTH PROTECTION OF MILITARY PERSONNEL PARTICIPATING 

IN PARTICULAR MILITARY OPERATIONS

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.

In order to administer an IND product:

•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.
7

Table of Contents

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
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INTRODUCTION

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.
9

HISTORY OF BIOLOGICAL WARFARE

AND CURRENT THREAT 

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, 
10

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). 
11

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.
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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.
13

DISTINGUISHING BETWEEN NATURAL AND 

INTENTIONAL DISEASE OUTBREAKS

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.
14

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
15

TEN STEPS IN THE MANAGEMENT OF

BIOLOGICAL CASUALTIES ON THE BATTLEFIELD

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 tenstep 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), 
16

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 postexposure administration of antibiotics; such strategies are discussed on an agentspecific 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
17

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

Rapid-Onset

 Nerve Agents

 Cyanide

 Mustard

 Lewisite

 Phosgene

 SEB Inhalation

Casualties

Delayed-Onset

 Inhalational Anthrax

 Pneumonic Plague

 Pneumonic Tularemia

 Q Fever

 SEB Inhalation

 Ricin Inhalation

 Mustard

 Lewisite

 Phosgene

Neurological

Rapid-Onset

 Nerve Agents

 Cyanide

Casualties

Delayed-Onset

 Botulism-peripheral symptoms

 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, 
18

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

Rapid-Onset

 Cyanide 

Casualties

Delayed-Onset

 Inhalational Anthrax

 Pneumonic Plague

 Pneumonic Tularemia

Neurological

Rapid-Onset

 Nerve Agents 

Casualties

Delayed-Onset

 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
19

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.
20

BACTERIAL AGENTS

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 diseasecausing 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).
21

ANTHRAX

SUMMARY

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).
22

OVERVIEW

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

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

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 
23

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

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

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 
24

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

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 oC (refrigerator temperature, not frozen).
25

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.
26

BRUCELLOSIS

SUMMARY

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. 
27

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 
28

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. 

99mTechnetium and 67Gallium 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 goatmilk 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.
29

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. 
30

GLANDERS AND MELIOIDOSIS

SUMMARY

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.
31

OVERVIEW

The causative agents of Glanders and Melioidosis are Burkholderia mallei and 

Burkholderia pseudomallei, respectively. Both are gram-negative bacilli with a “safetypin” 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 communityacquired 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

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 
32

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

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
33

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

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

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 
34

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

Vaccine: There is no vaccine available for human use. 

Antibiotics: Post-exposure chemoprophylaxis may be tried with TMP-SMX.
35

PLAGUE

SUMMARY

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.
36

OVERVIEW

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

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 plagueinfected 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

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. 
37

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 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. 
38

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

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.
39

PROPHYLAXIS

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. 
40

Q FEVER

SUMMARY

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. 
41

OVERVIEW

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

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

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, culturenegative endocarditis, aseptic meningitis, encephalitis and osteomyelitis. Most patients 

who develop endocarditis have pre-existing valvular heart disease. 
42

DIAGNOSIS

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

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

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 
43

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.
44

TULAREMIA

SUMMARY

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.
45

OVERVIEW

Francisella tularensis, the causative agent of tularemia, is a small, aerobic nonmotile, 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

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

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 108 organisms are required with oral challenge. 

Typhoidal tularemia (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
46

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 (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 (5-10 percent of cases) results in fever and tender

lymphadenopathy but no skin ulcer.

Oculoglandular tularemia (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 refers to primary ulceroglandular disease confined to the 

throat. It produces an acute exudative or membranous pharyngotonsillitis with cervical 

lymphadenopathy.

Pneumonic tularemia 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

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 
47

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. 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.
48

MEDICAL MANAGEMENT

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 streptomycinresistant 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

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. Vaccineinduced protection could be overwhelmed by extremely high doses of the tularemia 

bacteria. 
49

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 postexposure 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).
50

VIRAL AGENTS

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 timeconsuming. 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. 
51

SMALLPOX

SUMMARY

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. 
52

OVERVIEW

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

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

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.
53

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

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.
54

MEDICAL MANAGEMENT

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

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 
55

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.
56

VENEZUELAN EQUINE ENCEPHALITIS

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 (80oC for 30 min) and standard disinfectants. 
57

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 
58

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 (38oC-40.5oC), 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. 
59

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/mm3 (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 

(80C for 30 min) and standard disinfectants. 
60

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. 
61

VIRAL HEMORRHAGIC FEVERS

SUMMARY

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. 
62

OVERVIEW

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

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 rodentborne 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. 
63

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. Tickborne 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

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 Tcell 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. 
64

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

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
65

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 
66

Research Institute of Infectious Diseases (USAMRIID, Frederick, Maryland) have

diagnostic laboratories functioning at the highest (BL-4 or P-4) containment level.

MEDICAL MANAGEMENT

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.
67

PROPHYLAXIS

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).
68

ISOLATION AND CONTAINMENT

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.
69

BIOLOGICAL TOXINS

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.
70

BOTULINUM 

SUMMARY

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 

(80OC for 30 min., 100OC for several minutes) and chlorine (>99.7% inactivation by 3 

mg/L FAC in 20 min.) also destroy the toxin.
71

OVERVIEW

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

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

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. 
72

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 80OC and in several minutes at 100OC. 

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

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

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.
73

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

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 
74

antibody response due to the very small amount of toxin necessary to produce clinical 

symptoms.

MEDICAL MANAGEMENT

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
75

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

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

OC (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. 
76

RICIN

SUMMARY

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. 
77

OVERVIEW

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

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

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 (80OC for 10 

min., or 50OC 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). 
78

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

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

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

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. 
79

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

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

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. Preexposure Prophylaxis with such a vaccine is the most promising defense against a 

biological warfare attack with ricin.
80

STAPHYLOCOCCAL ENTEROTOXIN B

SUMMARY

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.
81

OVERVIEW

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

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

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 100OC. 

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

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 
82

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

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 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.
83

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

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

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).
84

T-2 MYCOTOXINS 

SUMMARY

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. 
85

OVERVIEW

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

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

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 1500o F for 30 minutes is 

required for inactivation. Hypochlorite solution alone is does not effectively inactivate the 
86

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

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

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

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. 
87

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

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

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. 
88

DETECTION

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 vehiclemounted 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.
89

PERSONAL PROTECTION

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 noncontaminated 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
90

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.
91

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.
92

DECONTAMINATION

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.
93

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.
94

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.
95

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.
96

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.
97

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.
98

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.
99

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.
100

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.
101

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. 
102

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.
103

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.
104

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.
105

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.
106

Appendix B: Patient Isolation Precautions

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

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.

Biothreat Diseases requiring Airborne Precautions: Smallpox.

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.

Biothreat Diseases requiring Droplet precautions: Pneumonic Plague.
107

Appendix B: Patient Isolation Precautions (continued)

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.

Biothreat Diseases requiring Contact Precautions: Viral Hemorrhagic Fevers.

For more information, see: Garner JS. Guideline for Infection Control Practices in 

Hospitals. Infect Control Hosp Epidemiol 1996;17:53-80.
108

Appendix C: BW Agent Characteristics

Disease Transmit 

Man to Man

Infective Dose

(Aerosol)

Incubation 

Period

Duration of Illness Lethality (approx. 

case fatality rates)

Persistence of Organism Vaccine Efficacy

(aerosol exposure)

Inhalation 

anthrax

No 8,000-50,000 

spores

1-6 days 3-5 days (usually 

fatal if untreated)

High Very stable - spores remain 

viable for > 40 years in soil

2 dose efficacy against up 

to 1,000 LD50 in monkeys

Brucellosis No 10 -100 

organisms

5-60 days 

(usually 1-2 

months)

Weeks to months <5% untreated Very stable No vaccine

Cholera Rare 10-500 organisms 4 hours -

5 days (usually 

2-3 days)

> 1 week Low with treatment, 

high without

Unstable in aerosols & fresh 

water; stable in salt water

No data on aerosol

Glanders Low Assumed low 10-14 days via 

aerosol

Death in 7-10 days 

in septicemic form

> 50% Very stable No vaccine

Pneumonic 

Plague

High 100-500 

organisms

2-3 days 1-6 days

(usually fatal)

High unless treated 

within 12-24 hours

For up to 1 year in soil; 270 days 

in live tissue

3 doses not protective 

against 118 LD50 in 

monkeys

Tularemia No 10-50 organisms 2-10 days 

(average 3-5)

> 2 weeks Moderate if 

untreated

For months in moist soil or other 

media

80% protection against 

1-10 LD50

Q Fever Rare 1-10 organisms 10-40 days 2-14 days Very low For months on wood and sand 94% protection against 

3,500 LD50 in guinea pigs

Smallpox High Assumed low

(10-100 

organisms)

7-17 days 

(average 12)

4 weeks High to moderate Very stable Vaccine protects against 

large doses in primates

Venezuelan 

Equine 

Encephalitis

Low 10-100 organisms 2-6 days Days to weeks Low Relatively unstable TC 83 protects against 30-

500 LD50 in hamsters

Viral

Hemorrhagic

Fevers

Moderate 1-10 organisms 4-21 days Death between 7-16 

days

High for Zaire 

strain, moderate 

with Sudan

Relatively unstable - depends on

agent

No vaccine

Botulism No 0.001 μg/kg is 

LD50 for type A

1-5 days Death in 24-72 

hours; lasts months 

if not lethal

High without 

respiratory support

For weeks in nonmoving water 

and food

3 dose efficacy 100% 

against 25-250 LD50 in 

primates

Staph 

Enterotoxin B

No 0.03 μg/person 

incapacitation

3-12 hours after 

inhalation

Hours < 1% Resistant to freezing No vaccine

Ricin No 3-5 μg/kg is LD50

in mice 

18-24 hours Days - death within 

10-12 days for 

ingestion

High Stable No vaccine

T-2 

Mycotoxins

No Moderate 2-4 hours Days to months Moderate For years at room temperature No vaccine
109

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

DISEASE VACCINE CHEMOTHERAPY (Rx) CHEMOPROPHYLAXIS (Px) COMMENTS

Anthrax Bioport vaccine (licensed) 

0.5 mL SC @ 0, 2, 4 wk, 6, 

12, 18 mo then annual 

boosters

Ciprofloxacin 400 mg IV q 12 h

 or

Doxycycline 200 mg IV, then 100 mg IV 

q 12 h

Ciprofloxacin 500 mg PO bid 

x 4 wk If unvaccinated, begin 

initial doses of vaccine

Potential alternates for Rx: gentamicin, 

erythromycin, and chloramphenicol

Penicillin 4 million units IV q 4 h Doxycycline 100 mg PO bid x 

4 wk plus vaccination

PCN for sensitive organisms only

Cholera Wyeth-Ayerst Vaccine 2 

doses 0.5 mL IM or SC @ 

0, 7-30 days, then boosters 

Q 6 months

Oral rehydration therapy during period 

of high fluid loss

NA Vaccine not recommended for routine protection in 

endemic areas (50% efficacy, short term)

Tetracycline 500 mg q 6 h x 3 d Alternates for Rx: erythromycin,

Doxycycline 300 mg once, or 100 mg q 

12 h x 3 d

trimethoprim and sulfamethoxazole, and 

furazolidone

Ciprofloxacin 500 mg q 12 h x 3 d Quinolones for tetra/doxy resistant strains

Norfloxacin 400 mg q 12 h x 3 d

Q Fever IND 610 - inactivated whole 

cell vaccine given as 

single 0.5 ml s.c. injection

Tetracycline 500 mg PO q 6 h x 5-7 d 

continued at least 2 d after afebrile

Tetracycline 500 mg PO qid x 

5 d (start 8-12 d postexposure)

Currently testing vaccine to determine the 

necessity of skin testing prior to use.

Doxycycline 100 mg PO q 12 h x 5-7 d 

continued at least 2 d after afebrile

Doxycycline 100 mg PO bid x 

5 d (start 8-12 d postexposure)

Glanders No vaccine available Antibiotic regimens vary depending 

on localization and severity of disease 

- refer to text

Post-exposure prophylaxis 

may be tried with TMP-SMX

No large therapeutic human trials have been 

conducted owing to the rarity of naturally 

occurring disease.

Plague Greer inactivated vaccine 

(FDA licensed) is no 

longer available.

Streptomycin 30 mg/kg/d IM in 2 

divided doses x 10 – 14 d 

 or

Gentamicin 5mg/kg IM or IV once daily 

x 10 - 14 d

 or

Ciprofloxacin 400mg IV q 12 h until 

clinically improved then 750 mg PO 

bid for total of 10 –14 d 

Doxycycline 100 mg PO bid x 

7 d or duration of exposure

Ciprofloxacin 500 mg PO bid 

x 7 d

Chloramphenicol for plague meningitis is required

25 mg/kg IV, then 15 mg/kg qid x 14 d

Doxycycline 200 mg IV then 100 mg IV 

bid, until clinically improved then 

100mg PO bid for total of 10-14 d

Tetracycline 500 mg PO qid x 

7 d

Alternate Rx: trimethoprim-sulfamethoxazole
110

DISEASE VACCINE CHEMOTHERAPY (Rx) CHEMOPROPHYLAXIS (Px) COMMENTS

Brucellosis No human vaccine 

available

Doxycycline 200 mg/d PO plus 

rifampin 600 mg/d PO x 6 wk

Doxycycline 200 mg/d PO 

plus rifampin 600 mg/d PO x 6 

wk

Trimethoprim-sulfamethoxazole may be 

substituted for rifampin; however, relapse may 

reach 30%

Ofloxacin 400/rifampin 600 mg/d PO x 

6 wks

Tularemia IND - Live attenuated 

vaccine: single 0.1ml dose 

by scarification

Streptomycin 7.5-10 mg/kg IM bid x 

10-14 d

Doxycycline 100 mg PO bid x 

14 d

Gentamicin 3-5 mg/kg/d IV x 10-14 d Tetracycline 500 mg PO qid x 

14 d

Ciprofloxacin 400 mg IV q 12h until 

improved, then 500 mg PO q 12 h for 

total of 10 - 14 d

Ciprofloxacin 500 mg PO q 12 

h for 14 d

Ciprofloxacin 750 mg PO q 12 h for 10 

- 14 d

Viral 

encephalitides

VEE DOD TC-83 live 

attenuated vaccine (IND):

0.5 mL SC x1 dose 

Supportive therapy: analgesics and 

anticonvulsants prn

NA TC-83 reactogenic in 20%

No seroconversion in 20%

Only effective against subtypes 1A, 1B, and 1C

VEE DOD C-84 (formalin 

inactivated TC-83) (IND): 

0.5 mL SC for up to 3 

doses

C-84 vaccine used for non-responders to TC-83

EEE inactivated (IND): 

 0.5 mL SC at 0 & 28 d

EEE and WEE inactivated vaccines are poorly

WEE inactivated (IND): 

0.5 mL SC at 0, 7, and 28 d

Immunogenic. Multiple immunizations are 

required

Viral 

Hemorrhagic 

Fevers

AHF Candid #1 vaccine 

(x-protection for BHF) 

(IND)

Ribavirin (CCHF/Lassa) (IND)

30 mg/kg IV initial dose; then

16 mg/kg IV q 6 h x 4 d; then

8 mg/kg IV q 8 h x 6 d

NA Aggressive supportive care and management of 

hypotension very important

RVF inactivated vaccine 

(IND)

Passive antibody for AHF, BHF, Lassa 

fever, and CCHF

Smallpox Wyeth calf lymph vaccinia 

vaccine (licensed): 1 

dose by scarification

No current Rx other than supportive; 

Cidofovir (effective in vitro); animal 

studies ongoing

Vaccinia immune globulin 0.6 

mL/kg IM (within 3 d of 

exposure, best within 24 h)

Pre and post exposure vaccination recommended 

if > 3 years since last vaccine
111

DISEASE VACCINE CHEMOTHERAPY (Rx) CHEMOPROPHYLAXIS (Px) COMMENTS

Botulism DOD pentavalent toxoid 

for serotypes A - E (IND): 

0.5 ml deep SC @ 0, 2 & 12 

wk, then yearly boosters

DOD heptavalent equine despeciated 

antitoxin for serotypes A-G (IND): 1 

vial (10 mL) IV

NA Skin test for hypersensitivity before equine

antitoxin administration

CDC trivalent equine antitoxin for 

serotypes A, B, E (licensed)

NA

Staphylococcus

Enterotoxin B

No vaccine available Ventilatory support for inhalation 

exposure

NA

Ricin No vaccine available Inhalation: supportive therapy

G-I : gastric lavage, superactivated 

charcoal, cathartics

NA

T-2 Mycotoxins No vaccine available Decontamination of clothing 

and skin
112

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” timeframes. 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 

• Clinical: samples from those individuals presenting with clinical symptoms

• Convalescent/Terminal/Postmortem: samples taken during convalescence, 

the terminal stages of infection or toxicosis or postmortem during autopsy

Shipping Samples: Most specimens sent rapidly (less than 24 h) to analytical labs 

require only blue or wet ice or refrigeration at 2 to 8C. 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: 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: 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).
113

Appendix E: Medical Sample Collection for Biological Threat Agents

Bacteria and Rickettsia

Early post-exposure Convalescent/ Clinical Terminal/Postmortem

Anthrax

Bacillus anthracis

0 – 24 h

Nasal and throat swabs, 

induced respiratory 

secretions for culture, FA, 

and PCR

24 to 72 h

Serum (TT, RT) for toxin 

assays Blood (E, C, H) for 

PCR. Blood (BC, C) for 

culture

3 to 10 days

Serum (TT, RT) for toxin 

assays Blood (BC, C) for 

culture. Pathology 

samples

Plague

Yersinia pestis

0 – 24 h

Nasal swabs, sputum, 

induced respiratory 

secretions for culture, FA, 

and PCR

24 – 72 h

Blood (BC, C) and bloody 

sputum for culture and FA 

(C), F-1 Antigen assays 

(TT, RT), PCR (E, C, H)

>6 days

Serum (TT, RT) for IgM 

later for IgG . Pathology 

samples

Tularemia

Francisella tularensis

0 – 24 h

Nasal swabs, sputum, 

induced respiratory 

secretions for culture, FA 

and PCR

24 – 72 h

Blood (BC, C) for culture

Blood (E, C, H) for PCR 

Sputum for FA & PCR

>6 days

Serum (TT, RT) for IgM 

and later IgG, agglutination 

titers. Pathology Samples

Glanders

Burkholderia mallei

0 – 24 h

Nasal swabs, sputum, 

induced respiratory 

secretions for culture and 

PCR.

24 – 72 h

Blood (BC, C) for culture

Blood (E, C, H) for PCR 

Sputum & drainage from 

skin lesions for PCR & 

culture.

>6 days

Blood (BC, C) and tissues 

for culture. Serum (TT, 

RT) for immunoassays. 

Pathology samples.

BC: Blood culture bottle

C: Citrated blood (3-ml)

E: EDTA (3-ml)

H: Heparin (3-ml)

TT: Tiger-top (5 – 10 ml)

RT: Red top if no TT
114

Appendix E: Medical Sample Collection for Biological Threat Agents

Bacteria and Rickettsia

Early post-exposure Convalescent/ Clinical Terminal/Postmortem

Brucellosis

Brucella abortus, suis, & 

melitensis

0 – 24 h

Nasal swabs, sputum, 

induced respiratory 

secretions for culture and 

PCR.

24 – 72 h

Blood (BC, C) for 

culture.

Blood (E, C, H) for PCR.

>6 days

Blood (BC, C) and tissues 

for culture. Serum (TT, 

RT) for immunoassays.

Pathology samples

Q-Fever

Coxiella burnetii

0 – 24 h

Nasal swabs, sputum, 

induced respiratory 

secretions for culture and 

PCR.

2 to 5 days

Blood (BC, C) for culture 

in eggs or mouse 

inoculation

Blood (E, C, H) for PCR. 

>6 days

Blood (BC, C) for culture in 

eggs or mouse inoculation

Pathology samples.

Botulism 

Botulinum toxin from 

Clostridium botulinum

0 – 24 h 

Nasal swabs, induced 

respiratory secretions for 

PCR (contaminating 

bacterial DNA) and toxin 

assays. Serum (TT, RT) 

for toxin assays

24 to 72 h 

Nasal swabs, respiratory 

secretions for PCR 

(contaminating bacterial 

DNA) and toxin assays.

>6 days 

Usually no IgM or IgG

Pathology samples (liver 

and spleen for toxin 

detection)

BC: Blood culture bottle

C: Citrated blood (3-ml)

E: EDTA (3-ml)

H: Heparin (3-ml)

TT: Tiger-top (5 – 10 ml)

RT: Red top if no TT
115

Appendix E: Medical Sample Collection for Biological Threat Agents

Bacteria and Rickettsia

Early post-exposure Convalescent/ Clinical Terminal/Postmortem

Ricin Intoxication

Ricin toxin from Castor 

beans

0 – 24 h 

Nasal swabs, induced 

respiratory secretions for 

PCR (contaminating castor 

bean DNA) and toxin 

assays.

Serum (TT) for toxin assays

36 to 48 h 

Serum (TT, RT) for toxin 

assay

Tissues for immunohistological stain in pathology 

samples.

>6 days 

Serum (TT, RT) for IgM 

and IgG in survivors

Staph enterotoxicosis

Staphylococcus Enterotoxin 

B

0 – 3 h 

Nasal swabs, induced 

respiratory secretions for 

PCR (contaminating 

bacterial DNA) and toxin 

assays.

Serum (TT, RT) for toxin 

assays

2 - 6 h 

Urine for immunoassays 

Nasal swabs, induced 

respiratory secretions for 

PCR (contaminating 

bacterial DNA) and toxin 

assays.

Serum (TT, RT) for toxin 

assays

>6 days 

Serum for IgM and IgG

T-2 toxicosis

0 – 24 h postexposure 

Nasal & throat swabs, 

induced respiratory 

secretions for 

immunoassays, HPLC/ 

mass spectrometry 

(HPLC/MS).

1 to 5 days

Serum (TT, RT), tissue for 

toxin detection

>6 days postexposure

Urine for detection of toxin 

metabolites

BC: Blood culture bottle

C: Citrated blood (3-ml)

E: EDTA (3-ml)

H: Heparin (3-ml)

TT: Tiger-top (5 – 10 ml)

RT: Red top if no TT
116

Appendix E: Medical Sample Collection for Biological Threat Agents

Bacteria and Rickettsia

Early post-exposure Convalescent/ Clinical Terminal/Postmortem

Equine Encephalmyelitis

VEE, EEE and WEE viruses

0 – 24 h

Nasal swabs & induced 

respiratory secretions for RTPCR and viral culture

24 to 72 h 

Serum & Throat swabs 

for culture (TT, RT), RTPCR (E, C, H, TT, RT) 

and Antigen ELISA (TT, 

RT), CSF, Throat swabs 

up to 5 days

>6 days 

Serum (TT, RT) for IgM

Pathology samples plus 

brain

Ebola

0 – 24 h

Nasal swabs & induced 

respiratory secretions for RTPCR and viral culture

2 to 5 days 

Serum (TT, RT) for viral 

culture

>6 days 

Serum (TT, RT) for viral 

culture. Pathology 

samples plus adrenal 

gland.

Pox (Small pox, monkey 

pox)

Orthopoxvirus

0 – 24 h

Nasal swabs & induced 

respiratory secretions for 

PCR and viral culture

2 to 5 days 

Serum (TT, RT) for viral 

culture

>6 days 

Serum (TT, RT) for viral 

culture. Drainage from 

skin lesions/ scrapings for 

microscopy, EM, viral 

culture, PCR. Pathology 

samples

BC: Blood culture bottle

C: Citrated blood (3-ml)

E: EDTA (3-ml)

H: Heparin (3-ml)

TT: Tiger-top (5 – 10 ml)

RT: Red top if no TT
117

Appendix F: Specimens for Laboratory Diagnosis

Agent

Face or 

Nasal 

Swab

Blood

Culture Smear

Acute & 

Convalescent 

Sera Stool Urine Other

Anthrax + + Pleural and 

CS Fluids

Mediastinal

+ +

(24-48 hrs 

after 

exposure)

- Cutaneous 

lesion 

aspirates

Brecellosis + + - + - - Bone marrow 

and spinal 

fluid cultures;

tissues, 

exudates

Cholera - - - + +

Plague + + Sputum + - - Bubo 

aspirate, 

CSF, sputum

Tuleremia + + +

2

+ - - Lesion 

scraping, 

Lymph nodes

Q-fever + 4 Lesions + Lung, spleen, 

lymph nodes,

Bone marrow

CongoCrimean 

Hemorrhagic 

Fever

+ 3 - + - - Liver

VEE + 3 - + - CSF

Clostridial 

Toxins

+ Wound 

tissues

+ + -

SEB Toxin + - - + + + Lung, kidney

Ricin Toxin + - - + + + Spleen, lung, 

kidney

1Within 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.

4C. burnetii can persist for days in blood and resists desiccation. EDTA anticoagulated blood preferred. 

Culturing should not be done except in BL3 containment.
118

Appendix G: BW Agent Lab Identification

 Immunoassays

Agent Gold Standard Antigen 

Detection

IgG IgM PCR Animals

Aflatoxins Mass spectrometry

Arboviruses (incl. 

Alphaviruses

Virus isolation/FA, 

neutralization

X X X X X

Bacillus anthracis FA/Std. Microbiology X (PA) X X X X

Bacillus globigii Std. Microbiology X

Bacillus thuringiensis Std. Microbiology X

Bot Toxins (A-G)/C. 

botulinum

Mouse neutralization/ 

standard microbiology

X (A,B,E Toxin) X X

Brucella sp. FA/Std. Microbiology X X X X X

C. burnetii FA/eggs or cell Cx/serology X X X X X

C. perfringens/toxins Std. Micro./ELISA (alpha

and enterotoxin

X X X

F. tularensis FA/Std. Microbiology X X X X X

Filoviruses Virus 

isolation/neutralization

X X X X X

Hantaviruses Virus isolation/ 

FA/neutralization

X X X X X

Orthopox Viruses Virus isolation/ 

FA/neutralization

X X X X

Ricin Toxin ELISA X X X X X

Saxitoxin Bioassay (neutralizing 

antibodies)

X

SEA Toxin ELISA X X *

SEB Toxin ELISA X X * X

Shigella sp. Std. Microbiology X X

Tetrodotoxins Bioassay X (neutralizing 

antibodies)

X

Vibrio cholerae Std. Microbiology/serology X(toxin) X X X

Yersinia pestis FA/Std. Microbiology X (F1) X X X X

______ 

*Toxin gene detected

ELISA - enzyme-linked immunosorbent assays

FA - indirect or direct immunofluorescence assays

Std. Micro./serology - standard microbiological techniques available, including electron microscopy
119

Appendix H: Differential Diagnosis of Chemical Nerve Agent, 

Botulinum Toxin and SEB Intoxication following 

Inhalation Exposure

Chemical Nerve Agent Botulinum Toxin SEB

Time to Symptoms Minutes Hours (12-24) Hours (1-6)

Nervous Convulsions

Muscle Twitching

Progressive paralysis Headache

Muscle Aches

Cardiovascular Slow heart rate Normal rate Normal or Rapid rate

Respiratory Difficult breathing

Airways constriction

Normal, then 

progressive paralysis

Nonproductive cough

Severe case: chest 

pain/difficult breathing

Gastrointestinal Increased motility,

Pain, diarrhea

Decreased motility Nausea, vomiting and/or 

diarrhea

Ocular Small pupils Droopy eyelids

Large pupils

May see “red eyes”

(conjuntival injection)

Salivary Profuse, watery 

Saliva

Normal

Difficulty swallowing

May be slightly 

increased quantities of 

saliva

Death Minutes 2-3 days Unlikely

Response to Atropine/ 

2-PAM Chloride

Yes No Atropine may reduce 

gastrointinal symptoms
120

Appendix I: Comparative Lethality of Selected Toxins & Chemical 

 Agents in Laboratory Mice

AGENT LD50 MOLECULAR SOURCE

(mg/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 (ED50~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
121

Appendix J. Aerosol Toxicity in LD50 vs. Quantity of Toxin

 

Aerosol toxicity in LD50 (see Appendix C) vs. quantity of toxin required to provide a 

theoretically effective open-air exposure, under ideal meteorological conditions, to an 

area 100 km2 . 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)

 kilogram metric ton

Ricin/ 

Saxitoxin

SEB toxin

Bot toxin

Moderately 

Toxic

Highly 

Toxic

Most 

Toxic

8 80 800 8 80 800 8000

2500

250

25

2.5

0.25

0.025

0.0025 .

Aerosol

Toxicity 

(ug/kg)

.

.

.
122

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 ChemicalBiological Defense Guidebook. Alexandria, Va; Jane’s Information Group; 

1999.
123

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:

www.nbc-med.org/SiteContent/MedRef/OnlineRef/GovDocs/BioWarfare

www.nbc-med.org/SiteContent/MedRef/OnlineRef/GovDocs/Anthrax

 www.nbc-med.org/SiteContent/MedRef/OnlineRef/GovDocs/BioAgents.html
124

www.nbc-med.org/SiteContent/MedRef/OnlineRef/GovDocs/SmallPox/index.htm

www.nbc-med.org/SiteContent/MedRef/OnlineRef/GovDocs/Viral/index.htm

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. 
125

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

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.
126

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.
127

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 feverUnited 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.
128

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, 6th 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.
129

Federal Bureau of Investigation (FBI) Field Offices

Revised FBI 1/5/99

FIELD OFFICE STREET ADDRESS ZIP 

CODE

TELEPHONE 

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 6th 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 8th 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 Blvd 28285 704/377-9200

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 9th 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, 26th Floor 48226 313/965-2323

El Paso, TX Suite 3000, 660 South Mesa Hills Drive 79912 915/832-5000

Honolulu, HI 300 Ala Moana Blvd., Room 4-230, Kalanianaole FOB 96850 808/521-1411

Houston, TX 2500 East T.C. Jester 77008 713/693-5000

Indianapolis, IN 575 N. Pennsylvania St., Room 679, FOB 46204 317/639-3301

Jackson, MS 100 W. Capitol Street, Suite 1553, FOB 39269 601/948-5000

Jacksonville, FL 7820 Arlington Expy, Suite 200 32211 904/721-1211

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. Charleston Blvd. 89104 702/385-1281

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 500 40202 502/583-3941

Memphis, TN 225 North Humphreys Blvd., Suite 3000, Eagle Crest 

Bldg.

38120 901/747-4300

Miami, FL 16320 NW 2nd 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, 3rd Floor, One St. Louis Centre 36602 334/438-3674

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, 

NY

26 Federal Plaza, 23rd Floor 10278 212/384-1000

Newark, NJ One Gateway Center, 22nd Floor 07102 973/622-5613

Norfolk, VA 150 Corporate Blvd. 23502 757/455-0100

Oklahoma City, 

OK

50 Penn Place, Suite 1600 73118 405/290-7770

Omaha, NE 10755 Burt Street 68114 402/493-8688

Philadelphia, PA 600 Arch Street, 8th Floor; William J. Green, Jr., FOB 19106 215/418-4000

Phoenix, AZ 201 E. Indianola Avenue, Suite 400 85012 602/279-5511
130

Pittsburgh, PA 700 Grant Street, Suite 300 USPO 15219 412/471-2000

Portland, OR 1500 S.W. 1st Avenue, Suite 400; Crown Plaza Bldg. 97201 503/224-4181

Richmond, VA 111 Greencourt Road 23228 804/261-1044

Sacramento, CA 4500 Orange Grove Avenue 95841 916/481-9110

Salt Lake City, 

UT

257 East 200 South, Suite 1200 84111 801/579-1400

San Antonio. TX 615 E. Houston Street, Suite 200; US Post Office & 

Courthouse Bldg.

78205 210/225-6741

San Diego, CA 9797 Aero Drive 92123 619/565-1255

San Francisco, 

CA

450 Golden Gate Avenue, 13th Floor 94102 415/553-7400

San Juan, PR 150 Carlos Chardon, Room 526; U.S. Federal Building, 

Hato Roy, PR

00918 787/754-6000

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, 

D.C.

601 4th Street, NW 20535 202/278-2000
131

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
132

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
133

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
134

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

Phone No. (801) 538-6111

Fax No. (801) 538-6306
135

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

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