Biological Agents

Clinicians Course / Version 1

4 April 2009

SECTION I. ADMINISTRATIVE DATA

All Courses Course Number Version Course Title

Including Emergency Preparedness Readiness
This Lesson Course (Clinician)

Task(s) Task Number Task Title

Taught(*) or Biological Agents
Supported

Reinforced Task Number Task Title

Task(s)

Academic The academic hours required to teach this lesson are as follows:
Hours
Resident
Hours/Methods
1.5 mins / Conference / Discussion
0.0 mins / Conference/Demonstration
0.0 mins / Conference/Demonstration
0.0 hrs / Practical Exercise (Performance)
Test 0 hrs
Test Review 0 hrs
Total Hours: 1.5 hrs

Test Lesson Hours Lesson No.

Number
Testing
(to include test review) N/A

Prerequisite Lesson Number Lesson Title

Lesson(s)

Clearance
Security Level: Unclassified
Access
Requirements: There are no clearance or access requirements for the
lesson.

Foreign
FD5. This product/publication has been reviewed by the product developers
Disclosure
in coordination with the USAMEDDC&S foreign disclosure authority. This
Restrictions
product is releasable to students from all requesting foreign countries
without restrictions.

1
References Number Title Date Additional
Information
FM 3-11 MULTISERVICE 10 Mar 2003
TACTICS,
TECHNIQUES, AND
PROCEDURES FOR
NUCLEAR,
BIOLOGICAL, AND
CHEMICAL DEFENSE
OPERATIONS
FM 3-11.9 POTENTIAL MILITARY 10 Jan 2005
CHEMICAL/BIOLOGICAL
AGENTS AND
COMPOUNDS
FM 3-11.5 MULTISERVICE 04 Apr 2006
TACTICS,
TECHNIQUES, AND
PROCEDURES FOR
CHEMICAL,
BIOLOGICAL,
RADIOLOGICAL, AND
NUCLEAR
DECONTAMINATION
FM 4-25.11 FIRST AID (INCL 23 Dec 2002
CHANGE 1)
FM 4-02.285 MULTISERVICE 18 Sep 2007
TACTICS,
TECHNIQUES AND
PROCEDURES FOR
TREATMENT OF
CHEMICAL AGENT
CASUALTIES AND
CONVENTIONAL
MILITARY CHEMICAL
INJURIES
FM 8-9 NATO HANDBOOK ON 01 Feb 1996
THE MEDICAL
ASPECTS OF NBC
DEFENSE
OPERATIONS
AMEDP-6(B)
STP 21-1-SMCT SOLDIER'S MANUAL 14 Dec 2007
OF COMMON TASKS,
WARRIOR SKILLS,
LEVEL 1
STP 21-24-SMCT SOLDIER'S MANUAL 09 Sep 2008
OF COMMON TASKS,
WARRIOR LEADER,
SKILL LEVELS 2, 3,
AND 4
Student
Study
Assignments

2
Instructor
Requirements
One instructor, Civilian (CBRNE/NBC), 74D2/30, 74A- ITC qualified

Additional Name Stu Qty Man Hours

Support Ratio
Personnel None
Requirements
Equipment Id Stu Inst Spt Qty Exp
Required Name Rati Ratio
o
COMPUTER-INSTRUCTOR No 1 No
COMPUTER (CPU) WITH KEYBOARD,
INSTRUCTOR USE ONLY
MONITOR-INSTRUCTOR No 1 No
COMPUTER MONITOR
PROJECTOR-INSTRUCTOR No 1 No
OVERHEAD PROJECTOR WITH
COMPUTER INTERFACE
SCREEN-INSTRUCTOR No 1 No
SCREEN PROJECTOR, INSTRUCTOR
USE
* Before Id indicates a TADSS

Materials Instructor Materials:

Required PowerPoint presentation and lesson plan.

Student Materials:
Duty uniform, student handouts, pen/pencil, paper

Classroom,
Training Area, LEVEL ONE, GENERAL PURPOSE CLASSROOM, 60 PN
and Range
Requirements

Ammunition Exp Stu Instr Spt

Requirements Id Name Ratio Ratio Qty
None

Instructional Before presenting this lesson, instructors must thoroughly prepare by

Guidance studying this lesson and identified reference material.
Ensure the classroom is open, computer, PowerPoint presentation, and
projector work at least 15 minutes prior to the class.

3
Proponent Name Rank Position Date
Lesson Plan
CBRNE SCI BR, PN
Approvals

SECTION II. INTRODUCTION

Method of Instruction:
Conference/Demonstration:
Instructor to Student Ratio is:
Time of Instruction:
Media:

Motivator
Being familiar with facts and principles relating to the identification and
pathophysiology of biological agents is imperative to obtain a presumptive
diagnosis and provide treatment to exposed casualties. Early treatment
dramatically increases the probability of survival.

Terminal
NOTE: Inform the students of the following Terminal Learning Objective
Learning
requirements. At the completion of this lesson, you [the student] will:
Objective

Action:
Recognize facts and principles relating to the identification
and pathophysiology of biological agents so expedient and
appropriate diagnosis and treatment can be provided to
exposed casualties and thus increase survival.

Conditions:
Given a possible biological event scenario (terrorism, or on
the battlefield)

Standards:
Recognized facts and principles relating to the identification
and pathophysiology of biological agents so expedient and
appropriate diagnosis and treatment can be provided to
exposed casualties and thus increase survival, IAW Textbook
of Military Medicine, Medical Aspects of Biological Warfare,
Office of the Surgeon General Department of the Army,
United States of America and US Army Department Center
and School. FM 3-11, FM 3-11.9, FM 4-02.285, FM 4-25.11,
FM 8-9, FM 3-11.5, STP 21-1-SMCT and STP 21-24-SMCT.

Safety
Requirements
Low

4
Risk
NOTE: It is the responsibility of all Soldiers and DA civilians to protect the
Assessment
Environment from damage.
Level

Environmental
Considerations
Low

Evaluation
Students will be evaluated using a written exam. Students must score at
least a 70% to receive a GO.

Instructional A critical aspect of providing timely and appropriate medical care of a

Lead-In biological agent exposure is the ability to recognize the signs and
symptoms observed in a casualty. In addition to death, biological agents
can cause chronic, deteriorating, or debilitating conditions. Early detection
and presumptive identification will provide the opportunity to treat patients
immediately or soon after an event. Knowing facts and principles relating to
the identification and pathophysiology of the most probable biological
terrorist or warfare agents will make a significant difference in the overall
survival rate of those exposed to these agents. The earlier preventive or
definitive medical care is given the greater probability for survival and the
sooner soldiers can returned to the mission.

5
 SECTION III. PRESENTATION

NOTE: Inform the students of the Enabling Learning Objective requirements.

A. ENABLING LEARNING OBJECTIVE

ACTION: Identify the biological agents that are most likely to be utilized
as a biological threat or weapon and what biological category
the agent belongs, bacteria, virus or toxin.
CONDITIONS: None
STANDARDS: Identified the biological agents that are most likely to be
utilized as a biological threat or weapon and what biological
category the agent belongs, bacteria, virus or toxin IAW
Textbook of Military Medicine, Medical Aspects of Biological
Warfare, Office of the Surgeon General Department of the
Army, United States of America and US Army Department
Center and School. FM 3-11, FM 4-02.285, and FM 8-9.

1. Learning Step / Activity 1. Classification of biological threat agents

Method of Instruction:
Conference/ Demonstration
Instructor to Student Ratio is:
Time of Instruction:
Media:

NOTE: See Slide 3

a. Biological agents
(1) Biological agents are living organisms, or materials derived from them, that cause
disease or harm to humans, animals, or plants.
(2) Biological agents can be bacterial, viral, or toxins
(3) Biological agents may be used as liquid droplets, aerosols, or dry powders.
(4) Biological agents are likely to used as a terrorist threat due to the following attributes:
(a) Ease of availability, relatively inexpensive to obtain and the ease of use and
dissemination
(b) The agents can be manufactured or modified to increase their virulent characteristics
and effective dispersal as aerosols
(c) Effectively meets varied terrorist objective scenarios, e.g. individual or mass human,
animal targets, illness, incapacitation, or death and immediate or delayed onset of
clinical symptoms
(d) Many agents have no treatment beyond supportive care, prophylaxis or vaccination
or require early intervention with antibiotics, anti-toxins, etc.

b. Bacteria - Single-cell organisms that multiply by cell division and can cause disease in
humans, plants, and animals.
(a) Anthrax
(b) Plague

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 (c) Tularemia
(d) Q Fever
(e) Brucellosis

c. Viruses - Infectious microorganisms that exist as a particle rather than as one complete cell
and are not capable of reproducing outside of a host cell.
(a) Smallpox
(b) Hemorrhagic Fever Viruses
(c) Encephalitis Viruses

d. Toxins - Toxins. Poisonous substances that are produced by living organisms and have
different effects, depending on the toxin.
(a) Botulinum toxin
(b) Ricin
(c) Staphylococcal Enterotoxin B (SEB)
(d) T-2 Mycotoxins

NOTE: Conduct a check on learning and summarize the learning activity.

1. Living organisms, or materials derived from them, that cause disease tor harm to
humans, animals, or plants are known as BIOLOGICAL agents.

2. Name the three types of biological agents. BACTERIA, VIRUS, TOXINS

B. ENABLING LEARNING OBJECTIVE

ACTION: Identify facts and principles of biological agents to include the

pathophysiological indicators, signs, and symptoms of
exposure, conditions and decision criteria of diagnosis and
treatment course of casualties.
CONDITIONS: Given a scenario involving a biological agent casualty
STANDARDS: Identified facts and principles of biological agents to include
the indicators, signs, and symptoms of exposure, conditions
and decision criteria of diagnosis and treatment course of
casualties IAW Textbook of Military Medicine, Medical
Aspects of Biological Warfare, Office of the Surgeon General
Department of the Army, United States of America and US
Army Department Center and School. FM 3-11, FM 4-25.11,
FM 4-02.285, FM 8-9, FM 3-11.5, STP 21-1-SMCT and STP
21-24-SMCT.

1. Learning Step / Activity 1. Bacterial agents

Method of Instruction:
Conference/ Demonstration
Instructor to Student Ratio is:
Time of Instruction:
Media:

7
NOTE: See Slide 4

NOTE: A terrorism incident will bear enormous pressure to apprehend and convict
perpetrators. Identification, verification, and confirmation of agents can be valuable
investigational tools; determination of genetic differences in pathogens may establish the source
laboratories or other useful information.

NOTE: See Slides 5-14

a. Anthrax - The disease anthrax results from the gram-positive sporulating rod of Bacillus
anthracis. Humans usually contract the disease by handling contaminated hides, flesh,
or blood of infected animals, or by ingesting products such as bone meal or a
contaminated meat. The spores of anthrax that are protected from sunlight may remain
viable in the soil for many years.

(1) Anthrax: Clinical Forms

(a) Cutaneous - This form of the disease typically follows exposure to anthrax-
infected animals. Spores enter the body through skin abrasions or mucous
membranes. It is the most common naturally occurring form, responsible for over
95% of identified cases with an estimated 2,000 cases reported annually
worldwide. Standard precautions are recommended for patient care in all forms
of anthrax disease. There are no data to suggest direct person-to-person spread
from any form of anthrax disease. Decontamination can be achieved using a
sporicidal agent such as hypochlorite. Cutaneous anthrax is often not fatal, even
if untreated. Death is rare unless skin lesions have progressed leading to
bacteremia and sepsis or lesions have become secondarily infected
(b) Inhalational - This form of the disease, also known as Woolsorter's Disease, in its
naturally occurring form is quite rare. However, it accounts for the highest
morbidity and mortality among the three forms of the disease. This is the form we
would expect to see in a biological warfare attack. Prior to the anthrax attacks in
2001, only 18 cases of inhalational anthrax were reported in the United States in
the 20th century.
(c) Gastrointestinal - This form of the disease occurs following the ingestion of
insufficiently cooked, contaminated meat of an anthrax infected animal.
Gastrointestinal anthrax is not a common form of the disease. It is generally
estimated that there are fewer than 100 cases worldwide per year.
(d) Systemic - A small percentage of cutaneous infections become systemic, and
these can be fatal. Most systemic anthrax is the result inhalation of the organism
has a mortality rate approaching 100 percent, with death usually occurring within
a few days after the onset of symptoms. Whatever the portal of entry, systemic
anthrax involves massive bacteremia and toxemia with nondescript initial
symptoms until the onset of hypotension, shock, and sudden death.
Manifestations of advanced disease, including shock and sudden death, are
believed to result from the action of the exotoxin complex secreted by anthrax
bacilli.

NOTE: Anthrax is bacterial infection that occurs when Bacillus anthracis endospores enter the
body through abrasions in the skin or by inhalation or ingestion. It is a zoonotic disease to
which most mammals, especially grazing herbivores, are considered susceptible. Human

8
infections result from contact with contaminated animals or animal products, and there are no
known cases of human-to-human transmission.

(2) Anthrax: Behavior and Risk - Method of presentation depends on whether it enters
through a break in the skin, is inhaled, or ingested.
(a) Behavior
i Initial symptoms are flu-like in nature and progress to severe respiratory
distress/difficulty breathing.
ii Death typically occurs within 24 to 36 hours after onset of severe symptoms.
(b) Risk
i Although it is not transmittable person-to-person, if not recognized and
treated, anthrax can have a high mortality rate.
ii Spores are hardy and may necessitate decontamination.
iii Treatment should ideally occur prior to onset of symptoms.

(3) Anthrax: Signs and Symptoms

(a) Cutaneous
i Incubation Period: Initial lesions develop within 1 to 5 days.
ii Signs and Symptoms: Local edema followed by:
• Macule, or papule progressing to a vesicle, which then ulcerates over
several days.
• Painless black eschar.
• Eschar drying, loosening, and falling off within 1 to 2 weeks.
• Lymphangitis and painful lymphadenopathy occurring with associated
systemic symptoms.
• Local infection in some cases disseminating into a fatal systemic
infection.
(b) Inhalational
i Incubation Period: Incubation period of 1 to 6 days
ii Signs and Symptoms: Begin gradually and nonspecifically:
• Fever
• Malaise
• Fatigue
• Nonproductive cough
• Mild chest discomfort
iii May be followed by a short period of improvement (hours to 1 day), then:
• Abrupt onset development of severe respiratory distress
• Dyspnea
• Diaphoresis
• Stridor
• Cyanosis
• Septicemia, shock, and death usually follow within 24 to 36 hours.
(c) Gastrointestinal
i Incubation Period: Unknown, but thought to be days.
ii Signs and Symptoms:
• May affect the upper or lower Gastrointestinal (GI) tract
(i) Disease in the lower GI tract may manifest as:
° Primary intestinal lesions
° Nausea, vomiting, malaise

9
 ° Bloody diarrhea, acute abdomen bowel infarction or sepsis
leading to death
(ii) Oral-pharyngeal form begins with an oral or esophageal ulcer leading
to regional lymphadenopathy, edema, and sepsis
(iii) Adenopathy may develop rapidly leading to acute airway compromise
and asphyxiation before the development of sepsis
(iv) Disease in the lower GI tract
(v) Massive ascites have occurred in some cases.

(4) Anthrax: Laboratory Diagnosis

(a) Cutaneous - In addition to signs and symptoms, laboratory results may reveal
important information and diagnostic clues. Bacillus anthracis will be detectable
in routine blood cultures, often within hours, and occasionally by Gram stain of
the blood. If vegetative organisms are detected in the blood, indicating the
presence of a life-threatening infection, which may be fatal within hours, even
with aggressive therapy.
i Presents with vesicles that discharge clear or serosanguinous fluid revealing
gram-positive bacilli with few neutrophils.
ii Lesions may be confused with Staph infections or ulcerated spider bites.
iii Culture of the fluid or a skin biopsy may yield B. anthracis within 24hours.
Identification of cultured bacteria can be confirmed with gram stain, gamma
phage, and fatty acid analysis.
iv Polymerase Chain Reaction (PCR) of the lesion fluid or a biopsy may also be
used to confirm the diagnosis, as well as Enzyme Link Immunosorbent Assay
(ELISA) and Electrochemiluminescence (ECL).
(b) Inhalational - Inhalational anthrax is primarily a disease of the mediastinum.
i Pathology resembles that of a Ghon complex similar to that seen in
pulmonary tuberculosis. It rarely causes a primary pneumonia. In those few
cases when a pneumonic process occurs. Studies show that bacilli and toxin
appear in the blood late on day 2 or early on day 3 post-exposure, often prior
to the onset of symptoms or only in association with mild illness. Concurrently
the White Blood Cell Count (WBC) becomes elevated and remains so until
death. Approximately 50% of cases are accompanied by hemorrhagic
meningitis. Therefore, organisms may also be identified or cultured from the
cerebrospinal fluid.
ii Chest x-ray or CT scan may reveal a widened mediastinum, with or without
pleural effusions, in about half the cases.
iii Not typically seen in the sputum until there is overwhelming infection.
iv Gram stain and culture of pleural fluid commonly reveal Bacillus anthracis.
v Identification of cultured bacteria can be confirmed with gamma phage and
fatty acid analysis.
vi PCR, ELISA, and ECL can also reveal the presence of Bacillus anthracis.
vii Tests to rapidly detect the toxin are available at research centers and the
Centers for Disease Control and Prevention (CDC).
viii Approximately 50% of cases are accompanied by hemorrhagic meningitis.
(c) Gastrointestinal
i This will likely be a clinical or pathological diagnosis. Lab may reveal positive
blood cultures but nothing more specific.

(5) Anthrax: Treatment - Early use of appropriate antibiotics is key to the effective
treatment of all three clinical forms of anthrax.

10
 (a) Cutaneous
i Treat orally with a quinolone (ciprofloxacin, levofloxacin, or gatifloxacin),
doxycycline, or penicillin and adjust accordingly as sensitivities become
available.
ii No antibiotic therapy may result in mortality as high as 20% (Cutaneous
anthrax is often not fatal, even if untreated, death is rare unless skin lesions
have progressed leading to bacteremia and sepsis or lesions have become
secondarily infected.)
(b) Inhalational/Gastrointestinal
i Inhalation - Supportive therapy for shock, fluid volume deficit, and adequacy
of airway may be needed. With very early treatment survival is greater than
80%.
• Treat using Ciprofloxacin or Doxycycline plus one or two of the following:
(i) Rifampin
(ii) Vancomycin
(iii) Penicillin
(iv) Ampicillin
(v) Clindamycin
(vi) Imipenem
(vii)Chloramphenicol
(viii) Clarithromycin
• CDC recommends the following guidelines:
(i) Treat empirically first as noted above.
(ii) Adjust treatment accordingly as sensitivities become available.
(iii) Switch to oral antibiotics when appropriate.
(iv) Total treatment may require 60 days therapy or longer.
ii Gastrointestinal - Though difficult to diagnose early, aggressive supportive
care and antibiotics may reduce mortality. Supportive therapy for shock, fluid
volume deficit, and adequacy of airway may be needed. With early treatment
survival may be greater than 50%. There is very little data or published
studies on the subject of gastrointestinal anthrax.
iii Systemic - The effectiveness of therapy, if initiated during the incubation
period, and due to the rapid course of the disease once symptoms appear
make early intervention an absolute necessity.

NOTE: See Slides 15-21

b. Plague: Plague is caused by Yersinia pestis, a rod-shaped, non-motile, non-

sporulating, Gram-negative bacterium. The organism can remain viable for several
weeks in water, moist soil, dry sputum, flea feces, grains, and buried bodies. It remains
alive at near freezing temperatures from months to years, but is killed by 15 minutes of
exposure to 131°F (55°C) or several hours of exposure to sunlight.

(1) Clinical Forms

(a) Bubonic - The bite from an infected flea inoculates plague organisms into a
patient's skin. The bacteria migrate through cutaneous lymphatics to regional
lymph nodes, where they are phagocytositized but resist destruction. They
rapidly multiply, causing destruction and necrosis of lymph node architecture with
subsequent bacteremia, septicemia, and end toxemia
(b) Pneumonic - Yersinia pestis can enter the lungs either through direct inhalation
(primary pneumonic plague) or through hematogenous spread as a complication

11
 of bubonic or septicemic plague. The infectious dose by inhalation is estimated to
be quite low, as few as 100 to 500 organisms. The patient will often develop a
rapidly progressive fulminant pneumonia that will be fatal unless the patient is
promptly treated with appropriate antibiotics.
(c) Septicemic - may occur secondary to bubonic plague or primarily (septicemic
without lymphadenopathy). Septicemic plague can also develop as a
consequence of pneumonic plague. This form of plague may also be rapidly fatal
if not aggressively treated with antibiotics and other standard supportive
measures.

(2) Plague: Behavior and Risk

(a) Behavior - Method of presentation depends on whether it enters through a break
in the skin, is inhaled, or ingested.
i Exposure via inhalation of aerosols of Yersinia pestis results in pneumonic
plague, the most severe and transmissible form.
ii Cutaneous exposure, such as through plague-carrying vectors (fleas) results
in bubonic plague.
(b) Risk
i Pneumonic plague is highly contagious, which puts close contacts and
healthcare workers at increased risk of infection.

(3) Plague: Signs and Symptoms

(a) Bubonic Plague (contracted from infected fleas)
i Sudden onset of fever, chills and weakness.
ii Exquisitely swollen, tender lymph nodes of bubo soon after initial systemic
symptoms appear.
iii Bubo typically develops in the groin, axilla, or cervical region and is often so
painful that it prevents patients from moving the affected area.
iv Buboes are 1 to 10 cm in diameter, exquisitely tender, nonfluctuant, and
warm; often associated with considerable edema, but seldom lymphadenitis.
The overlying skin is warm and erythromatous.
v Buboes rarely become fluctuant and suppurate. Skin ulcerations may occur at
the site of the fleabite in a minority of patients.
(b) Pneumonic Plague (Results secondarily from the bubonic or pneumonic forms.
Infection of the lungs may be via direct inhalation of droplets from an infected
person or animal or inhalation of weaponized Yersinia pestis biological aerosol.
It can also occur primarily. Septicemia without adenopathy).
i Fever, chills, vomiting, abdominal pain
ii DIC
iii Necrosis of small blood vessels leading to gangrene of affected extremities
iv Purpuric skin lesions
(c) Septicemic Plague (Results secondarily from bubonic or pneumonic forms. It can
also occur primarily. Septicemia without adenopathy)
i Fever
ii Cough
iii Dyspnea, sometimes with the production of bloody, watery, or, less
commonly, purulent sputum
iv Prominent Gastrointestinal (GI) symptoms such as:
• Nausea
• Vomiting
• Abdominal pain

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 • Diarrhea
v Absence of buboes (In rare cases, cervical buboes may be present.)

(4) Plague: Laboratory Diagnosis (Standard precautions for bubonic plague, and
droplet/airborne precautions for suspected pneumonic plague should be taken.
Decontamination is achieved using soap and water.)
(a) Presumptive diagnosis can be made microscopically by identification of the
coccobacillus in Gram, Wright, Giemsa, or Wayson‘s stained smears from lymph
node needle aspirate, sputum, blood, or Cerebrospinal Fluid (CSF) samples.
(b) Immunofluorescent staining and fatty acid analysis can be used to identify
cultured Yersinia pestis.
(c) Definitive diagnosis relies on culturing the organism from blood, sputum, CSF, or
bubo aspirates.
(d) Can be identified using ECL, ELISA, or PCR.

(5) Plague: Treatment

(a) Streptomycin, gentamicin or doxycycline.
(b) Duration of therapy should be 10 to 14 days to prevent relapses.
(c) If secondary plague meningitis develops, treatment requires the addition of
chloramphenicol since other antibiotics do not penetrate the CSF.
(d) Aggressive supportive therapy with use of hemodynamic monitoring and
pressors may be necessary if patient develops secondary septicemic or
pneumonic plague.
(e) Watch for the development of DIC (disseminated intravascular coagulation).
(f) Buboes should almost never be I&D'd (incision and drainage) since it greatly
increases the risk of nosocomial infection. However, buboes may be aspirated for
diagnostic purposes and pain relief.

NOTE: See Slides 22-30

c. Tularemia - Francisella tularensis, the causative agent of tularemia, is a small, aerobic,

non-motile, Gram-negative cocco-bacillus. Tularemia, also known as rabbit fever or
deer fly fever, is a disease that humans acquire after skin or mucous membranes come
into contact with tissues, body fluids of infected animals, or bites from infected ticks,
deerflies, or mosquitoes. Respiratory exposure by aerosol typically causes typhoidal or
pneumonic tularemia. Francisella tularensis remains viable for weeks in water, soil,
carcasses, hides, and for years in frozen rabbit meat. It is resistant for months to
temperatures of freezing and below, and is easily killed by heat and disinfectants.

(1) Tularemia: Behavior and Risk

(a) Behavior - May produce pneumonia but may affect other tissues as well,
including various glands and the eyes.
(b) Risk - Has a lower, but still significant, mortality rate compared with pneumonic
plague.

(2) Tularemia: Signs and Symptoms (incubation period varying from 1 to 21 days;
average 3-5)
(a) Fever from 100°F (38°C) to 104°F (40°C)
(b) Headache, chills, and rigors
(c) Generalized body aches, prominent in the low back
(d) Watery eyes

13
 (e) Sore throat
(f) Dry or slightly productive cough
(g) Substernal pain or tightness frequently occurs with or without signs of
pneumonia, such as purulent sputum, dyspnea, tachypnea, pleuritic pain, or
hemoptysis
(h) Nausea and vomiting
(i) Diarrhea
(j) Malaise
(k) Anorexia and weight loss

(3) Tularemia: Clinical Forms

(a) Oculoglandular - Ulceration occurs on the conjunctiva, accompanied by
pronounced chemosis, vasculitis, and regional lymphadenitis
(b) Pneumonic - Inhalational exposures commonly result in an initial clinical picture
of systemic illness without prominent signs of respiratory disease. Pulmonary
infection can rapidly progress to severe pneumonia, respiratory failure, and
death. Results as one or more of the following, accompanied by various
manifestations of systemic illness:
i Pharyngitis
ii Bronchiolitis
iii Pleuropneumonitis
iv Hilar lymphadenitis
(c) Oropharyngeal - Acquired by drinking contaminated water, ingesting
contaminated food, or inhaling contaminated droplets or aerosols. Affected
persons may develop:
i Stomatitis
ii Exudative pharyngitis
iii Tonsillitis, sometimes with ulceration
iv Pronounced cervical or retropharyngeal lymphadenopathy may occur.
(d) Glandular - Characterized by fever and tender lymphadenopathy without an
ulcer.
(e) Typhoidal – Affected persons may develop:
i Fever
ii Malaise and weakness
iii Gastrointestinal symptoms:
• Watery, non-bloody diarrhea
• Vomiting
• Abdominal pain
iv Chills
v Myalgias
vi Arthralgias
vii Prostration
viii Dehydration
ix Skin lesions may appear on hands, arms, or legs
• Erythema nodosum
• Erythema multiform
• Maculopapular rash
• Acneiform lesions
• Urticaria
(f) Ulceroglandular - Affected persons may develop:

14
 i Local cutaneous papule appears at the inoculation site at the onset of
generalized symptoms, becomes pustular, and ulcerates within a few days of
its appearance.
ii Initially the ulcer will be tender. Over the next few days it will be covered by
an eschar. Typically, one or more regional afferent lymph nodes may become
enlarged and tender within several days of the appearance of the papule.

(4) Tularemia: Laboratory Diagnosis - The definitive means of confirming a diagnosis of

tularemia is the growth of Francisella tularensis in cultures. Although growth may be
visible as early as 24 to 48 hours after inoculation, it may be delayed and should be
held for at least 10 days before discarding.
(a) May be identified by direct examination of secretions, exudates, or biopsy
specimens using direct fluorescent antibody or immunohistochemical stains.
(b) Gram-stain will reveal gram-negative rod. Light microscopy will reveal the
organism's small size (0.2 μm X 0.2-0.7 μm), pleomorphism, and faint staining.
(c) Antigen detection assays, PCR, ELISAs, immunoblotting, pulsed-field gel
electrophoresis, and other specialized techniques may be used to identify
Francisella tularensis and to characterize strains.
(5) Tularemia: Treatment
(a) Appropriate therapy includes one of the following antibiotics:
i Gentamicin
ii Ciprofloxacin
iii Streptomycin
(b) Standard precautions should be taken.
(c) For decontamination, mild heat (55° Celsius for 10 minutes) and standard
disinfectants will render the organism harmless.

NOTE: See Slides 31-34

d. Q Fever - Q fever is a disease caused by a rickettsial-like bacterium, known as Coxiella

burnetti. Its natural reservoirs are sheep, cattle, goats, dogs, cats, and birds. The
infected animals do not develop the disease, but shed large numbers of the organisms.
Humans acquire the disease by inhalation of aerosols contaminated with the organisms
or ingestion of contaminated dairy products. Farmers and slaughterhouse workers are
occupationally at greatest risk.

(1) Q Fever: Behavior and Risk

(a) Behavior - Produces nonspecific illnesses that may be incapacitating or require
prolonged recuperation.
(b) Risk - Rarely causes death, but may be incapacitating or require prolonged
recuperation.

(2) Q Fever: Signs and Symptoms - Following an incubation period of 2 to 14 days, Q

fever generally occurs as a self-limiting febrile illness lasting 2 days to 2 weeks.
(a) Headaches
(b) Fatigue
(c) Myalgias
(d) Uncommon complications include chronic hepatitis, endocarditis, aseptic
meningitis, encephalitis, and osteomyelitis.
(e) Physical examination of the chest is usually normal.
(f) Pneumonia occurs in about half of all patients.

15
 (g) Half of patients with pneumonia will exhibit nonproductive cough or rales.
(h) Pleuritic chest pain occurs in about one-fourth of patients.
(i) 33% of Q fever patients will develop acute hepatitis, with fever and abnormal liver
function tests in the absence of pulmonary signs and symptoms. A more acute
form of the disease may be seen after a biological weapons attack.

(3) Q Fever: Laboratory Diagnosis - Isolation of the organism is impractical, as it is

difficult to culture and is a significant hazard to laboratory workers. Keep the
following facts in mind when conducting tests or analyzing laboratory results:
(a) The most commonly available serologic test is the complement fixation test. It is
relatively insensitive and may not be useful if sera have intrinsic anticomplement
activity.
(b) Chest radiographs are usually nonspecific. Findings may include: patchy
infiltrates, rounded opacities and adenopathy.
(c) Nonspecific leukocytosis may be present in one-third of patients.
(d) Most patients with Q fever have a mild elevation of hepatic transaminase levels.
(e) Serological tests for Q fever include Indirect Fluorescent Antibody (IFA), ELISA,
ECL, and Complement Fixation (CF).
(f) PCR can also identify the bacteria's DNA.

(4) Q Fever: Treatment - Most cases of acute Q fever will eventually resolve without
antibiotic treatment. To shorten the duration of the illness and reduce the risk of
complications, administer:
(a) Tetracycline 500 mg every 6 hours
(b) Doxycycline 100 mg every 12 hours for 5 to 7 days
(c) Ciprofloxacin and other quinolones should be considered in patients unable to
take tetracycline or doxycycline.
(d) Successful treatment of Q Fever endocarditis is much more difficult. Tetracycline
or doxycycline given in combination with Trimethoprim-sulfamethoxazole (TMP-
SMX) or rifampin for 12 months or longer has been successful in some cases.
(e) Standard precautions are recommended.
(f) Person-to-person transmission is rare.
(g) Decontamination is achieved using soap and water or 0.5% hypochlorite.

NOTE: Q fever prophylaxis. A Q fever vaccine exists which is licensed in Australia but is an
investigational new drug (IND) in the United States. Patients exposed to Q fever may receive
chemoprophylaxis with antibiotics but the drugs should be started 8 to 12 days post-exposure. If
they are administered too early in the incubation period disease will merely be delayed not
prevented. Begin tetracycline or doxycycline 8 to 12 days after exposure for a total of 5 days

NOTE: See Slides 35-40

e. Brucellosis - Four of the six species of Brucella, a group of Gram-negative

coccobaccillary facultative intracellular pathogens, are pathogenic to humans. The four
species are: Brucella abortus, Brucella melitensis, Brucella suis, and, rarely Brucella
canis.

(1) Brucellosis: Behavior and Risk

(a) Behavior - Brucellosis typically presents as a nonspecific febrile illness
resembling influenza. Fever is usually intermittent and can assume an undulant
pattern.

16
 (b) Risk - Highly infectious via aerosol exposure, but a low mortality rate. It is
estimated that inhalation of only 10 to 100 bacteria are necessary to cause
disease in humans. In naturally occurring infections only 5% of untreated cases
result in death. In rare cases death is caused by endocarditis or meningitis.

(2) Brucellosis: Signs and Symptoms

(a) General
i Fever
ii Headache
iii Myalgias
iv Arthralgias
v Back pain
vi Sweats and chills
vii Generalized weakness and malaise
(b) Neurological
i Encephalitis.
ii Peripheral neuropathy.
iii Radiculoneuropathy.
iv Meningovascular syndromes have also been observed in rare instances.
v Behavioral disturbances and psychoses appear to occur out of proportion to
the height of fever, or to the amount of overt Central Nervous System (CNS)
disease.
vi Meningitis complicates a small minority of cases.
(c) Pulmonary
i Pulmonary symptoms may not correlate with radiographic findings.
ii Cough and pleuritic chest pain occur in up to 20% of cases.
iii Acute pneumonitis is unusual.
(d) Gastrointestinal
i Symptoms such as anorexia, nausea, vomiting, diarrhea, and constipation
occur in up to 70% of adult cases, but less frequently in children.
ii Ileitis, colitis, and granulomatous or mononuclear infiltrative hepatitis may
occur, with hepato- and spleno-megaly present in 45 to 63% of cases.
(e) Lumbar
i Lumbar pain and tenderness can occur in up to 60% of cases and are
sometimes due to various osteoarticular infections of the axial skeleton.
ii Vertebral osteomyelitis, intervertebral disc space infection, paravertebral
abscess, and sacroiliac infection occur in a minority of cases, but may cause
chronic symptoms.
(f) Joint
i Joint involvement may vary from pain to joint immobility and effusion.
ii While the sacroiliac joints are most commonly involved, peripheral joints,
notably, hips, knees, and ankles, may also be affected.
(3) Brucellosis: Laboratory Diagnosis - Clinical laboratories should always use selective
isolation media and implement BSL-3 safety precautions if a diagnosis of brucellosis
is suspected.
(a) Chest x-rays are often normal, but may show lung abscesses, single or miliary
nodules, bronchopneumonia, enlarged hilar lymph nodes, or pleural effusions
(b) Leukocyte count is usually normal but may be low; anemia and
thrombocytopenia may also occur
(c) During the acute febrile phase of illness, blood cultures yield the organism in 15
to 70% of cases, and bone marrow cultures detect it in 92%

17
 (d) Serum Agglutination Test (SAT) is available. ELISA, ECL, and PCR methods are
becoming more widely utilized
(4) Brucellosis: Treatment
(a) Oral antibiotic therapy alone is sufficient
(b) Combination of doxycycline 200 mg/day orally and rifampin 600 mg/day orally is
generally recommended - administered for 6 weeks
(c) Or Doxycycline 200 mg/day orally for 6 weeks in combination with 2
weeks of streptomycin (1 g/day IM) is an acceptable alternative
(d) Standard precautions are adequate in managing brucellosis patients, as the
disease is not generally transmissible from person-to-person.
(e) Decontamination is achieved using a 0.5% hypochlorite solution.

NOTE: Conduct a check on learning and summarize the learning activity.

1. Name the three clinical forms of the disease Anthrax. CUTANEOUS,

GASTROENTESTIONAL, AND INHALATION

2. After a bite from a flea infected with Yersinia pestis, a bubo typically develops in
the groin, axilla,or cervical region. What disease does the patient most likely
have? BUBONIC PLAGUE

3. This bacteria causes a disease also known as Rabbit Fever. The bacteria
remains viable for weeks to months in water, soil, carcasses, and animal hides
and to temperatures of freezing and below, but is easily killed by heat and
disinfectants. What biological agent is this? FRANCISELLA TULARENSIS

4. Q-Fever rarely causes death, but may be incapacitating or require prolonged

recuperation. True or False? TRUE

5. This organism is highly infectious via aerosol exposure, but has a low mortality
rate. It is estimated that inhalation of only 10 to 100 bacteria are necessary to
cause disease in humans. Rare cases of death are caused by endocarditis or
meningitis. What species of bacteria commonly associated with animals is
responsible? BRUCELLA
2. Learning Step / Activity 2. Viral Agents

Method of Instruction:
Conference/ Demonstration
Instructor to Student Ratio is:
Time of Instruction:
Media:

NOTE: See Slide 42

NOTE: The use of viral agents as weapons is a concern because of the surreptitious manner
in which they could be unleashed. They are difficult and time consuming to detect because
symptoms occur several days to weeks after exposure. Clinicians need a high index of
suspicion coupled with adequate familiarization with how these agents may present. Early
detection and reporting will be crucial to successful mitigation of any attack.

18
NOTE: See Slides 43-48

a. Smallpox

NOTE: Variola virus is a member of the Orthopox virus family. Variola is a large, double-
stranded DNA virus that is relatively stable in the environment. Infection is spread via
respiratory droplets or aerosols by a patient sneezing or face to face contact, or by contact with
contaminated materials, including scabs; however, predominant spread is by respiratory
droplets, requiring prolonged, close contact with an infected individual. Historically,
approximately 30% of non-immune contacts became infected.

(1) Smallpox: Behavior and Risk

(a) Behavior
i Is a serious, communicable, and sometimes fatal disease.
ii Treatment is supportive care.
iii The only licensed prevention is vaccination.
(b) Risk
i Up to thirty percent of those infected may die, usually from overwhelming sepsis,
dehydration, or secondary bacterial infections.

(2) Smallpox: Signs & Symptoms - For about 2 weeks after exposure to the virus, usually by
inhalation, patients are without any symptoms. This period is followed by the sudden
onset of symptoms. The rash lasts 2 to 3 weeks and results in severe scarring. Mortality
is expected to be at least 30% in non-immune patients.
(a) High fever
(b) Chills
(c) Weakness
(d) Muscle and backaches
(e) Painful rash beginning on the hands, feet, and face and spreading over time toward
the trunk, back, and chest (2 to 3 days after onset of fever)

(3) Smallpox: Smallpox has two distinct clinical types

(a) Variola major (classic) - Variola major, the more virulent form of the virus, resulted in
disease with case fatality rates of at least 30% in most immunologically naïve
populations, and approximately 3% in immunized populations. The disease occurred
in several distinct clinical forms, which appeared to be related to the host's
immunologic response. The "classic" form occurred in 95% of patients. Flat type
smallpox and hemorrhagic smallpox occurred in 2 to 5% and 1 to 3% respectively,
both with mortality rates of at least 95%.
(b) Variola minor (alastrim) - Variola minor exhibits milder disease with less systemic
toxicity and fewer pox lesions, causing 1% mortality in unvaccinated victims.

(4) Smallpox and chickenpox can be difficult to distinguish clinically.

(a) Smallpox
i Incubation Period: After exposure to the virus, patients remain asymptomatic for
7 to 17 days (12 days on average).
ii Prodrome: During this initial phase, which lasts 2 to 4 days, patients remain
generally non-contagious.
iii Sudden onset of high fevers, extreme malaise, rigors, headache, backache, and
prostration. Patients experience a sudden onset of severe abdominal pains,

19
 approximately 15% of patients develop delirium, and 10% of light-skinned
patients may exhibit a non-descript erythromatous rash during this phase.
iv Rash: Exanthema of the mouth, tongue, and oropharynx typically precede the
exanthema by a day. Patients shed large amounts of virus into their saliva and
are most contagious beginning at this phase.
v If death occurs it is usually on the 5th or 6th day of the rash.
vi Recovery: Crusts begin to form on about the 8th or 9th day of rash.

NOTE: See Slide 46 (Smallpox and Chickenpox Comparison chart)

(5) Smallpox: Laboratory Diagnosis - Differentiation classically requires isolation of the virus
and characterization of its growth on chorioallantoic membrane.

NOTE: Electron microscopy and Gispen's modified silver stain do not discriminate from other
orthopox viruses such as, monkeypox, or cowpox. Differentiation classically requires isolation of
the virus and characterization of its growth on chorioallantoic membrane. Growth of the organism
should only be attempted at Biosafety Level-4 (BSL-4) labs.

(a) Electron Microscopy - A method of laboratory diagnosis is a demonstration of

characteristic virions on electron microscopy of vesicular scrapings. Under light
microscopy, aggregations of variola virus particles (Guarnieri bodies) are found.
(b) Gispen's Modified Silver Stain - Another rapid but relatively insensitive test of
Guarnieri bodies in vesicular scrapings is Gispen's modified silver stain. With this
technique, cytoplasmic inclusions appear black.
(c) Polymerase Chain Reaction (PCR) - PCR is currently available which will allow the
specific diagnosis, or exclusion, of smallpox.
(d) Immunoassay - There is an Electrochemiluminescence (ECL) assay for orthopox.

(6) Smallpox: Treatment

(a) Adequate hydration and nutrition, with treatment of secondary bacterial infections are
the keys to effective clinical management of smallpox cases.
(b) No antiviral approved by the FDA for treatment of clinical smallpox disease.
(c) In the event of an epidemic, drugs like cidofovir may be made available on an
experimental basis.
(d) Post Exposure Prophylaxis/Vaccine:
i Protective if given within 3-4 days exposure
ii Reduces incidence 2-3 fold
iii Decreases mortality by ~50%

NOTE: See Slides 49-56

b. Equine Encephalitis Viruses- Alphavirus of the togavirdae family cause the equine
encephalitis are spread by various species of mosquitoes. Birds serve as principal
reservoirs. These have a single stranded RNA genome, which codes for eight proteins.
Case fatality rates for orthopod-born viral encephalitis range from 0.3% to 60%. The overall
case fatality rate for VEE is less than 1%, although it is somewhat higher in the very young
aged. Case fatality rates for WEE and EEE may approach 50-75%. The enzootic vector for
these viruses is primarily the Culex mosquito. There is no evidence of direct human-to-
human or horse-to-human transmission, and natural aerosol transmission is not known to
occur.

20
 (1) Equine Encephalitis Viruses: Clinical Forms
(a) Venezuelan Equine Encephalitis (VEE)
i VEE was first found to be responsible for encephalitis outbreaks involving
humans and equines in the 1930s. It has a geographic distribution from northern
South America to Mexico and Florida.
ii VEE particles are not considered stable, and heat [175 °F (79° C) for 30 minutes]
and standard disinfectants destroy the virus complex. The human infective dose
is considered to be 10 to 100 organisms.
(b) Eastern Equine Encephalitis (EEE)
i EEE is found principally in the Eastern United States. About 12 to 17 sporadic
cases are reported to the Centers for Disease Control (CDC) annually. 256
cases occurred between 1955 and 1997. EEE was first recognized in 1938.
(c) Western Equine Encephalitis (WEE)
i Occurring particularly in the Western United States, there have been over 630
confirmed cases of WEE in the United States since 1964.

NOTE: EEE and WEE share similar aspects of transmission and epidemiology, and are often
difficult to distinguish clinically.

(2) Equine Encephalitis Viruses: Behavior and Risk

(a) Behavior
i After exposure, the tissues of the Central Nervous System (CNS) and other
organ systems are affected in both humans and animals.
(b) Risk
i Highly infectious.
ii No antiviral drugs are effective for treatment, and vaccine availability is very
limited.
iii Not transmittable from person to person.

(3) Equine Encephalitis Viruses: Signs & Symptoms

(a) After an incubation period ranging from days to weeks, victims develop:
i Brain infection and inflammation (encephalitis).
ii Severe headaches
iii Fevers
iv Incapacitation
(4) Equine Encephalitis Viruses: Diagnosis and Treatment
(a) VEE: Diagnosis and Treatment
i Onset of disease is usually sudden and is manifested by:
(a) generalized malaise
(b) sore throat
(c) spiking high fevers 100 °F-105 °F
(d) rigors
(e) myalgias in the legs and lumbosacral area
(f) chills
(g) photophobia
(h) nausea
(i) vomiting
(j) cough
(k) severe headache
(l) diarrhea
ii No specific antiviral therapy exists. Treat uncomplicated VEE with analgesics.

21
 iii Treat encephalitis with anticonvulsants and intensive supportive care (maintain
fluid/electrolyte balance, ensure adequate ventilation, and prevent secondary
bacterial infections).
iv The fatality rate in adults is up to 10%, and 30% in children.
(b) EEE: Diagnosis and Treatment
i EEE in humans is characterized by an acute onset of fever and flu-like
symptoms, such as:
(a) Headache
(b) Sore throat
(c) Abdominal pain
(d) Lethargy
ii May progress rapidly to:
(a) – Delirium
(b) Coma
(c) Possibly death
iii Clinical cases of EEE are often severe. Estimates of case fatalities are 30-70%.
iv Permanent brain damage and long-term aftereffects can occur especially in
children.
v There is no vaccine or specific therapy other than supportive care
(c) WEE: Diagnosis and Treatment
i There is a lack Infection can cause a range of illnesses, from no symptoms to
fatal disease of specificity of symptoms, making it difficult to diagnose.
ii Most patients commonly present with the warning signs and symptoms of a virus
that may progress to more severe signs and symptoms. Onset of illness is
sudden, especially in adults
iii WEE is less severe than EEE but still has a higher mortality than VEE especially
in children.
iv Warning signs and symptoms include:
(a) Headache
(b) Chills
(c) Nausea
(d) Vomiting.
v People with more severe disease can have:
(a) Sudden high fever
(b) Headache
(c) Drowsiness
(d) Irritability
(e) Nausea
(f) Vomiting
(g) Followed by confusion, weakness, and coma.
vi There is no specific treatment for WEE
vii Management consists of treatment of symptoms and complications

(5) Equine Encephalitis Viruses: Laboratory Diagnosis

(a) VEE: Laboratory Diagnosis
i Serology – IgM, ELISA indirect FA, hemagglutination inhibition, Complement-
fixation, and IgG.
ii Isolation – VEE should be isolated only in a Biosafety Level-3 (BSL-3) laboratory.
iii PCR – RNA PCR test available.
iv Biochemical Assay – WBC count shows a striking leukopenia and lymphopenia.
In cases with encephalitis, the Cerebrospinal Fluid (CSF) pressure may increase

22
 and contain up to 1,000 WBCs/mm3 (predominantly mononuclear cells) and a
mildly elevated protein concentration.
v Culture – Can be cultured
vi ECL – ECL test available.
(b) EEE: Laboratory Diagnosis – (Numerous infections produce signs and symptoms
similar to EEE making clinical diagnosis difficult)
i Serology - Viral titers, IgM, and complement-fixation.
ii Isolation - Viral isolation from the Cerebrospinal Fluid (CSF), blood, or tissue is
often difficult due to low levels of virus associated with EEE.
iii PCR - There is an RNA PCR test for this virus (Use as final alternative for
analysis of differential diagnosis)
iv Culture - The virus can be cultured.
(c) WEE: Laboratory Diagnosis
i Blood cultures – Perform if suspicion of bacterial meningitis exists but unlikely to
be helpful.
ii Isolation – Due to low presence of the virus associated with WEE in the blood,
viral isolation from the Cerebrospinal Fluid (CSF), blood, or tissue is difficult.
iii Biochemical Assays – ELISA detects IgM and may detect anti-arboviral IgG.
Serum hemagglutinin inhibition titer of at least 1:320 is used most commonly and
allows differentiation among EEE, WEE, and VEE.
iv CSF Findings (Lumbar puncture indicated if suspicion is high)
(a) Elevated CSF RBCs.
(b) Elevated CSF WBCs.
v PCR - There is an RNA PCR test for this virus and can act as final alternative of
various organisms known to cause encephalitis.
vi Culture - The virus can be cultured

NOTE: See Slides 57-65

c. Viral Hemorrhagic Fevers

NOTE: VHFs are a group of viruses that have similar clinical manifestations. VHFs are spread
in a variety of ways. Most VHFs are zoonotic diseases, residing naturally in an animal reservoir
host or arthropod vector. However, the hosts of some viruses remain unknown. Examples of
reservoir hosts include the deer mouse, cotton rat, multimammate rat, house mouse, and other
field rodents. Mosquitoes and ticks serve as vectors for some viruses. Marburg and Ebola are
well-known viruses whose host reservoir remains unknown. Although generally restricted
geographically due to reservoir dependence, laboratory aerosol contamination is possible.

(1) VHFs are caused by virus from four distinct viral families:
(a) Arenaviridae - Lassa virus (a highly infectious virus with a rodent host found in West
Africa) is a member of the arenaviridae family. Another member, Argentine
Hemorrhagic Fever (AHF), infects from 300 to 600 people yearly in areas of the
Argentine pampas. Viral transmission occurs by inhalation of dust contaminated with
rodent excreta.
(b) Bunyviridae - is a family of more than 200 viruses. Hantavirus is a member of the
Bunyaviridae family. It is believed the disease is spread by direct contact with
infected rodents or by inhalation or ingestion of dust containing infected rodents'
dried urine. Rift Valley, a fever-causing virus, is most commonly associated with
mosquito-borne epidemics during years of unusually heavy rainfall.

23
 (c) Filoviridae - Marburg hemorrhagic fever, a rare, severe type of hemorrhagic fever, is
a member of this family. The four species of Ebola virus are the only other known
members of the filovirus family. Filoviridae natural reservoirs (animal or insect host)
are not known.
(d) Flaviviridae viruses cause hemorrhagic fever in a wide range of mammals. They are
transmitted by ticks and mosquitoes. Two well known mosquito-borne viruses in this
category are yellow fever and dengue fever.

(2) VHFs: Behavior and Risk

(a) VHFs behavior - Includes approximately 20 different viruses such as Ebola that
attack the endothelium (lining) of blood vessels.
(b) VHFs Risk – Require diligent hygiene and personal protective precautions.
i Mortality rates range from less than 10% to close to 100%, depending on the
virus involved, host factors, and the aggressiveness of supportive therapy.
ii Are also transmissible person-to-person, and pose an increased risk to
healthcare workers and close contacts.
(c) VHFs: Signs and Symptoms
i Common
(a) Fever
(b) Myalgia
(c) Prostration
(d) Abdominal pain
(e) Petechial hemorrhages
(f) Conjunctival injection
(g) Mild hypotension
(h) Flushing
ii Full-blown VHF typically includes:
(a) Rash
(b) Shock
(c) Generalized mucous membrane hemorrhage, often accompanied by
pulmonary hematopoietic and neurologic involvement.

(d) VHFs: Clinical Diagnosis

i Biphasic form of this illness will include CNS manifestations.
ii Renal insufficiency is proportional to cardiovascular compromise.
iii While hepatic involvement is common among the VHFs, a clinical picture
involving jaundice and other features of hepatitis are only seen in some cases.
Aspartate aminotransferase (AST) elevation may correlate with the severity of
the illness, and jaundice is a poor prognostic sign.
iv Pulmonary hemorrhage often accompanies full-blown VHFs

(e) VHFs: Laboratory Diagnosis

i Specialized microbiologic containment is required.
ii Electron micrographs have been used to identify these viruses.
iii Many of these viruses can be cultured or identified by RNA, PCR, or various
immunoassays
iv Specific virology studies are necessary for definitive diagnosis.
v Thrombocytopenia and leukopenia are the rule in VHFs.
vi ELISA can detect viral antigens in acute sera. IgM may often be found during the
acute stage of the illness.
vii Proteinuria and/or hematuria are common.

24
NOTE: See Slide 61. Figure (see below): (left to right) Arenaviridae (Lassa Virus), Flaviviridae
(Yellow Fever), Bunyaviridae (Hantavirus), Filoviridae (Ebola Virus).

NOTE: IgM may often be found during the acute stage of the illness.
ELISA can detect viral antigens in acute sera. Aspartate aminotransferase (AST) elevation may
correlate with the severity of the illness, and jaundice is a poor prognostic sign.

(f) VHFs: Treatment

i Supportive care includes managing fluids and bleeding problems
ii Restlessness, confusion, myalgia, and hyperesthesia should be managed by
conservative measures and the judicious use of sedatives and analgesics
iii Severely ill patients require intensive care, including:
(a) Vigorous fluid resuscitation
(b) Pressor agents
(c) Intravascular devices
(d) Invasive hemodynamic monitoring

NOTE: Remember the propensity of some VHFs for pulmonary capillary leak. Consider the
use of these devices in the context of potential benefit versus the risk of hemorrhage.
Secondary infections may occur upon use of invasive procedures and devices such as
Intravenous (IV) lines and indwelling catheters.

(g) VHFs: Prophylaxis

i Licensed vaccine exists for yellow fever.
ii Prophylactic ribavirin may be effective for Lassa fever, Rift Valley fever, Congo-
Crimean Hemorrhagic Fever (CCHF), and hemorrhagic fever with renal
syndrome as an IND.

NOTE: Conduct a check on learning and summarize the learning activity.

1. Variola major, the more virulent form of this virus from the Orthopox family
causes what disease? SMALLPOX

2. Bacteria are infectious microorganisms that exist as a particle rather than as

one complete cell and are NOT capable of reproducing outside of a host cell.
True or False? FALSE – This statement describes a virus, bacteria are
single-cell organisms that multiply by cell division.

3. The treatment for VEE is ciprofloxacin. True or False? FALSE. VEE is

caused by a virus thus the antibiotic, ciprofloxacin is ineffective. No
specific antiviral therapy exists. Treat uncomplicated VEE with
analgesics. Treat encephalitis with anticonvulsants and intensive
supportive care (maintain fluid/electrolyte balance, ensure adequate
ventilation, and prevent secondary bacterial infections).

4. Ebola is spread ONLY by the bite of an infected mosquito and can not be
spread person to person. True or False. FALSE, some VHFs, e.g. Ebola
are also transmissible person-to-person, and pose an increased risk to
healthcare workers and close contacts.

25
3. Learning Step / Activity 3. Toxin agents

Method of Instruction: Conference/

Demonstration
Instructor to Student Ratio is:
Time of Instruction:
Media:

NOTE: See Slide 65

NOTE: Biological toxins are poisonous substances produced and derived from living plants,
animals, or some microorganisms. Some toxins may be produced or altered by chemical
means. By weight, they usually are more toxic than some chemical agents. Toxins may be
countered by specific antisera and selected pharmacological agents.

NOTE: See Slides 66-71

a. Ricin - Ricin is a cytotoxin derived predominantly from the beans of the castor plant (Ricinus
communis). Castor beans are ubiquitous worldwide. The toxin is fairly easy to extract.
Therefore, ricin is potentially widely available. Its use by belligerents might involve poisoning
of water or foodstuffs, inoculation via ricin-laced projectiles, or aerosolization of liquid ricin or
lyophilized powder. Can be produced relatively easily and inexpensively in large quantities
in a fairly low technology setting. Can be prepared in liquid or crystalline form, or it can be
lyophilized to make a dry powder.

(1) Ricin: Behavior and Risk

(a) Ricin: Behavior
i Poison made from castor bean extract.
ii Can be in the form of powder, mist, or pellet.
iii Causes toxicity by inhibition of DNA replication and protein synthesis, leading to
cell death (cytotoxin).
(b) Ricin: Risk
i May cause severe allergic reactions.
ii No effective treatment and supportive care will depend on route of exposure.

(2) Ricin: Signs & Symptoms

(a) Inhalation
i Acute onset of the following symptoms appears in 4 to 8 hours:
• Fever
• Cough
• Chest tightness
• Dyspnea
• Nausea
• Arthralgias
ii Within 36 to 72 hours this may be followed by:
• Cyanosis
• Pulmonary edema
• Death from ARDS and respiratory failure

26
 (b) Ingestion
i Necrosis of the Gastrointestinal (GI) epithelium
ii Local hemorrhage
iii Hepatic, splenic, and renal necrosis
iv Hematuria
v Jaundice
(c) Injection
i Severe local necrosis of muscle and regional lymph nodes with moderate to
severe visceral organ involvement.

(3) Ricin: Treatment - Management of ricin-intoxicated patients depends on the route of

exposure. Aerosol exposure is the most serious method of entry.
i Inhalation
• Appropriate respiratory support
(i) Oxygen
(ii) Intubation
(iii) Ventilation
(iv) PEEP
(v) Hemodynamic monitoring
• Treatment for pulmonary edema, as indicated
ii Ingestion
• Vigorous gastric lavage, followed by use of cathartics such as magnesium
citrate, if within one hour of ingestion, activated charcoal (if not counter
indicated).
• Volume replacement of GI fluid losses is important.
iii Injection
• Treatment is primarily supportive.
(4) Ricin: Diagnosis
(a) Aerosolized ricin may be supported by clinical and epidemiological evidence (see
note below)
(b) Supportive clinical or diagnostic features may include:
i Bilateral infiltrates on chest radiographs
ii Arterial hypoxemia
iii Neutrophilic leukocytosis
iv Bronchial aspirate rich in protein compared to plasma, which is characteristic of
high permeability pulmonary edema

NOTE: PCR is also good for detecting impure ricin in the environment.

NOTE: See Slides 72-74

c. Staphylococcal Enterotoxin B (SEB)

(1) (SEB): Behavior and Risk

(a) SEB Behavior:
i SEB is an exotoxin excreted by Staphylococcus aureus.
ii Toxins are produced in unrefrigerated meats, daily, and bakery products,
processed foods and temperature-abused foods.
iii Ingested SEB can cause a form of food poisoning.
iv Causes symptoms at very low doses.

27
 (b) SEB Risk:
i SEB may not make many people critically ill, but it can incapacitate large
numbers of individuals.
ii Those with an underlying disease process reaction more severely.

(2) SEB: Signs & Symptoms

(a) When ingested, causes a self-limited form of "food poisoning" with:
i Severe nausea
ii Vomiting
iii Diarrhea
(b) When inhaled (possibly aerosolized) it causes sudden onset of:
i High fever
ii Chills
iii Muscle aches
iv Headache
v Dry cough
NOTE: Severe cases can clinically demonstrate difficulty breathing, chest pain, sometimes can
worsen with developing shock or even death. Illness is rarely seen by inhalation. If
inhalation SEB is suspected then intentional (aerosolized) harm should also be
seriously considered.

(3) SEB: Laboratory Diagnosis

(a) Respiratory secretions and nasal swabs may show the toxin early (within 24 hours of
exposure).
(b) ELISA and ECL may be used to confirm the diagnosis. Enzyme Linked
Immunosorbent Assays (ELISAs) and Electrochemiluminescence (ECL) testing on
serum and respiratory secretions or immunohistochemical stains of tissue may be
used where available to confirm the diagnosis.

NOTE: Acute and convalescent sera should be drawn for retrospective diagnosis.

NOTE: See Slides 75-80

c. Botulinum Toxin - Botulinum toxins are a group of seven related neurotoxins produced by
the spore-forming bacillus Clostridium botulinum and two other Clostridium species.
These toxins, types A - G, are the most potent neurotoxins known to man. These
neurotoxins could be delivered intentionally by aerosol or used to contaminate food or
water supplies. Hallmark of disease is a progressive, descending, flaccid paralysis
that starts with cranial nerves and facial involvement (motor involvement only).
Contrast this with the usual presentation of Guillain-Barre syndrome, which typically
begins in the lower extremities and ascends (motor and sensory). The three
epidemiologic forms of naturally occurring botulism are food-borne, infantile and
wound.

(4) Botulinum Toxin: Behavior and Risk

(a) Behavior
i Several toxins produced by the bacterium Clostridium botulinum which causes a
muscle paralyzing disease.
ii Environmental conditions easily denature these toxins.
iii When inhaled, these toxins produce a clinical picture very similar to food-borne
intoxication.

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 iv Hallmark of disease is a progressive, descending, flaccid paralysis
(b) Risk
i Mortality from untreated cases is approximately 60%.
ii With supportive care can have a mortality rate of less than 5%.
iii Most will survive with supportive care alone, although the care may be
prolonged.

NOTE: Physical examination usually reveals an afebrile, alert, and oriented patient.

(5) Botulinum Toxins: Signs and Symptoms

(a) Central Nervous System (CNS)

i Cranial nerve palsies are prominent early and are often first manifested by the
following:
(a) Dysarthria
(b) Dysphonia
(c) Dysphagia
(b) Ocular
i Blurred vision due to mydriasis; seen in approximately 50% of cases.
ii Diplopia
iii Photophobia
iv Pupils may be dilated and even fixed
v Possibly Ptosis and extraocular muscle palsies
(c) Mucous Membranes
i Mucous membranes may be dry and crusted and the patient may complain of dry
mouth or sore throat.
ii There may be difficulty with speaking and swallowing.
iii Gag reflex may be absent.
(d) Muscle
i Variable degrees of skeletal muscle weakness may be observed, depending on
the degree of progression in the patient.
ii Flaccid skeletal muscle paralysis follows early symptoms in a symmetrical,
descending, and progressive manner.
iii Collapse of the upper airway may occur due to weakness of the oropharyngeal
musculature.
iv Progression from onset of symptoms to respiratory failure has occurred in as little
as 24 hours in cases of severe food-borne botulism.
v Deep tendon reflexes may be present or absent

NOTE: Onset of symptoms of inhalation botulism usually occurs within 12 to 36 hours

following exposure, but could be quicker following a Biological Warfare (BW) attack. When a
low dose of the toxin is inhaled, signs and symptoms may not appear for several days.
Respiratory failure is generally the cause of death.

NOTE: Death from botulism in the modern Intensive Care Unit (ICU) is usually due to the
complications of long-term ventilatory dependence (nosocomial infections, aspiration
pneumonia, pulmonary emboli, etc.), and not directly to the toxin's effects.

(6) Botulinum Toxins: Treatment

(a) Supportive care, including prompt respiratory support, can be lifesaving. With
ventilator assistance, fatalities are less than 5%.

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 (b) Prevention of nosocomial infections is a primary concern along with hydration,
nasogastric suctioning for ileus, bowel and bladder care, and prevention of decubitus
ulcers and deep venous thromboses.
(c) Intensive and prolonged nursing care may be required for recovery, which may take
up to 3 months for initial signs of improvement and up to a year for complete
resolution of symptoms.
(d) Early administration of botulinum antitoxin is critical because the antitoxin can
neutralize the circulating toxin only in patients with symptoms that continue to
progress. When symptom progression ceases, no circulating toxin remains and the
antitoxin has no effect.

NOTE: Antitoxin may be particularly effective in food-borne cases, where toxin presumably
continues to be absorbed through the gut wall. Antitoxin is very effective if given before the
onset of clinical signs. If it is delayed until after the onset of symptoms, it does not protect
against respiratory failure.

(7) Botulinum Toxins: Laboratory Diagnosis

(a) Laboratory testing is generally not helpful to the diagnosis of botulism.
i Mouse neutralization (bioassay) remains the most sensitive test.
ii PCR might detect Clostridium botulinum genes (DNA) in an environmental
sample in impure preparations.
iii Detection of toxin in clinical or environmental samples is sometimes possible
using an ELISA or ECL test.

NOTE: See Slides 81-88

d. Trichothecene (T-2) Mycotoxins - The trichothecene (T-2) mycotoxins are a group of over 40
compounds produced by fungi of the genus Fusarium, a common grain mold. Intentional use
of T-2 may involve aerosolization or the deliberate contamination of foodstuffs. Mycotoxins
have a low molecular weight can adhere to and penetrate the skin.

(1) T-2 Mycotoxin: Behavior and Risk

(a) Behavior
i Very stable, even when autoclaved, and have multiple mechanisms of action.
ii These toxins can adhere to and penetrate the skin, and cause pain within
minutes of contact with human skin similar to the chemical warfare agent
Lewisite.
(b) Risk
i T-2 Mycotoxins may gain access to the body though different modes of entry:
(a) skin penetration
(b) inhalation
(c) ingestion
ii Systemic toxicity and death may occur.

(2) T-2 Mycotoxin: Broad clinical picture

(a) General symptoms most commonly include:
i Vomiting
ii Diarrhea
iii Dyspnea

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 iv Skin involvement may include burning pain, redness, pruritus rash, or blisters,
and bleeding
(b) Systemic toxicity can occur via any route of exposure, resulting in:
i Weakness
ii Prostration
iii Ataxia
iv Loss of coordination
v Dizziness
vi Tachycardia, hypothermia, and hypotension follow in fatal cases
vii Death may occur in minutes, hours, or days.
viii Treatment of systemic T-2 toxicity is supportive care

(3) T-2 Mycotoxin: Signs, Symptoms and Treatment

(a) Inhalation
i Signs and symptoms include:
(a) Upper respiratory exposure may result in the following:
(i) Nasal itching
(ii) Pain
(iii) Sneezing
(iv) Epistaxis
(v) Rhinorrhea
(b) Pulmonary/tracheobronchial toxicity produces:
(i) Dyspnea
(ii) Wheezing
(iii) Cough
(c) Treatment of inhalation T-2: Due to the toxicity respiratory support may be
necessary
(b) Ingestion
i Signs and symptoms include:
(a) Mouth and throat exposure causes pain and blood-tinged saliva and sputum.
(b) Following occur with Gastrointestinal (GI) toxicity:
(i) Anorexia
(ii) Nausea
(iii) Watery or bloody diarrhea with cramping abdominal pain
(iv) Dyspnea
(c) Treatment of Ingestion of T-2: Standard therapy for poison ingestion,
including the use of superactivated charcoal, should be administered.
(c) Ocular exposure can cause the following symptoms within minutes:
i Eye pain
ii Tearing
iii Redness
iv Blurred vision
v Foreign body sensation
vi Treatment for T-2 ocular involvement is flushing eyes with copious amounts of
water and timeliness is essential
(d) Dermal (skin) penetration and involvement
i Signs and symptoms include:
(a) burning pain
(b) redness, and pruritus
(c) rash or blisters
(d) bleeding

31
 (e) progression to skin necrosis with leathery blackening and sloughing of large
areas of skin.
ii Treatment for T-2 skin involvement is decontamination and timeliness is essential

(e) T-2 Mycotoxins: Laboratory Diagnosis

i Mycotoxins and metabolites are eliminated in the urine and feces; 50 to 75% is
eliminated within 24 hours
ii Metabolites can be detected as late as 28 days after exposure
iii Pathologic specimens include blood, urine, lung, liver, and stomach contents
iv A Gas Chromatography-Mass Spectrometry (GCMS) technique can test
environmental and clinical samples.

NOTE: Conduct a check on learning and summarize the learning activity.

1. What toxin is the cytotoxin derived predominantly from the beans of the castor
plant? RICIN

2. Toxins are poisonous substances that are produced by living organisms and
have different effects, depending on the toxin. SEB is a toxin excreted by
what bacteria? STAPHYLOCOCCUS AUREUS.

3. The hallmark of a disease caused by toxicity from this agent is a progressive,

descending, flaccid paralysis that starts with cranial nerves and facial
involvement, what toxin is this? BOTULINUM

4. What toxin can adhere to and penetrate the skin, and cause pain within
minutes of contact with human skin similar to the chemical warfare agent
Lewisite. TRICHOTHECENE (T-2) MYCOTOXINS

SECTION IV. SUMMARY

Method of Instruction:
Conference/Demonstration
Instructor to Student Ratio is:
Time of Instruction:
Media: Group Instruction

A. Review of Main Points

Review /
1. Identification of the biological agents that are most likely to be utilized as a
Summarize
biological threat or weapon and what biological category the agent belongs;
Lesson
bacteria, virus or toxins.

2. Identify facts and principles of biological agents to include the pathophysiological

indicators, signs, and symptoms of exposure, conditions and decision criteria of

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 diagnosis and treatment course of casualties.

B. Closing Statement: Biological agents may be bacterial, viral, or toxins. Biological

agents are very likely to used as a terrorist threat; these agents are readily
available, relatively inexpensive to obtain and easy of work with, modify,
manufacture and disseminate. Aerosol dissemination is the signature route for
most biological agents for the most the severe clinical symptoms and outcomes
but agents can be disseminated as liquid droplets, aerosols, or dry powders or by
vectors. Biological agents are effective terrorist threat weapons, whether the
objective is aimed at an individual or many hundreds of persons, animals.
Biological agents can cause a variety of clinical symptoms which can range from
self limiting illness, incapacitation, or death with immediate to delayed onset of
disease manifestations. Many agents have no treatment beyond supportive care,
prophylaxis or vaccination. Early intervention is essential for the most favorable
results. Treatment varies with the biological agent used, thus both presumptive
and definitive identification is imperative to treating and controlling the effects of
the terrorism threat.

SECTION V. STUDENT EVALUATION

NOTE: Describe how the student must demonstrate accomplishment of the

Testing TLO. Refer student to the Student Evaluation Plan.
Requirements Students will be evaluated using a written exam. Students must score at
least a 70% to receive a GO.

Feedback NOTE: Feedback is essential to effective learning. Schedule and provide

Requirements feedback on the evaluation and any information to help answer students'
questions about the test. Provide remedial training as needed.

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 Appendix A - Viewgraph Masters

VIEWGRAPHS FOR LESSON 1: Biological Agents

EPRC / Version 1
04 April 2009

Multi Media Attached! Click here and then press F9 to view.

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Appendix B - Test(s) and Test Solution(s) (N/A)

B-1
 Appendix C - Student Handouts

HANDOUTS FOR LESSON 1: Biological Agents

EPRC / Version 1
04 April 2009

Multi Media Attached! Click here and then press F9 to view.

C-1