Preparedness Against Biological Weapons: A Module for Nursing ...

Biological Weapons: Essential Biological Weapons: Essential Information on Category A AgentsInformation on Category A Agents

Felissa R. Lashley, RN, PhD, FAAN, FACMGFelissa R. Lashley, RN, PhD, FAAN, FACMGProfessor, College of Nursing, and Professor, College of Nursing, and

Interim Director, Nursing Center for Bioterrorism and Interim Director, Nursing Center for Bioterrorism and Infectious Disease PreparednessInfectious Disease Preparedness

College of NursingCollege of NursingRutgers, The State University of New JerseyRutgers, The State University of New Jersey

This module on the use of biological This module on the use of biological agents as bioweapons covers general agents as bioweapons covers general material, the classification of biological material, the classification of biological agents as to their use in bioterrorism and agents as to their use in bioterrorism and gives the most important information gives the most important information regarding the Category A Agents regarding the Category A Agents according to the Centers for Disease according to the Centers for Disease Control and Prevention (CDC) Control and Prevention (CDC) classification. Separate modules address classification. Separate modules address Category B and Category C agents. This Category B and Category C agents. This module was supported in part by USDHHS, module was supported in part by USDHHS, HRSA Grant No. T01HP01407.HRSA Grant No. T01HP01407.

The format and information in this moduleThe format and information in this modulefocuses on the use of the agent or outbreak of focuses on the use of the agent or outbreak of disease particularly in regard to bioterrorismdisease particularly in regard to bioterrorismincluding emphasis on management with including emphasis on management with nursing applications and infection controlnursing applications and infection controlmaterial. Detailed material on general material. Detailed material on general transmission of disease, infection control andtransmission of disease, infection control andisolation precautions is in a separate module isolation precautions is in a separate module and this should be consulted. Aspects ofand this should be consulted. Aspects ofpreparedness are also in a separate module.preparedness are also in a separate module.Note that for the care of persons exposed to Note that for the care of persons exposed to any biological agent, the nurse should be sure any biological agent, the nurse should be sure he/she is adequately protected he/she is adequately protected firstfirst..

ObjectivesObjectives

At the completion of this module, participantsAt the completion of this module, participantswill be able to:will be able to:1.1. Identify at least 10 factors that make a biological Identify at least 10 factors that make a biological

agent or biological toxin suitable for use as a agent or biological toxin suitable for use as a bioterror agent.bioterror agent.

2.2. List the 3 CDC categories for critical biological List the 3 CDC categories for critical biological agents and why they are so categorized.agents and why they are so categorized.

3.3. Identify and list CDC Category A biological agents Identify and list CDC Category A biological agents with potential for use in a bioterrorism attack.with potential for use in a bioterrorism attack.

4.4. Describe the signs and symptoms of infection with Describe the signs and symptoms of infection with Category A agents.Category A agents.

5.5. Discuss isolation precautions for each Category A Discuss isolation precautions for each Category A agent.agent.

Using Biological Agents as Using Biological Agents as BioweaponsBioweapons

Biological Agents and BioterrorismBiological Agents and Bioterrorism

Includes microorganisms, especially Includes microorganisms, especially certain bacteria and viruses, and biological certain bacteria and viruses, and biological toxins such as botulinum toxin, which act toxins such as botulinum toxin, which act like chemical agents.like chemical agents.

May be directed at humans, plants, May be directed at humans, plants, animals, and be a threat to crops, animals, and be a threat to crops, livestock, food products (agroterrorism) livestock, food products (agroterrorism) during processing, distribution, storage during processing, distribution, storage and transportation which could cause and transportation which could cause illness and also have severe economic illness and also have severe economic consequences such as bovine spongiform consequences such as bovine spongiform encephalopathy, and foot and mouth encephalopathy, and foot and mouth disease.disease.

Biological Agents and BioterrorismBiological Agents and Bioterrorism-2-2

Biological agents can be used as weapons Biological agents can be used as weapons in:in:• BiocrimesBiocrimes• BioterrorismBioterrorism• BiowarfareBiowarfare

Definition: North Atlantic Treaty Definition: North Atlantic Treaty Organization (NATO) defines a biological Organization (NATO) defines a biological weapon as “the provision of any infectious weapon as “the provision of any infectious agent or toxin by any means of delivery in agent or toxin by any means of delivery in order to cause harm to humans, animals, order to cause harm to humans, animals, or plants.”or plants.”


Various definitions for bioterrorism Various definitions for bioterrorism have been given. The following may have been given. The following may be used: “the intentional use or be used: “the intentional use or threat of use of biological agents on threat of use of biological agents on a population to achieve political, a population to achieve political, social, religious, ethnic, or ideological social, religious, ethnic, or ideological ends by causing illness, death and ends by causing illness, death and wide scale panic and disruption.” The wide scale panic and disruption.” The aim may not be maximum damage aim may not be maximum damage but rather a political statement.but rather a political statement.


The technology exists to modify existing The technology exists to modify existing biological agents, or weaponize them, to, biological agents, or weaponize them, to, for example, make it easier to disseminate for example, make it easier to disseminate and/or cause greater harm in their and/or cause greater harm in their dissemination.dissemination.

The use of biological agents for The use of biological agents for bioterrorism has been referred to as the bioterrorism has been referred to as the “poor man’s nuclear bomb.”“poor man’s nuclear bomb.”

All involve the use of biological agents in All involve the use of biological agents in order to obtain an outcome: political, order to obtain an outcome: political, social, economic, theological, personal.social, economic, theological, personal.

Agents with Potential for USE in Agents with Potential for USE in BIOTERRORISMBIOTERRORISM

Varies according to sourceVaries according to source NATO handbook lists 39 agentsNATO handbook lists 39 agents World Health Organization (WHO) has another listWorld Health Organization (WHO) has another list CDC lists biological agents in various categories, A, CDC lists biological agents in various categories, A,

B, and CB, and C National Institute for Allergy and Infectious Diseases National Institute for Allergy and Infectious Diseases

(NIAID), National Institutes of Health (NIH) also lists (NIAID), National Institutes of Health (NIH) also lists categories A, B, and C, but they differ somewhat categories A, B, and C, but they differ somewhat from how CDC categorizes agents and lists a greater from how CDC categorizes agents and lists a greater number of agentsnumber of agents

OthersOthers

The Following are Desirable Characteristics for The Following are Desirable Characteristics for Biological Agents to be Used for Harmful IntentBiological Agents to be Used for Harmful Intent

Generate high levels of panic among Generate high levels of panic among populationpopulation

Easy to obtainEasy to obtain InexpensiveInexpensive Easy to produce in mass quantitiesEasy to produce in mass quantities Can be relatively easily “weaponized” or Can be relatively easily “weaponized” or

altered for maximum effect (even with altered for maximum effect (even with genetic manipulation)genetic manipulation)

High infectivityHigh infectivity High person-to-person contagionHigh person-to-person contagion High mortalityHigh mortality

The Following are Desirable Characteristics for The Following are Desirable Characteristics for Biological Agents to be Used for Harmful Intent-Biological Agents to be Used for Harmful Intent-22

Lack of effective treatmentLack of effective treatment Need for intensive care, straining Need for intensive care, straining

resourcesresources High potential for casualties/morbidityHigh potential for casualties/morbidity Result in lengthy illness with prolonged Result in lengthy illness with prolonged

care neededcare needed Non-specific symptoms, especially early, Non-specific symptoms, especially early,

delaying recognitiondelaying recognition Long incubation periodsLong incubation periods Hard to diagnoseHard to diagnose Great degree of helplessness from effectGreat degree of helplessness from effect

Examples of Historical Uses of the Examples of Historical Uses of the Deliberate Release of Biological AgentsDeliberate Release of Biological Agents

Known as early as the 6Known as early as the 6thth century BC century BC Soldiers dropped corpses of those who Soldiers dropped corpses of those who

died of plague over city walls during siege died of plague over city walls during siege of Kaffa to start a plague epidemic and of Kaffa to start a plague epidemic and force surrender.force surrender.

British soldiers used variola contaminated British soldiers used variola contaminated blankets to spread smallpox to American blankets to spread smallpox to American Indians during the French and Indian Wars Indians during the French and Indian Wars (1754-1767).(1754-1767).

Examples of Historical Uses of the Examples of Historical Uses of the Deliberate Release of Biological AgentsDeliberate Release of Biological Agents-2-2

Followers of Bhagwan Shree Rajneesh Followers of Bhagwan Shree Rajneesh intentionally contaminated salad bars in intentionally contaminated salad bars in the The Dalles, Oregon with the The Dalles, Oregon with SalmonellaSalmonella. . The purpose was to keep people from The purpose was to keep people from voting in a local election in November, voting in a local election in November, 1984. More than 750 people were 1984. More than 750 people were affected.affected.

The Aum Shinrikyo group in Japan The Aum Shinrikyo group in Japan attempted to carry out attacks using attempted to carry out attacks using aerosolized anthrax spores and botulinum aerosolized anthrax spores and botulinum toxin before releasing sarin in the Tokyo toxin before releasing sarin in the Tokyo subway in 1995.subway in 1995.

Examples of Historical Uses of the Examples of Historical Uses of the Deliberate Release of Biological AgentsDeliberate Release of Biological Agents-3-3

Intentional distribution Intentional distribution of anthrax spores of anthrax spores mainly through the US mainly through the US mail to various people mail to various people occurred in the fall of occurred in the fall of 2001. In all, there were 2001. In all, there were 22 known cases of 22 known cases of anthrax; 11 were anthrax; 11 were inhalational.inhalational.

Picture from CDC. InhalationalPicture from CDC. Inhalationalanthrax.anthrax.

Categories of Critical Biological Categories of Critical Biological Agents as Specified by CDCAgents as Specified by CDC

Three Categories of Agents:Three Categories of Agents:• Category A Agents: Pose the greatest Category A Agents: Pose the greatest

threat to national securitythreat to national security• Category B Agents: Second highest Category B Agents: Second highest

priority to national security.priority to national security.• Category C Agents: Third highest priority Category C Agents: Third highest priority

agents include emerging pathogens that agents include emerging pathogens that could be engineered for mass could be engineered for mass dissemination in the future.dissemination in the future.

Category A AgentsCategory A Agents Pose a threat to national security Pose a threat to national security

because they:because they:• Can be easily disseminated or Can be easily disseminated or

transmitted person-to-persontransmitted person-to-person• Cause high mortality with potential for Cause high mortality with potential for

major public health impactmajor public health impact• Might cause public panic and social Might cause public panic and social

disruptiondisruption• Require special action for public health Require special action for public health

preparednesspreparedness

Category B AgentsCategory B Agents

Second highest priority to national Second highest priority to national security:security:• Are moderately easy to disseminateAre moderately easy to disseminate• Cause moderate morbidity and low Cause moderate morbidity and low

mortalitymortality• Require specific enhancements of CDC’s Require specific enhancements of CDC’s

diagnostic capacity and enhanced diagnostic capacity and enhanced disease surveillancedisease surveillance

Category C AgentsCategory C Agents

Third highest priority agents include Third highest priority agents include emerging pathogens that could be emerging pathogens that could be engineered for mass dissemination in engineered for mass dissemination in the future because of:the future because of:• AvailabilityAvailability• Ease of production and disseminationEase of production and dissemination• Potential for high morbidity and Potential for high morbidity and

mortality and major health impactmortality and major health impact

Category A AgentsCategory A Agents These agents include the following These agents include the following

diseases, with the organism in diseases, with the organism in parentheses. Discussion of each individual parentheses. Discussion of each individual organism listed below follows:organism listed below follows:• Anthrax (Anthrax (BacillusBacillus anthracisanthracis))• Botulism (Botulism (ClostridiumClostridium botulinumbotulinum))• Ebola hemorrhagic fever (Ebola virus)Ebola hemorrhagic fever (Ebola virus)• Lassa Fever (Lassa virus)Lassa Fever (Lassa virus)• Marburg hemorrhagic fever (Marburg virus)Marburg hemorrhagic fever (Marburg virus)• Plague (Plague (YersiniaYersinia pestispestis))• Smallpox (Variola virus)Smallpox (Variola virus)• Tularemia (Tularemia (FrancisellaFrancisella tularensistularensis))

Category A AgentsCategory A Agents-2-2

Other hemorrhagic fever viruses, such Other hemorrhagic fever viruses, such as:as:• Junin virus (Argentine hemorrhagic fever) Junin virus (Argentine hemorrhagic fever) • Guanarito virus (Venezuelan hemorrhagic Guanarito virus (Venezuelan hemorrhagic

fever)fever)• Machupo virus (Bolivian hemorrhagic Machupo virus (Bolivian hemorrhagic

fever)fever)• Sabia virus (Brazilian hemorrhagic fever)Sabia virus (Brazilian hemorrhagic fever)

Anthrax (Anthrax (BacillusBacillus anthracisanthracis))

Etiology:Etiology:• A gram-positive rod-like bacteria, A gram-positive rod-like bacteria, B.B.

anthracisanthracis• Capable of aerobic spore formationCapable of aerobic spore formation• Spores can last 40 years or moreSpores can last 40 years or more• Non-motileNon-motile• Forms capsuleForms capsule

AnthraxAnthrax-2-2

Description – Description – has several clinical types:has several clinical types: • Cutaneous (skin) anthrax most common.Cutaneous (skin) anthrax most common.• Gastrointestinal (GI) anthraxGastrointestinal (GI) anthrax

Rare in developed countriesRare in developed countries Results from infected meat that is undercooked or Results from infected meat that is undercooked or

rawraw Can affect oropharynx or esophagus, causing ulcersCan affect oropharynx or esophagus, causing ulcers

• Inhalational (respiratory) anthraxInhalational (respiratory) anthrax Abrupt respiratory distressAbrupt respiratory distress No person-to-person transmissionNo person-to-person transmission

Other names –Other names – • Was known as woolsorters or ragpickers Was known as woolsorters or ragpickers

disease.disease.

AnthraxAnthrax-3-3

Epidemiology:Epidemiology:• A zoonotic disease, primarily of animals such A zoonotic disease, primarily of animals such

as cattle, sheep, goats, deer and horses.as cattle, sheep, goats, deer and horses.• Worldwide there can be up to 100,000 cases Worldwide there can be up to 100,000 cases

per year. Most natural cases occur in the per year. Most natural cases occur in the Middle East, India, Asia, Africa and Latin Middle East, India, Asia, Africa and Latin America. Usually rare in the US and western America. Usually rare in the US and western Europe.Europe.

• Until the deliberate release of anthrax spores Until the deliberate release of anthrax spores in the US in 2001, inhalational anthrax had not in the US in 2001, inhalational anthrax had not been reported in the US for more than 20 been reported in the US for more than 20 years. In 2001, 22 cases of human anthrax years. In 2001, 22 cases of human anthrax were reported in the US, 2 in 2002, none in were reported in the US, 2 in 2002, none in 2003, 2004, and 2005, 1 in 2006, and none in 2003, 2004, and 2005, 1 in 2006, and none in 2007.2007.

AnthraxAnthrax-4-4

Transmission:Transmission:• Animals become infected through ingestion of spores in Animals become infected through ingestion of spores in

soil which germinate and produce toxins.soil which germinate and produce toxins.• Humans usually contract anthrax from contact with Humans usually contract anthrax from contact with

anthrax infected animals or contaminated animal hair, anthrax infected animals or contaminated animal hair, hides, flax, wool, excretions, blood and products such as hides, flax, wool, excretions, blood and products such as bone meal.bone meal.

• Direct contact from infected person’s skin lesions.Direct contact from infected person’s skin lesions.• Inhalational anthrax is acquired by inhaling aerosolized Inhalational anthrax is acquired by inhaling aerosolized

spores.spores.• Gastrointestinal anthrax results from eating Gastrointestinal anthrax results from eating

undercooked or raw meat or dairy products from undercooked or raw meat or dairy products from infected animals.infected animals.

• Inhalational and gastrointestinal anthrax are not known Inhalational and gastrointestinal anthrax are not known to be transmitted person-to-person.to be transmitted person-to-person.

• Humans may also become infected through intentional Humans may also become infected through intentional exposure.exposure.

AnthraxAnthrax-5-5

Transmission cont.:Transmission cont.:• Occupational exposure in humans has been Occupational exposure in humans has been

the most usual way in which anthrax was the most usual way in which anthrax was acquired.acquired.

• Examples include farm workers, laboratory Examples include farm workers, laboratory workers or industrial exposure (see below).workers or industrial exposure (see below).

• Cutaneous and inhalational anthrax cases Cutaneous and inhalational anthrax cases formerly occurred during the manufacturing formerly occurred during the manufacturing process of infected wool, hair and hides. In process of infected wool, hair and hides. In 2006, one case occurred in a man who 2006, one case occurred in a man who acquired the disease from an infected animal acquired the disease from an infected animal hide he brought back from Africa to make hide he brought back from Africa to make drums.drums.

AnthraxAnthrax-6-6

Incubation period:Incubation period:• Cutaneous anthrax: a few hours to 12 Cutaneous anthrax: a few hours to 12

daysdays• Gastrointestinal anthrax: 1 to 7 daysGastrointestinal anthrax: 1 to 7 days• Inhalational anthrax: Less than 7 days Inhalational anthrax: Less than 7 days

(usually 4-6 days) but up to 2 months.(usually 4-6 days) but up to 2 months.

AnthraxAnthrax-7-7

Clinical manifestations:Clinical manifestations:• Cutaneous anthraxCutaneous anthrax

Local response is itching followed by small Local response is itching followed by small red macule progressing to papule formation red macule progressing to papule formation (3-5 days usual), resembling an insect bite.(3-5 days usual), resembling an insect bite.

This becomes a vesicle with a painless ulcer This becomes a vesicle with a painless ulcer formation that may enlarge to 1 to 3 cm.formation that may enlarge to 1 to 3 cm.

Black eschar develops within 7-10 days with Black eschar develops within 7-10 days with surrounding edema. surrounding edema.

Typically seen on arms, hands, head or Typically seen on arms, hands, head or neck. neck.

May also have lymphadenitis and fever, May also have lymphadenitis and fever, malaise and headache.malaise and headache.

Septicemia can occur.Septicemia can occur.

Cutaneous AnthraxCutaneous Anthrax(Notice the edema and typical lesions)(Notice the edema and typical lesions)

Photos from CDC.Photos from CDC.

Notice the edema and typical lesions

Further examples of Cutaneous Further examples of Cutaneous Anthrax lesionsAnthrax lesions Photos from CDC. Photos from CDC.

Ulcer and vesicle ring

Black eschar, redness remains

AnthraxAnthrax-8-8

Clinical manifestations cont.:Clinical manifestations cont.:• Gastrointestinal anthraxGastrointestinal anthrax

Symptoms initially are nausea, vomiting, Symptoms initially are nausea, vomiting, anorexia, fever, followed by abdominal pain, anorexia, fever, followed by abdominal pain, hematemesis and bloody diarrhea.hematemesis and bloody diarrhea.

Symptoms depend on site of lesions.Symptoms depend on site of lesions. If there are lesions in oral pharynx, may If there are lesions in oral pharynx, may

swell to affect the airway, and there may be swell to affect the airway, and there may be dysphagia and throat pain.dysphagia and throat pain.

In gastrointestinal anthrax, ascites may In gastrointestinal anthrax, ascites may develop as may septicemia within 5 days develop as may septicemia within 5 days after onset.after onset.

AnthraxAnthrax-9-9

Clinical manifestations cont.:Clinical manifestations cont.:• Inhalational anthraxInhalational anthrax

There are usually two phases.There are usually two phases. Initial symptoms are nonspecific and consist of Initial symptoms are nonspecific and consist of

malaise, low grade fever, nonproductive cough and malaise, low grade fever, nonproductive cough and gastrointestinal complaints such as nausea and/or gastrointestinal complaints such as nausea and/or vomiting.vomiting.

Sometimes there is improvement for a few days Sometimes there is improvement for a few days followed by a second phase with dry cough, dyspnea, followed by a second phase with dry cough, dyspnea, high fever, chills, diaphoresis, tachypnea and high fever, chills, diaphoresis, tachypnea and respiratory distress.respiratory distress.

Bacteria enter the blood causing bacteremia, and Bacteria enter the blood causing bacteremia, and seeding of the meninges and gastrointestinal tract.seeding of the meninges and gastrointestinal tract.

Abdominal pain, hematemesis, melena, cyanosis, Abdominal pain, hematemesis, melena, cyanosis, confusion and hemorrhagic, purulent meningitis confusion and hemorrhagic, purulent meningitis develop.develop.

AnthraxAnthrax-10-10

Clinical manifestations cont.:Clinical manifestations cont.:• Inhalational anthrax cont. –Inhalational anthrax cont. –

Meningitis occurs in about 50%.Meningitis occurs in about 50%. Cardiovascular collapse and death follow if Cardiovascular collapse and death follow if

untreated.untreated. Because early symptoms are non-specific, Because early symptoms are non-specific,

the presence of nausea and vomiting and the presence of nausea and vomiting and neurological symptoms help to differentiate neurological symptoms help to differentiate it from other disorders and a widened it from other disorders and a widened mediastinum on x-ray is suggestive of mediastinum on x-ray is suggestive of inhalational anthrax.inhalational anthrax.

Inhalational AnthraxInhalational Anthrax

Mediastinal widening and pleural effusion on Chest X-Ray in inhalational anthrax


Diagnosis:Diagnosis:• For all, blood cultures may be done if For all, blood cultures may be done if

organism has spread.organism has spread.• Lab may do rapid screening followed by Lab may do rapid screening followed by

confirmatory testing.confirmatory testing.• Combine lab testing with clinical Combine lab testing with clinical

findings.findings.


Diagnosis cont.:Diagnosis cont.:• Cutaneous –Cutaneous –

Gram stain, PCR, culture of exudate or escharGram stain, PCR, culture of exudate or eschar Should be done before antibiotic therapyShould be done before antibiotic therapy

• Gastrointestinal –Gastrointestinal – Blood culturesBlood cultures Oropharyngeal swabsOropharyngeal swabs

• Inhalational –Inhalational – Chest x-ray findings especially widened mediastinum, Chest x-ray findings especially widened mediastinum,

pleural effusions, and pulmonary congestionpleural effusions, and pulmonary congestion Tissue biopsyTissue biopsy Fluid for gram stain, PCR or culture if from sterile siteFluid for gram stain, PCR or culture if from sterile site


Mortality:Mortality:• Cutaneous - if untreated can be 10%-Cutaneous - if untreated can be 10%-

20%, less than 1% with treatment20%, less than 1% with treatment• Gastrointestinal - depends on site, 25%-Gastrointestinal - depends on site, 25%-

60%60%• Inhalation - mortality can be 45%-97% Inhalation - mortality can be 45%-97%

with antibiotic therapy. The case fatality with antibiotic therapy. The case fatality rate may be as high as 75%.rate may be as high as 75%.


Treatment:Treatment:• Cutaneous anthrax – Cutaneous anthrax –

Initial therapy in adults is usually ciprofloxacin or Initial therapy in adults is usually ciprofloxacin or doxycycline; in children both are also used, although doxycycline; in children both are also used, although care must be taken in children as doxycycline may care must be taken in children as doxycycline may discolor teeth. discolor teeth.

Therapy may be oral.Therapy may be oral.• Inhalational anthrax – Inhalational anthrax –

For adults and children, ciprofloxacin or doxycycline For adults and children, ciprofloxacin or doxycycline are used with one or two additional antimicrobials.are used with one or two additional antimicrobials.

Initial therapy is IV, switching to oral therapy when Initial therapy is IV, switching to oral therapy when appropriate.appropriate.

Therapy may be as long as 60 days.Therapy may be as long as 60 days. Therapy may be combined with a 3 dose regimen of Therapy may be combined with a 3 dose regimen of

anthrax vaccine for prophylaxis.anthrax vaccine for prophylaxis.


Treatment cont.:Treatment cont.:• Gastrointestinal anthrax – Gastrointestinal anthrax –

May be treated with the same antibiotic regimens as May be treated with the same antibiotic regimens as inhalation because of potential to spread to inhalation because of potential to spread to respiratory tract.respiratory tract.

• Note: Post-exposure prophylaxis may be given Note: Post-exposure prophylaxis may be given to those exposed to an initial release of to those exposed to an initial release of anthrax as soon as possible after exposure. anthrax as soon as possible after exposure. This is usually administered orally for 60 days This is usually administered orally for 60 days with ciprofloxacin and doxycycline being the with ciprofloxacin and doxycycline being the most desired followed by amoxicillin which is most desired followed by amoxicillin which is preferred for pregnant women. If organism is preferred for pregnant women. If organism is susceptible, children may also be switched to susceptible, children may also be switched to amoxicillin.amoxicillin.


Nursing considerations:Nursing considerations:• Be sure decontamination has taken place.Be sure decontamination has taken place.• Appropriate isolation precautions.Appropriate isolation precautions.• Supportive care as needed for symptoms.Supportive care as needed for symptoms.• If associated with intentional release, psychosocial If associated with intentional release, psychosocial

support/therapy is needed.support/therapy is needed.• In analysis of survivors of fall 2001 anthrax release, a In analysis of survivors of fall 2001 anthrax release, a

year later survivors had reported lower health-related year later survivors had reported lower health-related quality of life and greater overall psychological distress. quality of life and greater overall psychological distress. Those who had inhalation anthrax reported loss of Those who had inhalation anthrax reported loss of functional capacity, and some still had respiratory functional capacity, and some still had respiratory abnormalities.abnormalities.

• Adherence may be an issue for persons on long-term Adherence may be an issue for persons on long-term antimicrobial therapy and nurses should plan to address antimicrobial therapy and nurses should plan to address this.this.


Isolation Precautions:Isolation Precautions:• Cutaneous anthrax – Standard and the Cutaneous anthrax – Standard and the

transmission based contact precautions. Avoid transmission based contact precautions. Avoid any contact with skin lesions or drainage.any contact with skin lesions or drainage.

• Inhalational anthrax – Both standard and Inhalational anthrax – Both standard and contact precautions have been recommended contact precautions have been recommended in addition to respurology N95 mask or PAPR & in addition to respurology N95 mask or PAPR & protective clothing for environmental aerolized protective clothing for environmental aerolized powder on person.powder on person.

• Gastrointestinal anthrax – Standard Gastrointestinal anthrax – Standard precautions.precautions.


Vaccine:Vaccine:• Multidose vaccine available but currently used for special Multidose vaccine available but currently used for special

populations such as the military.populations such as the military.• Both live cellular and live acellular vaccines are available. Both live cellular and live acellular vaccines are available.

Recombinant vaccines are in development.Recombinant vaccines are in development. Other:Other:

• Persons known to be exposed to anthrax spores should Persons known to be exposed to anthrax spores should remove clothing and shoes and leave at worksite and wash remove clothing and shoes and leave at worksite and wash exposed skin including any jewelry and glasses.exposed skin including any jewelry and glasses.

• Removed clothing should be bagged.Removed clothing should be bagged.• At home, systematic showering with systematic cleaning At home, systematic showering with systematic cleaning

from hair down should be done if at risk for higher from hair down should be done if at risk for higher contamination.contamination.

• Care needs to be taken when removing outer clothing to Care needs to be taken when removing outer clothing to keep inner clothing from being contaminated.keep inner clothing from being contaminated.

• Biosafety level 2 handling.Biosafety level 2 handling.

Anthrax – Special Considerations Anthrax – Special Considerations Re: BioterrorismRe: Bioterrorism

Anthrax is considered one of the most Anthrax is considered one of the most important biological agents with potential important biological agents with potential for use as a bioterror agent.for use as a bioterror agent.• It can be weaponized in an aerosolized stable It can be weaponized in an aerosolized stable

spore form.spore form.• One deep breath at the site of intentional One deep breath at the site of intentional

release can result in inhalational anthrax with release can result in inhalational anthrax with high mortality.high mortality.

• Environmental surveillance and assessment is Environmental surveillance and assessment is needed.needed.

• Decontamination procedures are needed.Decontamination procedures are needed.

Anthrax – Special Considerations Anthrax – Special Considerations Re: BioterrorismRe: Bioterrorism-2-2

Anthrax potential for use as bioterror Anthrax potential for use as bioterror agent cont.:agent cont.:• Pre-exposure immunization available for Pre-exposure immunization available for

defined population segments.defined population segments.• If anthrax is suspected, one part of the patient If anthrax is suspected, one part of the patient

assessment is to assess whether there is an assessment is to assess whether there is an epidemiological linkage to a plausible epidemiological linkage to a plausible environmental exposure such as through the environmental exposure such as through the person’s occupation.person’s occupation.

• Antimicrobial prophylaxis will be used for Antimicrobial prophylaxis will be used for persons potentially exposed to anthrax. In persons potentially exposed to anthrax. In those who are demonstrated not to be those who are demonstrated not to be exposed, prophylaxis can be discontinued. For exposed, prophylaxis can be discontinued. For others, this will be continued for about 60 others, this will be continued for about 60 days.days.

BotulismBotulism(Clostridium(Clostridium botulinumbotulinum toxin) toxin)

Etiology:Etiology:• Toxin from Toxin from ClostridiumClostridium botulismbotulism, a spore- , a spore-

forming bacillus. forming bacillus. • Seven known types cause disease.Seven known types cause disease.• These toxins are potent neurotoxins.These toxins are potent neurotoxins.• Toxin prevents acetylcholine release and Toxin prevents acetylcholine release and

blocks neuromuscular transmission, blocks neuromuscular transmission, presynaptic inhibition affecting autonomic and presynaptic inhibition affecting autonomic and motor receptors.motor receptors.

• Minute quantities of botulinum toxins can Minute quantities of botulinum toxins can cause death, as they are extremely poisonous.cause death, as they are extremely poisonous.

• Infective dose: 0.001 micrograms.Infective dose: 0.001 micrograms.

BotulismBotulism-2-2

Types:Types:• Foodborne – most commonFoodborne – most common• WoundWound• InfantInfant• Inhalational - rare, may be intentionalInhalational - rare, may be intentional

Incubation period: For foodborne botulism: Incubation period: For foodborne botulism: 18-36 hours usual but can be 6 hours to 10 18-36 hours usual but can be 6 hours to 10 days.days.

Incubation period for inhalation botulism is Incubation period for inhalation botulism is 24-72 hours after exposure.24-72 hours after exposure.


Epidemiology:Epidemiology:• Most cases of foodborne botulism occur Most cases of foodborne botulism occur

through improperly canned or prepared foods through improperly canned or prepared foods especially those that are of low acidity such as especially those that are of low acidity such as corn, beans, tomato sauce.corn, beans, tomato sauce.

• Improperly heated and stored sauteed onions Improperly heated and stored sauteed onions were the cause of one outbreak in Peoria, were the cause of one outbreak in Peoria, Illinois.Illinois.

• Botulinum toxins have been weaponized to be Botulinum toxins have been weaponized to be delivered by aerosol means.delivered by aerosol means.

• Wound and infant botulism are not discussed Wound and infant botulism are not discussed here.here.


Transmission:Transmission:• Ingestion, Ingestion,

inhalation (in inhalation (in deliberate release deliberate release situation) or situation) or absorption. absorption.

• Not transmissable Not transmissable from person-to- from person-to- person.person.


Clinical manifestations:Clinical manifestations:• Blurred visionBlurred vision• Dilated pupilsDilated pupils• DiplopiaDiplopia• PtosisPtosis• Dry mouth, and Dry mouth, and • PhotophobiaPhotophobia• These may be followed by:These may be followed by:

DysarthriaDysarthria DysphagiaDysphagia DysphoniaDysphonia Generalized weakness, andGeneralized weakness, and A symmetrical descending progressive paralysis A symmetrical descending progressive paralysis

leading to respiratory failure.leading to respiratory failure.


Clinical manifestations cont.:Clinical manifestations cont.:• Cranial nerve palsies are responsible for Cranial nerve palsies are responsible for

symptoms, such as difficulty in speaking symptoms, such as difficulty in speaking or swallowing.or swallowing.

• Symptoms such as constipation and Symptoms such as constipation and urinary retention may be seen and urinary retention may be seen and nausea and vomiting may be present.nausea and vomiting may be present.

• Patients are usually alert and afebrile.Patients are usually alert and afebrile.


Diagnosis:Diagnosis:• By detection of By detection of

toxin in serum, toxin in serum, stools or gastric stools or gastric secretions.secretions.


Treatment:Treatment:• Important to recognize botulism early and Important to recognize botulism early and

administer botulism antitoxin as soon as administer botulism antitoxin as soon as possible to neutralize the circulating toxin or possible to neutralize the circulating toxin or progression will continue to occur. progression will continue to occur.

• Antitoxin does not reverse paralysis but limits Antitoxin does not reverse paralysis but limits it.it.

• In cases of aerosol exposure, the antitoxin is In cases of aerosol exposure, the antitoxin is effective before clinical symptoms are present effective before clinical symptoms are present but if given later will not prevent respiratory but if given later will not prevent respiratory failure.failure.

Botulism-Botulism-99

Treatment cont.:Treatment cont.:• Full recovery can take a long time—months--as Full recovery can take a long time—months--as

presynaptic axons regenerate and new presynaptic axons regenerate and new synapses are formed.synapses are formed.

• In the botulism outbreak in Peoria in the 1980s, In the botulism outbreak in Peoria in the 1980s, symptoms such as fatigue, headache, and symptoms such as fatigue, headache, and weakness lasted for years.weakness lasted for years.

• Therapy includes rapid administration of Therapy includes rapid administration of botulism antitoxin, monitoring of vital capacity botulism antitoxin, monitoring of vital capacity to institute rapid ventilatory support when vital to institute rapid ventilatory support when vital capacity falls below 12 ml/kg.capacity falls below 12 ml/kg.


Nursing considerations:Nursing considerations:• Use of standard precautionsUse of standard precautions• Isolation room not requiredIsolation room not required• Observe for possible respiratory distress which Observe for possible respiratory distress which

can occur rapidlycan occur rapidly• Assist patient with communication if on a Assist patient with communication if on a

mechanical ventilatormechanical ventilator• Prevent nosocomial infections through use of Prevent nosocomial infections through use of

good hygienegood hygiene• Prevent deep vein thromboses (DVT)Prevent deep vein thromboses (DVT)• Give appropriate bowel and bladder careGive appropriate bowel and bladder care


Nursing considerations cont.:Nursing considerations cont.:• May need extensive rehabilitation for May need extensive rehabilitation for

swallowing, speech, muscle strength and so swallowing, speech, muscle strength and so on.on.

• Address psychosocial issues and fears Address psychosocial issues and fears associated with the progressive paralysis and associated with the progressive paralysis and loss of voluntary movement and speech.loss of voluntary movement and speech.

• CDC recommends decontamination of patients CDC recommends decontamination of patients and their clothing with soap and water if and their clothing with soap and water if exposed to aerosolized botulism toxins and exposed to aerosolized botulism toxins and decontamination of exposed surfaces by decontamination of exposed surfaces by cleaning with a bleach solution.cleaning with a bleach solution.


Other:Other:• In case of use in bioterrorism, resources such In case of use in bioterrorism, resources such

as ventilatory support (which may be needed as ventilatory support (which may be needed in the long term) and supportive intensive care in the long term) and supportive intensive care services would be overwhelmed, as would the services would be overwhelmed, as would the availability of antitoxin.availability of antitoxin.

Prevention:Prevention:• Pre-exposure vaccination with toxoid is Pre-exposure vaccination with toxoid is

available for military personnel and laboratory available for military personnel and laboratory workers at high risk of exposure.workers at high risk of exposure.

• Development of recombinant toxoid vaccines Development of recombinant toxoid vaccines for wider use is underway.for wider use is underway.

Ebola Hemorrhagic Fever Ebola Hemorrhagic Fever (Ebola virus)(Ebola virus)

Etiology:Etiology:• Ebola virus, a rod-shaped RNA Ebola virus, a rod-shaped RNA

virus in the filovirus family. virus in the filovirus family. • Changes shape rapidly.Changes shape rapidly.• The filamentous form is The filamentous form is

associated with high infectivity. associated with high infectivity. • Has 4 (possibly 5 )Has 4 (possibly 5 )

subtypes to date:subtypes to date: ZaireZaire SudanSudan RestonReston Cote d’Ivoire (Ivory Coast)Cote d’Ivoire (Ivory Coast) A possible new subtype A possible new subtype

responsible for the outbreak in responsible for the outbreak in Uganda in 2007-8Uganda in 2007-8

Picture from CDCPicture from CDC

EbolaEbola-2-2

Description:Description:• Is a viral hemorrhagic fever caused by the Is a viral hemorrhagic fever caused by the

Ebola virus.Ebola virus.

Epidemiology:Epidemiology:• Ebola virus occurs naturally in Africa.Ebola virus occurs naturally in Africa.• While subclinical infections have been noted, While subclinical infections have been noted,

typically Ebola hemorrhagic fever emerges in typically Ebola hemorrhagic fever emerges in sporadic outbreaks.sporadic outbreaks.

• Outbreaks have been reported in the Outbreaks have been reported in the Democratic Republic of the Congo, Gabon, Democratic Republic of the Congo, Gabon, Sudan, the Ivory Coast, Uganda and Republic Sudan, the Ivory Coast, Uganda and Republic of the Congo.of the Congo.

EbolaEbola-3-3

Epidemiology cont.:Epidemiology cont.:• First outbreaks First outbreaks

recognized in 1976 in recognized in 1976 in Sudan and in Zaire, now Sudan and in Zaire, now part of the Democratic part of the Democratic Republic of the Congo.Republic of the Congo.

• It is believed to be a It is believed to be a zoonotic virus normally zoonotic virus normally maintained by a natural maintained by a natural host native to Africa.host native to Africa.

Photo from CDC.Photo from CDC.

EbolaEbola-4-4

Epidemiology cont.:Epidemiology cont.:• The natural reservoir for Ebola virus is not known, but it The natural reservoir for Ebola virus is not known, but it

is believed that human outbreaks occur when a person is believed that human outbreaks occur when a person is exposed to an infected animal. Fruit bats have been is exposed to an infected animal. Fruit bats have been suggested as having a role.suggested as having a role.

• Outbreaks also occur among gorillas and chimpanzees.Outbreaks also occur among gorillas and chimpanzees.• Ebola-Reston occurred in infected monkeys in the Ebola-Reston occurred in infected monkeys in the

Phillipines, but is not known if Ebola is also native to Asia Phillipines, but is not known if Ebola is also native to Asia since there have not been other recognized outbreaks since there have not been other recognized outbreaks there.there.

• The most recent reported outbreaks are in The The most recent reported outbreaks are in The Democratic Republic of the Congo (2007) and Uganda Democratic Republic of the Congo (2007) and Uganda (2007-2008)(2007-2008)

• The outbreak in Uganda is believed due to a previously The outbreak in Uganda is believed due to a previously unknown subtype with a lower mortality rate.unknown subtype with a lower mortality rate.

EbolaEbola-5-5

Transmission:Transmission:• Person-to-person spread may occur when a person Person-to-person spread may occur when a person

comes into contact with infected blood, tissues, comes into contact with infected blood, tissues, secretions, or excretions of another person.secretions, or excretions of another person.

• Infection may also occur through contact with Infection may also occur through contact with contaminated objects.contaminated objects.

• Infection may further occur in hospitals or health care Infection may further occur in hospitals or health care settings through: settings through:

The use of contaminated medical equipment, such as The use of contaminated medical equipment, such as reused needles and syringes,reused needles and syringes,

Contaminated multivials of medicine, and/orContaminated multivials of medicine, and/or Lack of appropriate infection control.Lack of appropriate infection control.

• Traditional burial ceremonies involving contact with the Traditional burial ceremonies involving contact with the infected corpse may spread Ebola virus.infected corpse may spread Ebola virus.

• Handling of infected wild animal carcasses, such as Handling of infected wild animal carcasses, such as chimpanzees, gorillas and duikers, including food chimpanzees, gorillas and duikers, including food preparation activities.preparation activities.

EbolaEbola-6-6

Incubation period: Incubation period: 2 to 21 days.2 to 21 days. Clinical manifestations:Clinical manifestations:

• Asymptomatic infection may occur.Asymptomatic infection may occur.• In most cases, the onset of illness is abrupt In most cases, the onset of illness is abrupt

with fever, headache, myalgia, weakness, with fever, headache, myalgia, weakness, malaise and pharyngitis.malaise and pharyngitis.

• These may be followed by nausea, diarrhea These may be followed by nausea, diarrhea and vomiting as well as stomach pain.and vomiting as well as stomach pain.

• A maculopapular rash may appear around the A maculopapular rash may appear around the 55thth day and desquamation can occur. day and desquamation can occur.

• Conjunctival injection, hiccups, and Conjunctival injection, hiccups, and hemorrhage from orifices as well as petechiae hemorrhage from orifices as well as petechiae and ecchymoses may be seen.and ecchymoses may be seen.

• Blindness can occur.Blindness can occur.• Obtunding may occur.Obtunding may occur.

EbolaEbola-7-7

Diagnosis:Diagnosis:• By antigen-capture enzyme-linked By antigen-capture enzyme-linked

immunosorbent assay (ELISA), IgM immunosorbent assay (ELISA), IgM ELISA, polymerase chain reaction (PCR), ELISA, polymerase chain reaction (PCR), and virus isolation.and virus isolation.

Mortality:Mortality:• The mortality rate is high, usually 25% The mortality rate is high, usually 25%

to 90%.to 90%.

EbolaEbola-8-8

Treatment:Treatment:• SupportiveSupportive

This may include maintenance of appropriate fluid This may include maintenance of appropriate fluid and electrolytes, oxygenation and blood pressure, and electrolytes, oxygenation and blood pressure, and treating complications promptly.and treating complications promptly.

Immune plasma from convalescent patients has been Immune plasma from convalescent patients has been used in some instances.used in some instances.

Nursing considerations:Nursing considerations:• Limit number of staff approaching patient, use Limit number of staff approaching patient, use

mask, gown, gloves, goggles, leg coverings, mask, gown, gloves, goggles, leg coverings, and shoe coverings.and shoe coverings.

• Be sure health care staff understands the Be sure health care staff understands the infection control procedures in use.infection control procedures in use.

• Prevent other cases by preventing nosocomial Prevent other cases by preventing nosocomial transmission, including to health care staff.transmission, including to health care staff.

EbolaEbola-9-9

Nursing considerations cont.:Nursing considerations cont.:• Appropriate infection control critical.Appropriate infection control critical.• Should use immediate isolation of suspected case with Should use immediate isolation of suspected case with

airborne and contact precautions, as well as standard airborne and contact precautions, as well as standard precautions and barrier nursing.precautions and barrier nursing.

• Because of the severity of the disease, many Because of the severity of the disease, many practitioners in the field use double masks, gowns, practitioners in the field use double masks, gowns, gloves and so on in implementing precautions.gloves and so on in implementing precautions.

• Individual room with negative air pressure.Individual room with negative air pressure.• In places where no negative pressure isolation rooms In places where no negative pressure isolation rooms

exist, the patient should be put in a private room with a exist, the patient should be put in a private room with a HEPA filtration unit.HEPA filtration unit.

• Limit unnecessary blood draws and other procedures.Limit unnecessary blood draws and other procedures.• Use N95 or higher respirators for aerosol generating Use N95 or higher respirators for aerosol generating

procedures in settings where AIIRs are unavailable.procedures in settings where AIIRs are unavailable.

EbolaEbola-10-10

Nursing considerations cont.:Nursing considerations cont.:• The patient should remain in their room with The patient should remain in their room with

doors and windows closed.doors and windows closed.• In full service hospitals, an anteroom may be used In full service hospitals, an anteroom may be used

between the private room and the corridor.between the private room and the corridor.• If there are a large number of patients needing If there are a large number of patients needing

care, a designated nursing unit may be created care, a designated nursing unit may be created with a barrier plan to seal off the existing with a barrier plan to seal off the existing ventilation system from other hospital areas and ventilation system from other hospital areas and limiting access to the unit.limiting access to the unit.

• In cases of mass numbers, a whole facility or large In cases of mass numbers, a whole facility or large gym may be dedicated.gym may be dedicated.

• Prevent cases through education of family and Prevent cases through education of family and community about methods of spread and how to community about methods of spread and how to avoid them and why these precautions are avoid them and why these precautions are necessary.necessary.

EbolaEbola-11-11

Nursing considerations cont.:Nursing considerations cont.:• Be sure staff fully understand isolation Be sure staff fully understand isolation

precautions.precautions.• During some Ebola outbreaks, governments During some Ebola outbreaks, governments

outlawed traditional ways of preparation of outlawed traditional ways of preparation of bodies and other burial practices.bodies and other burial practices.

• Specific guidelines are available online for Specific guidelines are available online for infection control for viral hemorrhagic fever in infection control for viral hemorrhagic fever in the African health care setting at:the African health care setting at:

http://www.cdc.gov/ncidod/dvrd/spb/mnpages/vhfmanual.htm

• Supportive care depending on manifestations Supportive care depending on manifestations including maintaining appropriate fluid and including maintaining appropriate fluid and electrolytes.electrolytes.

EbolaEbola-12-12

Vaccine:Vaccine:• Experimental Experimental

vaccine in animalsvaccine in animals

EbolaEbola-13-13

Prevention:Prevention:• Prevent other cases by preventing Prevent other cases by preventing

nosocomial transmission including to nosocomial transmission including to health care staff.health care staff.

• Prevent cases through education of the Prevent cases through education of the family and community about methods of family and community about methods of spread and how to avoid them.spread and how to avoid them.

• The latter should include information The latter should include information that Ebola virus may be transmitted in that Ebola virus may be transmitted in semen up to 12 weeks after infection.semen up to 12 weeks after infection.

EbolaEbola-14-14

Social, behavioral and cultural issues:Social, behavioral and cultural issues:• Affected families may be stigmatized and not be Affected families may be stigmatized and not be

allowed in other dwellings or schools.allowed in other dwellings or schools.• Families tend not to seek medical care because Families tend not to seek medical care because

of:of: Cost, Cost, Mistrust of hospitals (nosocomial spread supports these Mistrust of hospitals (nosocomial spread supports these

fears), fears), Belief in traditional remedies and healers, and Belief in traditional remedies and healers, and Problems of transportation to health care facilities Problems of transportation to health care facilities

especially in rainy season.especially in rainy season.• Traditional burial practices contribute to person-Traditional burial practices contribute to person-

to-person spread.to-person spread.• Civil unrest and wars can exacerbate outbreaks Civil unrest and wars can exacerbate outbreaks

through overcrowding, poor sanitation, and through overcrowding, poor sanitation, and economic dispair.economic dispair.

EbolaEbola-15-15

Other notes:Other notes:• Ebola outbreaks tend to burn out Ebola outbreaks tend to burn out

relatively quickly because of the high relatively quickly because of the high mortality rates.mortality rates.

• Ebola virus is studied in a level 4 Ebola virus is studied in a level 4 biosafety facility.biosafety facility.

• There are great fears that the Ebola There are great fears that the Ebola virus could mutate into a form that is virus could mutate into a form that is more easily transmitted from human-to- more easily transmitted from human-to- human or becomes airborne.human or becomes airborne.

Lassa Fever (Lassa virus)Lassa Fever (Lassa virus)

Etiology:Etiology:• Lassa virus, a single Lassa virus, a single

stranded RNA virus in stranded RNA virus in

the arenavirus family.the arenavirus family. Description:Description:

• Is a viral hemorrhagic Is a viral hemorrhagic

fever caused by the fever caused by the

Lassa virus.Lassa virus.

Lassa virus electron micrograph. Image courtesy, C.S. Goldsmith and M. Bowen (CDC).

Lassa FeverLassa Fever-2-2

Epidemiology:Epidemiology:• Endemic in West Africa, where it kills thousands per year, Endemic in West Africa, where it kills thousands per year,

especially in Sierra Leone.especially in Sierra Leone.• Fewer cases are seen in Nigeria, Guinea and Liberia.Fewer cases are seen in Nigeria, Guinea and Liberia.• Subclinical infection commonly occurs in areas of rural West Subclinical infection commonly occurs in areas of rural West

Africa where Lassa virus is endemic. This is known through Africa where Lassa virus is endemic. This is known through the high prevalence of antibodies to Lassa virus in the the high prevalence of antibodies to Lassa virus in the serum in seropositivity studies in West Africa.serum in seropositivity studies in West Africa.

• Occasional outbreaks occur, often with high mortality rates.Occasional outbreaks occur, often with high mortality rates.• In 2004, a case was identified in a New Jersey man who had In 2004, a case was identified in a New Jersey man who had

recently returned to the Trenton area from Africa, and in recently returned to the Trenton area from Africa, and in 2006 a case was diagnosed in a man who returned to 2006 a case was diagnosed in a man who returned to Germany from Sierra Leone.Germany from Sierra Leone.


Epidemiology Epidemiology cont:cont:• The natural hosts The natural hosts

are rodents of the are rodents of the MastomysMastomys genus. genus.

• These rodents These rodents prefer to live in or prefer to live in or around human around human dwellings. These dwellings. These rodents are rodents are persistently persistently infected and shed infected and shed virus in excreta.virus in excreta.


Transmission:Transmission:• Infection results through:Infection results through:

Direct contact with infected rodent urine or Direct contact with infected rodent urine or droppings,droppings,

Through touching objects or eating food Through touching objects or eating food contaminated by infected excreta,contaminated by infected excreta,

Through breaks in the skin,Through breaks in the skin, Through inhalation of infected rodent excreta in Through inhalation of infected rodent excreta in

aerosol form, such as when cleaning a heavily aerosol form, such as when cleaning a heavily contaminated area, andcontaminated area, and

Through food preparation or consumption of infected Through food preparation or consumption of infected rodents. These rodents are considered a delicacy in rodents. These rodents are considered a delicacy in this part of Africa.this part of Africa.


Transmission cont.:Transmission cont.:• Richmond & Baglole (2003) note that Lassa viral Richmond & Baglole (2003) note that Lassa viral

antibodies occur after a febrile illness in twice as antibodies occur after a febrile illness in twice as many people who eat these rodents than in those many people who eat these rodents than in those who do not, and deafness (one of the sequelae of who do not, and deafness (one of the sequelae of Lassa fever) occurs four times more frequently.Lassa fever) occurs four times more frequently.

• Person-to-person spread may occur when a person Person-to-person spread may occur when a person comes into contact with:comes into contact with:

Infected blood,Infected blood, Tissues,Tissues, Secretions, orSecretions, or Excretions.Excretions.


Transmission cont.:Transmission cont.:• Lassa virus is found in semen up to 3 months Lassa virus is found in semen up to 3 months

after infection and in urine a month after after infection and in urine a month after disease onset.disease onset.

• Infection may also occur in hospitals or health Infection may also occur in hospitals or health care settings through use of contaminated care settings through use of contaminated medical equipment such as needles and medical equipment such as needles and syringes that may be reused or through syringes that may be reused or through overcrowding and poor hygiene.overcrowding and poor hygiene.

• Traditional burial ceremonies involving contact Traditional burial ceremonies involving contact with the infected corpse may spread Lassa with the infected corpse may spread Lassa virus (see cultural considerations under Ebola).virus (see cultural considerations under Ebola).


Transmission cont.:Transmission cont.:• Lassa virus may be excreted in urine up to 9 Lassa virus may be excreted in urine up to 9

weeks after infection, and excreted in semen weeks after infection, and excreted in semen up to 3 months after infection.up to 3 months after infection.

Incubation period: Incubation period: 5 to 21 days.5 to 21 days. Clinical manifestations:Clinical manifestations:

• In about 80%, affected persons are In about 80%, affected persons are asymptomatic or mildly affected.asymptomatic or mildly affected.

• In 20%, symptoms may be severe and may In 20%, symptoms may be severe and may mimic other hemorrhagic fevers.mimic other hemorrhagic fevers.


Clinical manifestations cont.:Clinical manifestations cont.:• Richmond & Baglole (2003) divide clinical Richmond & Baglole (2003) divide clinical

stages and symptoms as follows:stages and symptoms as follows: Stage 1 (days 1-3)Stage 1 (days 1-3)

• Symptoms include general weakness and malaise, high Symptoms include general weakness and malaise, high fever, about 39fever, about 39oo C with higher peaks. C with higher peaks.

Stage 2 (days 4-7)Stage 2 (days 4-7)• Symptoms include sore throat (with white exudative Symptoms include sore throat (with white exudative

patches); headache; back, chest, side, or abdominal patches); headache; back, chest, side, or abdominal pain; conjunctivitis; nausea and vomiting; diarrhea; pain; conjunctivitis; nausea and vomiting; diarrhea; productive cough; proteinuria; low blood pressure productive cough; proteinuria; low blood pressure (systolic <100 mm/Hg); and anemia.(systolic <100 mm/Hg); and anemia.

Stage 3 (after 7 days)Stage 3 (after 7 days)• Symptoms include facial edema; convulsions; mucosal Symptoms include facial edema; convulsions; mucosal

bleeding (mouth, nose, eyes); internal bleeding; and bleeding (mouth, nose, eyes); internal bleeding; and confusion or disorientation.confusion or disorientation.

Stage 4 (after 14 days)Stage 4 (after 14 days)• Symptoms include coma and death.Symptoms include coma and death.

Not all progress through all stages.Not all progress through all stages.


Diagnosis:Diagnosis:• Reverse transcription polymerase chain Reverse transcription polymerase chain

reaction (PCR) can diagnose close to 100% but reaction (PCR) can diagnose close to 100% but takes time.takes time.

• Enzyme linked immunosorbent assays (ELISA) Enzyme linked immunosorbent assays (ELISA) for Lassa virus antigen and for virus IgM are for Lassa virus antigen and for virus IgM are more than 85% sensitive and specific together.more than 85% sensitive and specific together.

• If laboratory tests are not available, clinical If laboratory tests are not available, clinical diagnosis should be suspected in patient with diagnosis should be suspected in patient with fever at or above 38fever at or above 38oo C or 100.4 C or 100.4oo F who do not F who do not respond adequately to antibiotics or respond adequately to antibiotics or antimalarial drugs.antimalarial drugs.


Complications:Complications:• Includes mucosal bleeding, sensorineural Includes mucosal bleeding, sensorineural

deafness, hair loss, loss of coordination, deafness, hair loss, loss of coordination, spontaneous abortion in women, and both spontaneous abortion in women, and both pleural and pericardial effusionpleural and pericardial effusion

Treatment:Treatment:• Supportive such as fluid replacement.Supportive such as fluid replacement.• Intravenous ribavirin is effective especially Intravenous ribavirin is effective especially

when given early.when given early.• Thus, early diagnosis and clinical suspicion is Thus, early diagnosis and clinical suspicion is

needed.needed.


Management:Management:• Strict standard, contact and droplet isolation of Strict standard, contact and droplet isolation of

suspected cases and maintaining procedures suspected cases and maintaining procedures for handling body fluids and excreta as well as for handling body fluids and excreta as well as appropriate infection control procedures.appropriate infection control procedures.

• Stringent barrier nursing procedures.Stringent barrier nursing procedures.• Limit number of staff approaching patient.Limit number of staff approaching patient.• Use N95 or higher respirators when performing Use N95 or higher respirators when performing

aerosol – generating procedures.aerosol – generating procedures.


Management cont.:Management cont.:• Use mask, face shield, gown, gloves, leg Use mask, face shield, gown, gloves, leg

coverings, and shoe coverings.coverings, and shoe coverings.• Be sure health care staff understands Be sure health care staff understands

the infection control procedures in use.the infection control procedures in use.• Consult http://www.cdc.gov.mcidod.dhgp/pdf/isolation2007.pdfConsult http://www.cdc.gov.mcidod.dhgp/pdf/isolation2007.pdf


Management cont.:Management cont.:• Nurses should provide education to patients Nurses should provide education to patients

and families regarding why these precautions and families regarding why these precautions and procedures are necessary and how to and procedures are necessary and how to prevent the spread of the virus.prevent the spread of the virus.

• Specific guidelines are available online for Specific guidelines are available online for infection control for viral hemorrhagic fevers in infection control for viral hemorrhagic fevers in the African health care setting at: the African health care setting at: http://www.cdc.gov/ncidod/dvrd/spb/mnpages/vhfmanual.htm


Prevention:Prevention:• Prevent other cases by preventing nosocomial Prevent other cases by preventing nosocomial

transmission including to health care staff.transmission including to health care staff.• Prevent cases through education of the family and Prevent cases through education of the family and

community about methods of spread and how to avoid community about methods of spread and how to avoid them.them.

Vaccination: Vaccination: ExperimentalExperimental Mortality:Mortality:

• Varies.Varies.• In general population may be 1 to 2%, but in those who In general population may be 1 to 2%, but in those who

are hospitalized, is generally estimated at up to 25%.are hospitalized, is generally estimated at up to 25%.• In Sierra Leone, one study indicated that 25% of all In Sierra Leone, one study indicated that 25% of all

maternal deaths were due to Lassa fever (Price, Fisher-maternal deaths were due to Lassa fever (Price, Fisher-Hoch, Craven & McCormick, 1988).Hoch, Craven & McCormick, 1988).


Social, behavioral and cultural Social, behavioral and cultural issues:issues:• Because Lassa virus is spread through Because Lassa virus is spread through

rodents, families may wish to continue rodents, families may wish to continue to eat the “sweet meat” of this rodent to eat the “sweet meat” of this rodent and not associate that practice with and not associate that practice with developing Lassa fever since in many developing Lassa fever since in many cases, infection will be asymptomatic or cases, infection will be asymptomatic or mild.mild.

• Affected families may be stigmatized Affected families may be stigmatized and not be allowed in other dwellings or and not be allowed in other dwellings or schools.schools.


Social, behavioral and cultural issues Social, behavioral and cultural issues cont.:cont.:• Families tend not to seek medical care because Families tend not to seek medical care because

of:of: Cost, Cost, Mistrust of hospitals (nosocomial spread supports Mistrust of hospitals (nosocomial spread supports

these fears),these fears), Belief in traditional remedies and healers,Belief in traditional remedies and healers, Non-availability of a quick early diagnostic test in the Non-availability of a quick early diagnostic test in the

field,field, Problems of transportation to health care facilities Problems of transportation to health care facilities

especially in rainy season, andespecially in rainy season, and Attribution of some complications, such as Attribution of some complications, such as

miscarriage, to “witchcraft” or fault of the woman.miscarriage, to “witchcraft” or fault of the woman.


Social, behavioral and cultural Social, behavioral and cultural issues cont.:issues cont.:• Traditional burial practices contribute to Traditional burial practices contribute to

person-to-person spread.person-to-person spread.• The resulting deafness in some may The resulting deafness in some may

lead to social isolation.lead to social isolation.• Civil unrest and wars can exacerbate Civil unrest and wars can exacerbate

outbreaks through overcrowding, poor outbreaks through overcrowding, poor sanitation, and economic dispair.sanitation, and economic dispair.


Other notes:Other notes:• Lassa fever has been diagnosed in Lassa fever has been diagnosed in

travelers including relief workers and UN travelers including relief workers and UN peacekeepers returning from West peacekeepers returning from West Africa to Europe and North America.Africa to Europe and North America.

• A case was imported to New Jersey in A case was imported to New Jersey in August 2004. The patient was August 2004. The patient was hospitalized and subsequently died. No hospitalized and subsequently died. No further transmission was identified.further transmission was identified.

• Lassa fever is studied in a level 3 Lassa fever is studied in a level 3 biosafety facility.biosafety facility.

Marburg Hemorrhagic Fever Marburg Hemorrhagic Fever (Marburg virus)(Marburg virus)

Etiology:Etiology:• Marburg virus, a RNA Marburg virus, a RNA virus in the filovirus virus in the filovirus

family, the only other family, the only other member of which is member of which is Ebola virus. Ebola virus.

Description:Description:• Is a viral hemorrhagic Is a viral hemorrhagic

fever caused by the fever caused by the Marburg virus.Marburg virus.

• Also called Marburg Also called Marburg disease.disease.

Image courtesy of Russell Regnery, Image courtesy of Russell Regnery, Ph.D., DVRD, NCID, CDC.Ph.D., DVRD, NCID, CDC.

Marburg hemorrhagic feverMarburg hemorrhagic fever-2-2

Epidemiology:Epidemiology:• Marburg hemorrhagic fever was first Marburg hemorrhagic fever was first

recognized in 1967 among workers in recognized in 1967 among workers in laboratories in Germany and was then laboratories in Germany and was then Yugoslavia.Yugoslavia.

• The source of this infection was infected green The source of this infection was infected green monkeys imported from Africa, specifically monkeys imported from Africa, specifically Uganda.Uganda.

• The next reported index case was in 1975 in a The next reported index case was in 1975 in a tourist who apparently acquired the infection in tourist who apparently acquired the infection in Zimbabwe, and who was hospitalized in South Zimbabwe, and who was hospitalized in South Africa. He transmitted Marburg virus to his Africa. He transmitted Marburg virus to his travel companion and to a nurse who cared for travel companion and to a nurse who cared for him.him.


Epidemiology cont.:Epidemiology cont.:• In 1998, an outbreak occurred in the In 1998, an outbreak occurred in the

Democratic Republic of the Congo, and the Democratic Republic of the Congo, and the index case was believed to have acquired index case was believed to have acquired infection from a source in a gold mine there.infection from a source in a gold mine there.

• In late 2004 and 2005, an outbreak occurred in In late 2004 and 2005, an outbreak occurred in Angola. Of the 175 identified cases as of Angola. Of the 175 identified cases as of 4/4/05, 155 had been fatal. Other outbreaks 4/4/05, 155 had been fatal. Other outbreaks were relatively small. Another small outbreak were relatively small. Another small outbreak occurred in a mining community in Uganda in occurred in a mining community in Uganda in 2007. In July 2008 a Dutch tourist returned to 2007. In July 2008 a Dutch tourist returned to the Netherlands with Marburg fever.the Netherlands with Marburg fever.

• The natural host for Marburg virus is unknown.The natural host for Marburg virus is unknown.


Transmission:Transmission:• Person-to-person spread may occur when a Person-to-person spread may occur when a

person comes into contact with infected person comes into contact with infected blood, tissues, secretions, or excretions, or blood, tissues, secretions, or excretions, or has close contact with an infected person.has close contact with an infected person.

• Infection may also occur through contact Infection may also occur through contact with contaminated objects or through with contaminated objects or through droplets of body fluids. droplets of body fluids.

• The virus is still found in seminal fluid The virus is still found in seminal fluid months after infection, and sexual months after infection, and sexual transmission from a male to a female has transmission from a male to a female has been documented.been documented.


Incubation period:Incubation period: • Typically 3-10 daysTypically 3-10 days

Clinical manifestations:Clinical manifestations:• In most cases, the onset of illness is abrupt In most cases, the onset of illness is abrupt

with fever, chills, headache, and myalgia.with fever, chills, headache, and myalgia.• Nausea, vomiting, chest pain, pharyngitis, Nausea, vomiting, chest pain, pharyngitis,

abdominal pain and severe diarrhea may be abdominal pain and severe diarrhea may be seen.seen.

• A maculopapular rash may appear around the A maculopapular rash may appear around the 55thth day. day.


Clinical manifestations cont.:Clinical manifestations cont.:• Other severe symptoms such as jaundice; Other severe symptoms such as jaundice;

pancreatitis; severe weight loss; delirium; pancreatitis; severe weight loss; delirium; shock; liver failure; massive hemorrhage shock; liver failure; massive hemorrhage through vomitus, eyes, skin, and vagina; and through vomitus, eyes, skin, and vagina; and multiorgan dysfunction may be seen.multiorgan dysfunction may be seen.

• Recovery is prolonged and may include Recovery is prolonged and may include hepatitis, transverse myelitis, uvietis, and/or hepatitis, transverse myelitis, uvietis, and/or orchitis in men as well as prolonged hepatitis.orchitis in men as well as prolonged hepatitis.


Diagnosis:Diagnosis:• By antigen-capture enzyme-linked By antigen-capture enzyme-linked

immunosorbent assay (ELISA), IgM capture immunosorbent assay (ELISA), IgM capture ELISA, polymerase chain reaction (PCR), and ELISA, polymerase chain reaction (PCR), and virus isolation.virus isolation.

• Diagnosis can be difficult because signs and Diagnosis can be difficult because signs and symptoms can be similar to diseases such as symptoms can be similar to diseases such as malaria or typhoid fever or be nonspecific, malaria or typhoid fever or be nonspecific, especially initially.especially initially.

• Diagnosis is particularly difficult when only one Diagnosis is particularly difficult when only one or a few cases appear.or a few cases appear.


Treatment:Treatment:• Supportive, and may include:Supportive, and may include:

Maintenance of appropriate fluid and Maintenance of appropriate fluid and electrolytes, electrolytes,

Oxygenation, Oxygenation, Frequent blood pressure checks, Frequent blood pressure checks, Replacement of lost blood and clotting Replacement of lost blood and clotting

factors, andfactors, and Treating complications promptly.Treating complications promptly. Immune plasma from convalescent patients Immune plasma from convalescent patients

has been used in some instances.has been used in some instances.


Management:Management:• Strict isolation of suspected cases and Strict isolation of suspected cases and

maintaining procedures for handling maintaining procedures for handling body fluids and excreta as well as body fluids and excreta as well as appropriate infection control procedures appropriate infection control procedures using standard, contact, and airborne or using standard, contact, and airborne or droplet precautions.droplet precautions.

• Stringent barrier nursing procedures.Stringent barrier nursing procedures.• Do not wear jewelry.Do not wear jewelry.• Limit number of staff approaching Limit number of staff approaching

patient.patient.


Management cont.:Management cont.:• Use mask, fluid-proof long-sleeved gown, Use mask, fluid-proof long-sleeved gown,

gloves, goggles, leg coverings and shoe gloves, goggles, leg coverings and shoe coverings that are at least ankle high and fluid coverings that are at least ankle high and fluid proof (may need to be higher if floor is visibly proof (may need to be higher if floor is visibly soiled).soiled).

• Use double disposable gloves if handling any Use double disposable gloves if handling any sharp device, and be sure gloves cover cuff of sharp device, and be sure gloves cover cuff of gown.gown.

• Use hair covering and disposable face shields if Use hair covering and disposable face shields if needed.needed.


Management cont.:Management cont.:• Disposable N-95 respirators should be Disposable N-95 respirators should be

worn when entering room.worn when entering room.• Remove shoe covers and gloves as well Remove shoe covers and gloves as well

as gowns before exiting.as gowns before exiting.• Wash hands immediately on leaving Wash hands immediately on leaving

room with antimicrobial agent. room with antimicrobial agent. • Use disposable equipment when Use disposable equipment when

possible or dedicated equipment such as possible or dedicated equipment such as stethoscopes to be kept in patient’s stethoscopes to be kept in patient’s room.room.


Management cont.:Management cont.:• Be sure health care staff understands the Be sure health care staff understands the

infection control procedures in use.infection control procedures in use.• Prevent other cases by preventing nosocomial Prevent other cases by preventing nosocomial

transmission including to health care staff.transmission including to health care staff.• Specific guidelines are available online for Specific guidelines are available online for

infection control in the African health care infection control in the African health care setting at setting at http://www.cdc.gov/ncidod/dvrd/spb/mnpages/vhfmanual.htm

• Also see information in module discussing Also see information in module discussing infection control, and at infection control, and at http://www.cdc.gov/ncidod/dhgp/pdf/isolation2007.pdf


Prevention:Prevention:• Prevent other cases by preventing Prevent other cases by preventing

nosocomial transmission including to nosocomial transmission including to health care staff.health care staff.

• Prevent cases through education of the Prevent cases through education of the family and community about methods of family and community about methods of spread and how to avoid them.spread and how to avoid them.

• Should include information that Marburg Should include information that Marburg virus may be transmitted in semen as virus may be transmitted in semen as long as 3 months after infection.long as 3 months after infection.


Mortality:Mortality:• The mortality rate is high, usually 23 to 25% or The mortality rate is high, usually 23 to 25% or

more.more. Vaccine:Vaccine:

• Experimental vaccine is being looked at in Experimental vaccine is being looked at in animals.animals.

Other notes:Other notes:• Marburg virus is studied in a level 4 biosafety Marburg virus is studied in a level 4 biosafety

facility.facility.• Knowledge of Marburg hemorrhagic fever and Knowledge of Marburg hemorrhagic fever and

Marburg virus is somewhat limited due to the Marburg virus is somewhat limited due to the few number of cases known.few number of cases known.

Plague (Plague (YersiniaYersinia pestispestis)) Plague is considered a Category A agent Plague is considered a Category A agent

for bioterrorism because:for bioterrorism because:• Plague bacteria are not difficult to obtain, Plague bacteria are not difficult to obtain, • Aerosolized plague bacteria are easily Aerosolized plague bacteria are easily

transmitted, transmitted, • There is a high attack rate,There is a high attack rate,• Clinical disease is severe, andClinical disease is severe, and• The word “plague” has a high psychological The word “plague” has a high psychological

impact.impact. A sudden outbreak of disease due to an A sudden outbreak of disease due to an

intentional release might present as intentional release might present as severe pneumonia and sepsis.severe pneumonia and sepsis.

PlaguePlague-2-2Picture from CDCPicture from CDC

PlaguePlague-3-3

Etiology:Etiology:• YersiniaYersinia pestispestis, a small gram-negative , a small gram-negative

rod-like bacilli.rod-like bacilli. Description:Description:

• Was known as the Black death in the Was known as the Black death in the bubonic form in the middle ages when it bubonic form in the middle ages when it killed 20-30 million in Europe.killed 20-30 million in Europe.

• In the mid 1800s, it killed 12 million in In the mid 1800s, it killed 12 million in China.China.

PlaguePlague-4-4

Epidemiology:Epidemiology:• Plague is Plague is

considered a considered a zoonosis.zoonosis.

• Y.Y. pestispestis is is transmitted from transmitted from infected rodents infected rodents such as rats, mice, such as rats, mice, gerbils, chipmunks, gerbils, chipmunks, and prairie dogs to and prairie dogs to humans via infected humans via infected fleas. fleas.


PlaguePlague-5-5

Epidemiology cont.:Epidemiology cont.:• Cats and dogs, also may become infected by Cats and dogs, also may become infected by

eating infected rodents.eating infected rodents.• Plague occurs worldwide.Plague occurs worldwide.• In the US there are generally 10 to 15 reported In the US there are generally 10 to 15 reported

cases of plague each year, most commonly in cases of plague each year, most commonly in rural areas of New Mexico, Colorado, Arizona, rural areas of New Mexico, Colorado, Arizona, California, Oregon and Nevada.California, Oregon and Nevada.

• Worldwide there are 1,000-3,000 cases Worldwide there are 1,000-3,000 cases reported each year.reported each year.

PlaguePlague-6-6

Epidemiology cont.:Epidemiology cont.:• In the fall of 2002, a hospital in New In the fall of 2002, a hospital in New

York City admitted a couple who were York City admitted a couple who were found to have plague acquired in their found to have plague acquired in their home state of New Mexico before home state of New Mexico before traveling to New York.traveling to New York.

• Most cases occur in summer.Most cases occur in summer.• About 30% of cases occur in About 30% of cases occur in

southwestern US.southwestern US.• Suspicion should be raised if it occurs in Suspicion should be raised if it occurs in

other geographic areas.other geographic areas.

PlaguePlague-7-7

Clinical types:Clinical types:• BubonicBubonic – infected lymph nodes leading – infected lymph nodes leading

to development of buboes. Most to development of buboes. Most common.common.

• SepticemicSepticemic – organisms are blood-borne, – organisms are blood-borne, primary through dried inoculation or primary through dried inoculation or secondary from bubonic or pneumonic secondary from bubonic or pneumonic plague.plague.

• PneumonicPneumonic – is transmissible by aerosol. – is transmissible by aerosol. Rarest, high mortality.Rarest, high mortality.

PlaguePlague-8-8

Transmission:Transmission:• Via bite of infected fleas,Via bite of infected fleas,• Through contact with infected animals or their Through contact with infected animals or their

fluids, and fluids, and • In pneumonic plague, animal-to-person, or In pneumonic plague, animal-to-person, or

person-to-person via droplets.person-to-person via droplets.• In bioterrorism, organisms would most likely be In bioterrorism, organisms would most likely be

transmitted through aerosol dispersion.transmitted through aerosol dispersion. Incubation period:Incubation period:

• BubonicBubonic – 2 to 8 days after exposure – 2 to 8 days after exposure• PneumonicPneumonic – 1 to 4 days after exposure – 1 to 4 days after exposure

PlaguePlague-9-9

Clinical manifestations:Clinical manifestations:• Y.Y. pestispestis produces an endotoxin that can produces an endotoxin that can

lead to shock, sepsis, disseminated lead to shock, sepsis, disseminated intravascular coagulation (DIC), and intravascular coagulation (DIC), and multiorgan failure.multiorgan failure.

• Bubonic –Bubonic – May experience abrupt onset of flu-like May experience abrupt onset of flu-like

symptoms such as fever, chills, headache, symptoms such as fever, chills, headache, and malaise shortly before or at the same and malaise shortly before or at the same time as the bubo which is a swollen, warm, time as the bubo which is a swollen, warm, reddened (often around the edges), very reddened (often around the edges), very tender lymph node(s) usually in the inguinal, tender lymph node(s) usually in the inguinal, axillary or cervical region.axillary or cervical region.

PlaguePlague-10-10 Clinical Clinical

manifestations manifestations cont.:cont.:• Bubonic cont. –Bubonic cont. –

Patients may Patients may become prostrated become prostrated with episodes of with episodes of agitation and agitation and restlessness.restlessness.

Secondary Secondary septicemia may septicemia may result and this can result and this can lead to secondary lead to secondary pneumonic plague.pneumonic plague.


PlaguePlague-11-11

Clinical manifestations cont.:Clinical manifestations cont.:• Pneumonic (primary) –Pneumonic (primary) –

Presentation is severe, fulminant, rapidly Presentation is severe, fulminant, rapidly progressing pneumonia.progressing pneumonia.

Signs and symptoms include fever, dyspnea, Signs and symptoms include fever, dyspnea, and cough with hemoptysis, and chest pain.and cough with hemoptysis, and chest pain.

May also have nausea, vomiting, diarrhea, May also have nausea, vomiting, diarrhea, purpura, and abdominal pain.purpura, and abdominal pain.

PlaguePlague-12-12

Clinical manifestations cont.:Clinical manifestations cont.:• Septicemic (primary) –Septicemic (primary) –

Presentation resembles other gram-negative Presentation resembles other gram-negative septicemias including high fever, chills, septicemias including high fever, chills, malaise, hypotension, nausea, vomiting and malaise, hypotension, nausea, vomiting and diarrhea.diarrhea.

May also have purpura and disseminated May also have purpura and disseminated intravascular coagulation (DIC).intravascular coagulation (DIC).

May spread rapidly to central nervous May spread rapidly to central nervous system resulting in meningitis, lungs and system resulting in meningitis, lungs and other sites.other sites.

PlaguePlague-13-13

Diagnosis:Diagnosis:• There are three levels of laboratory test There are three levels of laboratory test

criteria for diagnosis according to CDC:criteria for diagnosis according to CDC: SuspectedSuspected PresumptivePresumptive ConfirmedConfirmed

PlaguePlague-14-14

Diagnosis cont.:Diagnosis cont.:• Diagnosis is by compatibility of clinical symptoms:Diagnosis is by compatibility of clinical symptoms:

Along with stain or smear positive specifically for Along with stain or smear positive specifically for Y.Y. pestispestis, or if a single serum specimen is tested and the , or if a single serum specimen is tested and the anti-F-1 titer by agglutination is greater than 1:10 anti-F-1 titer by agglutination is greater than 1:10 (presumptive),(presumptive),

Or a small gram-negative coccobacilli from affected Or a small gram-negative coccobacilli from affected tissue (suspected), or if an isolated culture is lysed by tissue (suspected), or if an isolated culture is lysed by specific bacteriophage,specific bacteriophage,

If two serum specimens demonstrate a four-fold anti-F-1 If two serum specimens demonstrate a four-fold anti-F-1 antigen titer difference by agglutination testing, or if a antigen titer difference by agglutination testing, or if a single serum specimen tested by agglutination has a single serum specimen tested by agglutination has a titer of more than 1:128, and the patient has no previous titer of more than 1:128, and the patient has no previous history of plague exposure or vaccination history history of plague exposure or vaccination history (confirmed).(confirmed).

PlaguePlague-15-15

Mortality:Mortality:• Bubonic – Bubonic – Untreated bubonic plague has a Untreated bubonic plague has a

mortality of 40 to 60% but with treatment is mortality of 40 to 60% but with treatment is less than 10%.less than 10%.

• Pneumonic – Pneumonic – Untreated pneumonic plague has Untreated pneumonic plague has a mortality rate of 95% to 100%. With a mortality rate of 95% to 100%. With treatment the mortality rate may still approach treatment the mortality rate may still approach 60%. It is essential that antimicrobial 60%. It is essential that antimicrobial treatment begin within 24 hours.treatment begin within 24 hours.

• Septicemic – Septicemic – Untreated septicemic plague has Untreated septicemic plague has a mortality rate of essentially 100%. With a mortality rate of essentially 100%. With treatment the mortality rate may still approach treatment the mortality rate may still approach 60%. It is essential that antimicrobial therapy 60%. It is essential that antimicrobial therapy begin within 24 hours.begin within 24 hours.

PlaguePlague-16-16

Treatment:Treatment:• Streptomycin, IM every 12 hours has been the Streptomycin, IM every 12 hours has been the

therapy of choice followed by gentamicin (5 therapy of choice followed by gentamicin (5 mg/kg per day) which is more readily available mg/kg per day) which is more readily available in the US.in the US.

• Doxycycline and the fluoroquinolones are Doxycycline and the fluoroquinolones are considered alternate therapies.considered alternate therapies.

• Supportive care, including hemodynamic Supportive care, including hemodynamic monitoring, especially for septic shock is monitoring, especially for septic shock is necessary.necessary.

• Buboes are generally not incised and drained, Buboes are generally not incised and drained, but regress with antibiotic treatment.but regress with antibiotic treatment.

• Chloramphenicol may be used for treatment of Chloramphenicol may be used for treatment of plague meningitis if it occurs.plague meningitis if it occurs.

PlaguePlague-17-17

Prophylaxis and VaccinationProphylaxis and Vaccination• Post-exposure prophylaxis with doxycycline or Post-exposure prophylaxis with doxycycline or

ciprofloxacin may be used for those with ciprofloxacin may be used for those with known exposure or close contact with an known exposure or close contact with an infected person.infected person.

• Pre-exposure prophylaxis is not available in the Pre-exposure prophylaxis is not available in the US.US.

• A killed cell vaccine is said to be available in A killed cell vaccine is said to be available in the UK.the UK.

• Usually will become non-infective after several Usually will become non-infective after several days of antimicrobial therapy.days of antimicrobial therapy.

PlaguePlague-18-18

Nursing considerations:Nursing considerations:• Standard and droplet isolation Standard and droplet isolation

precautions should be used for the precautions should be used for the pneumonic type and the ??? continued pneumonic type and the ??? continued until sputum is negative.until sputum is negative.

• Standard and contact precautions used Standard and contact precautions used for bubonic if open wounds unless for bubonic if open wounds unless progression to lungs occurs.progression to lungs occurs.

• Avoid contact with drainage.Avoid contact with drainage.• See module on infection control or CDC See module on infection control or CDC

site for details.site for details.

PlaguePlague-19-19

Nursing considerations cont.:Nursing considerations cont.:• Supportive nursing care varies Supportive nursing care varies

according to type and symptoms and according to type and symptoms and includes appropriate information to includes appropriate information to patients, family and staff about:patients, family and staff about:

Information on infection control (included in Information on infection control (included in another module as is instruction on large-another module as is instruction on large-scale outbreak management).scale outbreak management).

Consider emotional impact of word, Consider emotional impact of word, “plague.”“plague.”

On first patient contact with possible plague On first patient contact with possible plague case, assess travel history, animal contacts case, assess travel history, animal contacts and any infected insect bites especially from and any infected insect bites especially from fleas.fleas.

Smallpox (Smallpox (VariolaVariola virusvirus))

Description and Etiology:Description and Etiology:• Caused by the Caused by the variolavariola virusvirus, a DNA virus , a DNA virus

member of the orthopox virus family.member of the orthopox virus family.• Other orthopoxes include monkeypox, Other orthopoxes include monkeypox,

camelpox and chickenpox.camelpox and chickenpox. Epidemiology:Epidemiology:

• The last natural human case of smallpox The last natural human case of smallpox occurred in 1977 in Somalia.occurred in 1977 in Somalia.

• No animal reservoir has been identified.No animal reservoir has been identified.• Identification of even one case of smallpox Identification of even one case of smallpox

constitutes an international public health constitutes an international public health emergency.emergency.

SmallpoxSmallpox-2-2

Transmission:Transmission:• Droplet Droplet • Aerosol Aerosol • Direct person-to-person contact including skin lesions Direct person-to-person contact including skin lesions

and secretions or and secretions or • Through contact with contaminated linens, clothing, Through contact with contaminated linens, clothing,

surfaces, and other fomitessurfaces, and other fomites• Smallpox is highly contagiousSmallpox is highly contagious

Incubation:Incubation:• Typically 12 to 14 days after infection but can be 7 to 17 Typically 12 to 14 days after infection but can be 7 to 17

days.days.• The person may be contagious during prodrome phase The person may be contagious during prodrome phase

and is most contagious as rash forms.and is most contagious as rash forms.• Is contagious until all scabs are gone.Is contagious until all scabs are gone.• Typically virus is transmitted from an infected person by Typically virus is transmitted from an infected person by

coughing or sneezing to the oral mucosa of a susceptible coughing or sneezing to the oral mucosa of a susceptible person.person.


Clinical manifestations:Clinical manifestations:• Usually begins with the flu-like symptoms of Usually begins with the flu-like symptoms of

fever (typically 101fever (typically 101oo to 103 to 103oo F), malaise, F), malaise, headache, and body aches (prodrome).headache, and body aches (prodrome).

• In most people, about 90% develop a rash first In most people, about 90% develop a rash first as red spots on tongue and in mouth which as red spots on tongue and in mouth which develop into sores in mouth.develop into sores in mouth.

• A rash starts on face, then to arms and legs A rash starts on face, then to arms and legs and hands and feet within 24 hours.and hands and feet within 24 hours.

• Over days, the rash becomes raised bumps Over days, the rash becomes raised bumps which fill with opaque fluid and have a which fill with opaque fluid and have a depression in center (said to look like a belly depression in center (said to look like a belly button).button).

SmallpoxSmallpox-4-4Picture from CDCPicture from CDC


Clinical manifestations cont.:Clinical manifestations cont.:• Bumps become pustules (often said to Bumps become pustules (often said to

feel like BB pellets embedded).feel like BB pellets embedded).• The pustules crust over to form scabs.The pustules crust over to form scabs.• The scabs generally fall off after about a The scabs generally fall off after about a

total of 3 weeks after the rash first total of 3 weeks after the rash first appeared.appeared.

• Pitted scars are left at site of scabs.Pitted scars are left at site of scabs.• Lesions are generally round and 6-10 Lesions are generally round and 6-10

mm. in diameter with concentration on mm. in diameter with concentration on face and extremities. face and extremities.


Clinical manifestations cont.:Clinical manifestations cont.:• May be distributed in a centrifugal May be distributed in a centrifugal

pattern.pattern.• In some 5-10% of patients, a In some 5-10% of patients, a

hemorrhagic form occurs during which hemorrhagic form occurs during which the erythematous lesions are confluent, the erythematous lesions are confluent, and the skin is said to look like crepe and the skin is said to look like crepe rubber.rubber.

• There may be bleeding into the skin with There may be bleeding into the skin with petechiae and ecchymoses.petechiae and ecchymoses.

• This form is usually fatal within a week.This form is usually fatal within a week.


Clinical manifestations cont.:Clinical manifestations cont.:• There is also a flat type with an atypical rash There is also a flat type with an atypical rash

that never becomes pustules and has a high that never becomes pustules and has a high mortality. mortality.

• Less severe forms may occur in those with Less severe forms may occur in those with partial immunity from vaccination.partial immunity from vaccination.

• Note: In contrast to chickenpox, smallpox skin Note: In contrast to chickenpox, smallpox skin lesions in the same area develop at same pace lesions in the same area develop at same pace and appear similar while in chickenpox, the and appear similar while in chickenpox, the lesions develop in crops and lesions that are lesions develop in crops and lesions that are scales, vesicles and pustules may be seen scales, vesicles and pustules may be seen simultaneously. Chickenpox lesions are rarely simultaneously. Chickenpox lesions are rarely seen on palms of hands or soles of feet.seen on palms of hands or soles of feet.


Diagnosis:Diagnosis:• Sample from lesion should be taken by a Sample from lesion should be taken by a

recently vaccinated health care worker under recently vaccinated health care worker under appropriate precautions.appropriate precautions.

Mortality:Mortality:• About 30%.About 30%.

Treatment:Treatment:• Supportive including hydration, sedation and Supportive including hydration, sedation and

pain management.pain management.• Cidofovir may be promising.Cidofovir may be promising.• Post-exposure vaccination if given within 2 to 3 Post-exposure vaccination if given within 2 to 3

or possibly up to 5 days post-exposure may or possibly up to 5 days post-exposure may prevent or ameliorate disease.prevent or ameliorate disease.


Management and nursing Management and nursing considerations:considerations:• Supportive.Supportive.• Appropriate infection control critical.Appropriate infection control critical.• The smallpox virus is small in size and can be The smallpox virus is small in size and can be

carried by air currents or on dust particles over carried by air currents or on dust particles over long distances and thus be transmitted to long distances and thus be transmitted to susceptible persons in a small amount of time.susceptible persons in a small amount of time.

• An actual or suspected case of smallpox should An actual or suspected case of smallpox should be treated as a public health emergency and be treated as a public health emergency and reported as appropriate in the staff member’s reported as appropriate in the staff member’s institution per their disaster plan.institution per their disaster plan.


Management and nursing Management and nursing considerations cont.:considerations cont.:• Should use immediate isolation of suspected Should use immediate isolation of suspected

case with airborne, contact, and standard case with airborne, contact, and standard precautions and barrier nursing.precautions and barrier nursing.

• Individual room with negative air pressure is Individual room with negative air pressure is desirable.desirable.

• In places where no negative pressure isolation In places where no negative pressure isolation rooms exist, the patient should be put in a rooms exist, the patient should be put in a private room with a HEPA filtration unit.private room with a HEPA filtration unit.


Management and nursing Management and nursing considerations cont.:considerations cont.:• The patient should remain in their room with The patient should remain in their room with

doors and windows closed.doors and windows closed.• If there are a large number of patients needing If there are a large number of patients needing

care, a designated nursing unit may be created care, a designated nursing unit may be created with a barrier plan to seal off the existing with a barrier plan to seal off the existing ventilation system from other hospital areas ventilation system from other hospital areas and limiting access to the unit.and limiting access to the unit.

• In cases of mass numbers, a whole facility or In cases of mass numbers, a whole facility or large gym may be dedicated to smallpox large gym may be dedicated to smallpox cases.cases.


Management and nursing Management and nursing considerations cont.:considerations cont.:• Unvaccinated visitors should remain at home Unvaccinated visitors should remain at home

until vaccinated.until vaccinated.• Health care workers should use the personal Health care workers should use the personal

protective equipment (PPE) appropriate to the protective equipment (PPE) appropriate to the degree of exposure and tasks.degree of exposure and tasks.

• Disposable N95 respirators that filter particles Disposable N95 respirators that filter particles to 0.02 microns or powered air-purifying to 0.02 microns or powered air-purifying respirators should be worn when entering the respirators should be worn when entering the room, and removed after leaving.room, and removed after leaving.

• Unless absolutely necessary, the smallpox Unless absolutely necessary, the smallpox patient should not leave their room.patient should not leave their room.


Management and nursing Management and nursing considerations cont.:considerations cont.:• If the patient must leave their room, they If the patient must leave their room, they

should wear a N-100 mask, have their body should wear a N-100 mask, have their body completely covered, including the head and completely covered, including the head and face (nose and mouth should not be covered) face (nose and mouth should not be covered) except with mask.except with mask.

• Hallways should be cleared and anyone with Hallways should be cleared and anyone with the patient should wear PPE including N95 the patient should wear PPE including N95 respirators.respirators.

• Use disposable patient care equipment and Use disposable patient care equipment and dedicated non-disposable equipment.dedicated non-disposable equipment.


Management and nursing considerations Management and nursing considerations cont.:cont.:• Linens should be placed in one bag, sealed and then Linens should be placed in one bag, sealed and then

placed in a second leak-proof bag with clear placed in a second leak-proof bag with clear identification as contaminated and chutes should not be identification as contaminated and chutes should not be used.used.

• If patient dies, they should be placed in leak-proof If patient dies, they should be placed in leak-proof container.container.

• Specific infection control information is in another Specific infection control information is in another module or can be found on the CDC website.module or can be found on the CDC website.

• Provide psychological support to patient and family.Provide psychological support to patient and family.• Unvaccinated personnel should not care for smallpox Unvaccinated personnel should not care for smallpox

patients if an immune healthcare worker is available.patients if an immune healthcare worker is available.


Vaccination:Vaccination:• Available.Available.• Uses vaccinia virus for vaccination.Uses vaccinia virus for vaccination.• Complications of vaccination occur particularly Complications of vaccination occur particularly

in immunocompromised persons.in immunocompromised persons.• Post-exposure vaccination may be useful. See Post-exposure vaccination may be useful. See

above.above.• Passive immunization with vaccine Passive immunization with vaccine

immunoglobulin may be given especially if immunoglobulin may be given especially if more than 3 days have elapsed since more than 3 days have elapsed since exposure.exposure.


Vaccination cont.:Vaccination cont.:• Vaccination often performed for Vaccination often performed for

contacts as ring vaccination. In this contacts as ring vaccination. In this model, contacts of the patients are model, contacts of the patients are identified and vaccinated with further identified and vaccinated with further case identification, surveillance contact case identification, surveillance contact identification and vaccination in identification and vaccination in concentric “rings.” This has been concentric “rings.” This has been proposed rather than universal proposed rather than universal vaccination in which many more vaccination in which many more reactions to the vaccine would be seen.reactions to the vaccine would be seen.


Other notes:Other notes:• Requires biosafety level 4.Requires biosafety level 4.• Staff caring for patients with smallpox may be Staff caring for patients with smallpox may be

asked to monitor their temperatures daily, not asked to monitor their temperatures daily, not use main hospital entrance, shower and use main hospital entrance, shower and change before leaving and not enter main change before leaving and not enter main hospital area during work.hospital area during work.

• Some recommend not admitting smallpox Some recommend not admitting smallpox patients to hospitals but maintaining them in patients to hospitals but maintaining them in the home because smallpox is so contagious the home because smallpox is so contagious that hospitalization could increase the number that hospitalization could increase the number of people at potential risk of transmission.of people at potential risk of transmission.

Tularemia (Tularemia (FrancisellaFrancisella tularensistularensis))

Description:Description:• Is a category A agent because of Is a category A agent because of

infectivity, ease of dissemination, and infectivity, ease of dissemination, and ability to cause serious illness.ability to cause serious illness.

Other names:Other names:• Deer-fly fever, Glandular tick fever, Market Deer-fly fever, Glandular tick fever, Market

man’s disease, Rabbit fever, and O’Hara’s man’s disease, Rabbit fever, and O’Hara’s diseasedisease

TularemiaTularemia-2-2

Etiology:Etiology:• FrancisellaFrancisella tularensistularensis, a tiny, gram-negative, , a tiny, gram-negative,

non-spore forming, hardy, aerobic non-spore forming, hardy, aerobic coccobacillus.coccobacillus.

• Two subspecies:Two subspecies: Type A is more common in North America and is Type A is more common in North America and is

more virulent thanmore virulent than Type B, found in Asia, Europe and North America.Type B, found in Asia, Europe and North America. Type A typically associated with rabbits.Type A typically associated with rabbits. Type B typically associated with rodents or wet Type B typically associated with rodents or wet

environment.environment.


Epidemiology:Epidemiology:• A zoonotic infection. A zoonotic infection. • Occurs in the US, Europe, and Asia. Has diverse Occurs in the US, Europe, and Asia. Has diverse

small mammal animal hosts, including rabbits, small mammal animal hosts, including rabbits, squirrels, muskrats, mice, water rats, and squirrels, muskrats, mice, water rats, and others that are natural reservoirs of infection.others that are natural reservoirs of infection.

• F.F. tularensistularensis may be recovered from soil, may be recovered from soil, water, and vegetation.water, and vegetation.

• In the US, fewer than 200 recognized cases In the US, fewer than 200 recognized cases occur each year. occur each year.

• Disease is endemic in Martha’s Vineyard.Disease is endemic in Martha’s Vineyard.• Is occupational risk for hunters, trappers, and Is occupational risk for hunters, trappers, and

others who handle infected animal carcasses.others who handle infected animal carcasses.


Transmission:Transmission:• Direct contact with infected animal fluids or Direct contact with infected animal fluids or

tissues, tissues, • Ingestion of contaminated water,Ingestion of contaminated water,• Ingestion of contaminated undercooked meat, Ingestion of contaminated undercooked meat,

water or soil,water or soil,• Bites of infected arthropods, such as ticks,Bites of infected arthropods, such as ticks,• Inhalation of infectious aerosols, such as Inhalation of infectious aerosols, such as

contaminated dust, or deliberate release in contaminated dust, or deliberate release in laboratory, orlaboratory, or

• Direct contact with contaminated food, water, or Direct contact with contaminated food, water, or soil. soil.

• Person-to-person spread is unusual.Person-to-person spread is unusual.


Incubation period:Incubation period: • 1 to 21 days, typically 3 to 5 days1 to 21 days, typically 3 to 5 days

Clinical manifestations:Clinical manifestations:• Extremely variable depending on type, route of Extremely variable depending on type, route of

inoculation and dose.inoculation and dose.• Occurs in six recognized clinical forms: Occurs in six recognized clinical forms:

ulceroglandular, glandular, oculoglandular, ulceroglandular, glandular, oculoglandular, oropharyngeal, pneumonic, and typhoidal.oropharyngeal, pneumonic, and typhoidal.

• Tularemia sepsis may follow dissemination and Tularemia sepsis may follow dissemination and be severe leading to disseminated be severe leading to disseminated intravascular coagulation (DIC), acute intravascular coagulation (DIC), acute respiratory distress syndrome (ARDS), and respiratory distress syndrome (ARDS), and organ failure if not treated immediately and organ failure if not treated immediately and appropriately.appropriately.


Clinical manifestations cont.:Clinical manifestations cont.:• Ulceroglandular Ulceroglandular – is the most common – is the most common

type.type. Occurs following the bite of an infected Occurs following the bite of an infected

arthropod or handling an infected animal. arthropod or handling an infected animal. Begins as chills, fever, headache, generalized Begins as chills, fever, headache, generalized

aches, and can disseminate to lymph nodes, aches, and can disseminate to lymph nodes, and their enlargement or lymphadenopathy and their enlargement or lymphadenopathy may resemble buboes in bubonic plague.may resemble buboes in bubonic plague.

A skin papule develops that becomes pustular A skin papule develops that becomes pustular and eventually ulcerates.and eventually ulcerates.

The skin lesion can last for months.The skin lesion can last for months.


Clinical manifestations cont.:Clinical manifestations cont.:• GlandularGlandular – similar to above but without the ulcer. – similar to above but without the ulcer.• OculoglandularOculoglandular – occurs after eye contamination – occurs after eye contamination

causing conjunctival ulceration, inflamed eyelids causing conjunctival ulceration, inflamed eyelids and nodules, vasculitis and possibly regional and nodules, vasculitis and possibly regional lymphadenopathylymphadenopathy

• OropharyngealOropharyngeal – occurs after ingestion of – occurs after ingestion of contaminated food or water.contaminated food or water.

Results in pharyngitis with yellow-white Results in pharyngitis with yellow-white pseudomembrane, and tonsillitis with cervical or pseudomembrane, and tonsillitis with cervical or retropharyngeal lymphadenopathy.retropharyngeal lymphadenopathy.

In some cases, diarrhea and bowel ulceration may occur.In some cases, diarrhea and bowel ulceration may occur.


Clinical manifestations cont.:Clinical manifestations cont.:• Pneumonic (primary)Pneumonic (primary) – from inhaling – from inhaling

infected aerosols.infected aerosols. Can present as atypical pneumonia or Can present as atypical pneumonia or

present as acute illness with fever, fatigue, present as acute illness with fever, fatigue, chills, headache and malaise.chills, headache and malaise.

Cough, usually nonproductive, Cough, usually nonproductive, manifestations of bronchitis, pneumonitis, manifestations of bronchitis, pneumonitis, chest pain and dyspnea may occur.chest pain and dyspnea may occur.

Erythema multiforme may occur, and a rash Erythema multiforme may occur, and a rash or erythema nodosum may be seen in about or erythema nodosum may be seen in about one-third.one-third.


Clinical manifestations cont.:Clinical manifestations cont.:• TyphoidalTyphoidal – acute septicemic illness with – acute septicemic illness with

fever and prostration leading to delirium fever and prostration leading to delirium without skin lesion or lympohadenopathy.without skin lesion or lympohadenopathy.

Pneumonia is common.Pneumonia is common. May exhibit abdominal pain, vomiting and May exhibit abdominal pain, vomiting and

diarrhea.diarrhea. Mortality rate is about 35% to 60%.Mortality rate is about 35% to 60%.


Diagnosis:Diagnosis:• Clinical suspicion.Clinical suspicion.• Serological testing, culture sputum for Serological testing, culture sputum for

gram stain culture and other testing.gram stain culture and other testing.• Identification of organism in other Identification of organism in other

tissues as appropriate.tissues as appropriate. Mortality:Mortality:

• If untreated, ranges from 5% to 35%, If untreated, ranges from 5% to 35%, overall.overall.

• With prompt treatment may be only 1%.With prompt treatment may be only 1%.


Treatment:Treatment:• Preferred treatment is parenteral streptomycin Preferred treatment is parenteral streptomycin

or intravenous gentamicin or aminoglycosides or intravenous gentamicin or aminoglycosides for 10 days.for 10 days.

• Fluoroquinolones show promise in treatment.Fluoroquinolones show promise in treatment.• In a mass casualty situation, doxycycline and In a mass casualty situation, doxycycline and

ciprofloxacin given orally is recommended.ciprofloxacin given orally is recommended.• Postexposure prophylaxis with ciprofloxacin or Postexposure prophylaxis with ciprofloxacin or

doxycycline for 14 days is recommended to doxycycline for 14 days is recommended to prevent clinical disease if begun during the prevent clinical disease if begun during the incubation period.incubation period.


Nursing considerations:Nursing considerations:• Standard isolation precautions are recommended.Standard isolation precautions are recommended.• Supportive care.Supportive care.

Vaccine:Vaccine:• One form was available and recommended for One form was available and recommended for

certain occupations but some difficulties were certain occupations but some difficulties were found.found.

• The live attenuated vaccine is still being The live attenuated vaccine is still being investigated.investigated.

Other:Other:• Studied in biosafety lab 3.Studied in biosafety lab 3.• For laboratory workers, negative pressure For laboratory workers, negative pressure

microbiological cabinets as well as face masks microbiological cabinets as well as face masks are recommended.are recommended.


Prevention:Prevention:• In natural cases:In natural cases:

Avoid tick-infested areasAvoid tick-infested areas Avoid tick and mosquito bites through Avoid tick and mosquito bites through

protective clothing, repellents, tick checks.protective clothing, repellents, tick checks. Use gloves, masks, protective eye-cover Use gloves, masks, protective eye-cover

when handling wild animals.when handling wild animals. Cook wild game thoroughly.Cook wild game thoroughly. Avoid drinking untreated water.Avoid drinking untreated water.

Other Hemorrhagic Fever ArenavirusesOther Hemorrhagic Fever Arenaviruses The category includes 5 arenaviruses that The category includes 5 arenaviruses that

cause viral hemorrhagic fevers.cause viral hemorrhagic fevers.• Lassa virus (Lassa fever), which is one of these, Lassa virus (Lassa fever), which is one of these,

is discussed separately in this module.is discussed separately in this module. Other arenaviruses and the viral Other arenaviruses and the viral

hemorrhagic fevers they can cause hemorrhagic fevers they can cause include:include:

VirusVirus DiseaseDisease• Junin virusJunin virus Argentine hemorrhagic fever Argentine hemorrhagic fever• Sabia virus Brazilian hemorrhagic feverSabia virus Brazilian hemorrhagic fever• Machupo virus Bolivian hemorrhagic feverMachupo virus Bolivian hemorrhagic fever• Guanarito virus Venezuelan hemorrhagicGuanarito virus Venezuelan hemorrhagic feverfever

SAHFSAHF-2-2

These four viruses are sometimes known These four viruses are sometimes known collectively as South American hemorrhagic fever collectively as South American hemorrhagic fever (SAHF) viruses and are discussed collectively first. (SAHF) viruses and are discussed collectively first. Then Junin virus causing Argentine hemorrhagic Then Junin virus causing Argentine hemorrhagic fever is discussed specifically next along with fever is discussed specifically next along with information about the other SAHF viruses.information about the other SAHF viruses.

The SAHF viruses each cause diseases of similar The SAHF viruses each cause diseases of similar symptomatology.symptomatology.

Specific species of rodents are natural hosts for Specific species of rodents are natural hosts for the viruses.the viruses.

The typical incubation period is 7 to 14 days but The typical incubation period is 7 to 14 days but may extend from 5 to 21 days. Case fatality rates may extend from 5 to 21 days. Case fatality rates are estimated as 15 to 30%.are estimated as 15 to 30%.

SAHFSAHF-3-3

Rodents are implicated in Rodents are implicated in transmission through contaminated transmission through contaminated food, water or direct contact with food, water or direct contact with infected secretions or through infected secretions or through inhalation of infectious secretions or inhalation of infectious secretions or excretions such as infected rodent excretions such as infected rodent urine. Person-to-person transmission urine. Person-to-person transmission may occur especially for Machupo may occur especially for Machupo virus.virus.

SAHFSAHF-4-4

Clinical features tend to be similar with:Clinical features tend to be similar with:• Gradual onset of feverGradual onset of fever• Malaise followed by myalgia, back pain, Malaise followed by myalgia, back pain,

headache and dizziness with hyperesthesia of headache and dizziness with hyperesthesia of the skinthe skin

• Hemorrhagic manifestations include Hemorrhagic manifestations include hemorrhaging from gums, vagina and hemorrhaging from gums, vagina and gastrointestinal tract leading to hypovolemic gastrointestinal tract leading to hypovolemic shockshock

• Neurological manifestations include tremors, Neurological manifestations include tremors, inability to swallow, grand mal convulsions and inability to swallow, grand mal convulsions and coma.coma.

SAHFSAHF-5-5

Clinical features cont.:Clinical features cont.:• Some symptoms are more specifically Some symptoms are more specifically

associated with individual viruses.associated with individual viruses. For example, in Guanarito virus, pharyngitis, For example, in Guanarito virus, pharyngitis,

vomiting, and diarrhea are more commonly vomiting, and diarrhea are more commonly seen. seen.

In Junin and Machupo viral infections, In Junin and Machupo viral infections, petechiae, erythema, facial edema, petechiae, erythema, facial edema, hyperesthesia of the skin and shock may be hyperesthesia of the skin and shock may be more frequent. Both of these have a high more frequent. Both of these have a high fetal mortality if occurring in pregnant fetal mortality if occurring in pregnant women.women.

SAHFSAHF-6-6

Clinical features noted during an outbreak of Clinical features noted during an outbreak of Venezuelan hemorrhagic fever included fever, Venezuelan hemorrhagic fever included fever, conjunctivitis, pharyngitis, thrombocytopenia, conjunctivitis, pharyngitis, thrombocytopenia, myalgia, and hemorrhagic manifestations. Facial myalgia, and hemorrhagic manifestations. Facial edema was also observed. In this outbreak, 9 of edema was also observed. In this outbreak, 9 of 15 cases died. A few hundred cases have been 15 cases died. A few hundred cases have been reported.reported.

Clinical features noted in an outbreak of Bolivian Clinical features noted in an outbreak of Bolivian hemorrhagic fever included: fever, chills, malaise, hemorrhagic fever included: fever, chills, malaise, arthralgias, severe lower back pain, headache arthralgias, severe lower back pain, headache and hemorrhagic manifestations. The incubation and hemorrhagic manifestations. The incubation period was 1 to 2 weeks. The case fatality rate is period was 1 to 2 weeks. The case fatality rate is estimated at 20%. Nosocomial transmission has estimated at 20%. Nosocomial transmission has been noted.been noted.

SAHFSAHF-7-7

If used for bioterrorism, viremia may be If used for bioterrorism, viremia may be high with a higher transmission rate and high with a higher transmission rate and higher mortality as well as a greater higher mortality as well as a greater frequency of secondary cases because of frequency of secondary cases because of the large number of patients flowing into the large number of patients flowing into emergency facilities due to nosocomial emergency facilities due to nosocomial transmission.transmission.

Standard, contact and airborne isolation Standard, contact and airborne isolation precautions.precautions.

Barrier nursing precautions as outlined for Barrier nursing precautions as outlined for Lassa fever should be followed.Lassa fever should be followed.

Biosafety containment level 4 is used for Biosafety containment level 4 is used for these viruses.these viruses.

Junin Virus & SAHF VirusesJunin Virus & SAHF Viruses

Etiology:Etiology:• Junin virus is a RNA virus in the Junin virus is a RNA virus in the

arenavirus family.arenavirus family.• It belongs to what is commonly known It belongs to what is commonly known

as the New World arenaviruses-Machupo as the New World arenaviruses-Machupo virus, Guanarito virus and Sabia virus.virus, Guanarito virus and Sabia virus.

• Each of these can cause a viral Each of these can cause a viral hemorrhagic fever similar to the hemorrhagic fever similar to the Argentine hemorrhagic fever caused by Argentine hemorrhagic fever caused by Junin virus.Junin virus.

Junin Virus & SAHF VirusesJunin Virus & SAHF Viruses -2-2

Epidemiology:Epidemiology:• Junin and other new world viruses have mostly Junin and other new world viruses have mostly

been identified from the 1950s to date.been identified from the 1950s to date.• The natural hosts are rodents.The natural hosts are rodents.• The at-risk region is mainly Argentina.The at-risk region is mainly Argentina.• It tends to be seasonal with a peak during the It tends to be seasonal with a peak during the

corn harvest from March to June.corn harvest from March to June.• Most of those infected are agricultural workers Most of those infected are agricultural workers

who inhale infected aerosols from rodent excreta who inhale infected aerosols from rodent excreta or when rodents are caught in mechanical or when rodents are caught in mechanical harvesters.harvesters.

• Aerosol infections have been noted in laboratory Aerosol infections have been noted in laboratory workers.workers.

• Sabia virus infection has only been documented Sabia virus infection has only been documented rarely. In one case, it was laboratory acquired in rarely. In one case, it was laboratory acquired in the US and the researcher was treated with the US and the researcher was treated with ribavirin and survived.ribavirin and survived.


Transmission:Transmission:• Contact with infected rodents, inhalation of Contact with infected rodents, inhalation of

infectious rodent secretions or excretions.infectious rodent secretions or excretions.• Person-to-person airborne spread has been Person-to-person airborne spread has been

described for Machupo virus as well as Lassa described for Machupo virus as well as Lassa virus (discussed earlier).virus (discussed earlier).

• Machupo virus has been transmitted to Machupo virus has been transmitted to spouses 1-3 weeks after onset of illness.spouses 1-3 weeks after onset of illness.

• Nosocomial transmission mediated by infected Nosocomial transmission mediated by infected blood and excretion contact is described as blood and excretion contact is described as possible as is contact with medical equipment possible as is contact with medical equipment that has been contaminated by virus.that has been contaminated by virus.


Incubation period:Incubation period:• Typically 7 to 14 days, but can be 2 to 21 days.Typically 7 to 14 days, but can be 2 to 21 days.

Clinical manifestations:Clinical manifestations:• Are similar but not identical for the South Are similar but not identical for the South

American hemorrhagic fevers.American hemorrhagic fevers.• Typical onset is gradual with fever, malaise Typical onset is gradual with fever, malaise

followed by headache, myalgia, back pain, followed by headache, myalgia, back pain, dizziness, and hyperesthesia of the skin.dizziness, and hyperesthesia of the skin.

• Guanarito virus infections tend to include Guanarito virus infections tend to include pharyngitis, vomiting and diarrhea more pharyngitis, vomiting and diarrhea more frequently than others.frequently than others.


Clinical manifestations cont.:Clinical manifestations cont.:• Junin and Machupo infections tend to include Junin and Machupo infections tend to include

petechiae, erythema and flushing of face and petechiae, erythema and flushing of face and trunk, facial edema and lymphadenopathy.trunk, facial edema and lymphadenopathy.

• Hemorrhagic and neurological manifestations Hemorrhagic and neurological manifestations may occur alone or together.may occur alone or together.

• Hemorrhagic manifestations include Hemorrhagic manifestations include hemorrhaging from the gums and orifices, hemorrhaging from the gums and orifices, especially the gastrointestinal tract and vagina especially the gastrointestinal tract and vagina in females leading to shock, and capillary leak in females leading to shock, and capillary leak syndrome with thrombocytopenia.syndrome with thrombocytopenia.


Clinical manifestations cont.:Clinical manifestations cont.:• Neurological manifestations include tremors, Neurological manifestations include tremors,

inability to swallow, dysarthria, convulsions, inability to swallow, dysarthria, convulsions, coma and death which may occur 7 to 12 days coma and death which may occur 7 to 12 days after onset.after onset.

• Recovery is usually complete but there may be Recovery is usually complete but there may be a temporary loss of scalp hair.a temporary loss of scalp hair.

• Pregnant women are more likely to have a fatal Pregnant women are more likely to have a fatal outcome if infected with Junin virus and both outcome if infected with Junin virus and both Junin and Machupo viruses are associated with Junin and Machupo viruses are associated with high fetal mortality.high fetal mortality.


Mortality:Mortality:• Mortality rate is 15-30%.Mortality rate is 15-30%.

Treatment:Treatment:• Ribavirin as been used successfully intravenously Ribavirin as been used successfully intravenously

for about 10 days, and is recommended for at-risk for about 10 days, and is recommended for at-risk contacts orally for a week. Limited number of contacts orally for a week. Limited number of studies are available though.studies are available though.

• Other treatment is generally non-specific and Other treatment is generally non-specific and supportive, including fluid and electrolyte supportive, including fluid and electrolyte balance, monitoring, and clotting factor or platelet balance, monitoring, and clotting factor or platelet replacement may be done in cases of serious replacement may be done in cases of serious hemorrhage.hemorrhage.

• Convalescent or immune serum therapy has been Convalescent or immune serum therapy has been used for Junin and Machupo viral infections.used for Junin and Machupo viral infections.


Nursing considerations:Nursing considerations:• Strict barrier nursing precautions should be Strict barrier nursing precautions should be

used, including standard and contact isolation used, including standard and contact isolation precautions, and in the interests of absolute precautions, and in the interests of absolute safety, airborne precautions.safety, airborne precautions.

• Educate patient about isolation precautions Educate patient about isolation precautions being used.being used.

• Indicate what is expected of them in regard to Indicate what is expected of them in regard to cooperation if they are able to cooperate and cooperation if they are able to cooperate and understand.understand.

• See infection control module for details and See infection control module for details and CDC site as well as material previously CDC site as well as material previously discussed under Lassa, Ebola and Marburg discussed under Lassa, Ebola and Marburg viruses.viruses.

• Supportive care.Supportive care.


Other notes:Other notes:• Biosafety level 4 Biosafety level 4

conditions are used conditions are used for study.for study.

Picture from CDC.Picture from CDC.

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