Agents of Bioterrorism

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Agents of Bioterrorism

• 4th Intermountain Hazardous Materials Conference
• May 20-22, 2003
• Kim Christensen
• Utah Department of Health Laboratory

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Objectives

• Public Healths Role in BT
• LRN
• Bioterrorism Agents
• Specimen selection
• Specimen packaging
• Shipping/Transport
• Training Opportunities
• Contact Information

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UDOH Labs Core Functions

• Disease Identification and Outbreak Investigation
• Reference Services
• Specialized Testing
• Direct Services
• Environmental Testing

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UDOH Labs Core Functions

• Rapid Testing
• Laboratory Improvement
• Applied Research
• Support of Surveillance and Epidemiology
  Investigations
• Emergency Preparedness and Response

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UDOH Lab Testing

• Newborn Screening
• Rabies
• Influenza
• HIV
• STDs
• TB

• Arbovirus Surveillance
• Foodborne Organism Identification
• OME
• Molecular Biology

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Why is the UDOH LabInvolved with BT?

• Mandate by Congress
• Experience with Biological Agents of Concern and
  Outbreak Investigations
• Link between Local Laboratory Level and
  CDC/Federal Agencies

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Laboratory Response NetworkLRN

• Test According to Consensus Protocols
• Timely and Accurate Testing and Reporting
• Linked with Local, State and Federal Agencies

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LRN Laboratory Levels

• LEVEL A Clinical Labs
• LEVEL B Public Health Labs
• LEVEL C Typing Labs, Public Health Labs
• LEVEL D CDC

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Agents of Bioterrorism
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Agents of Highest ConcernCategory A

• Bacillus anthracis (Anthrax)
• Francisella tularensis (Tularemia)
• Yersinia pestis (Plague)
• Clostridium botulinum (Botulism)
• Variola major (Smallpox)
• Viral Hemorrhagic Fevers

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Other possible agentsCategory B

• Brucella species (Brucellosis)
• Burkholderia mallei (Glanders)
• Burkholderia pseudomallei (Melioidiosis)
• Coxiella burnetti (Q-fever)
• Arboviruses
• Mycotoxins
• Ricin toxin (castor beans)
• SEB (Staphylococcus Enterotoxin B)

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Why these Organisms?

• Can cause disease via aerosol route
• Fairly stable in aerosolized form
• Susceptible civilian population
• High morbidity and mortality rates
• Difficult to diagnose and/or treat
• Some can be transmitted person-to-person

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SmallpoxVariola major

• Orthopox virus
• DNA virus
• Brick-shaped structure 200 nm in diameter

• Incubation 8-16 days
• Mortality 30
• Clinical symptoms
• Acute
• Fever
• Headache
• Vomiting
• Backache

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Smallpox

• Spread by infected droplets
• Most infectious after onset of rash
• Contagious until the last scab falls off
• Vaccine given within 4 days of exposure can
  prevent disease or lessen symptoms
• 70 recovery rate
• Chicken pox vs. Smallpox

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Smallpox

• Disease Progression
• Incubation Period
• Initial Symptoms Prodrome
• Rash Development Distribution

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Smallpox - Rash

• Rash
• Begins on face, hands, forearms spreads to
  lower extremities within 7 days
• Lesions on palms soles of feet

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Smallpox - Rash

• Rash
• Synchronous progression
  macules?vesicles ?pustules ?scabs

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SmallpoxUDOH Testing

• Vaccinia virus
• Rule-out for Smallpox
• Varicella zoster virus
• Rule-out for Smallpox
• Variola major virus
• Smallpox beta testing lab

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Smallpox Specimen Selection

• Tissue biopsy
• Scabs
• Vesicular fluid
• Swab
• Dried on slide (touch prep)

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Utah Smallpox Immunization Program
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AnthraxBacillus anthracis

• Bacillus anthracis
• Gram-positive, spore-forming bacillus (rod)

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AnthraxBacillus anthracis

• Three forms of human anthrax occur
• Cutaneous
• Gastrointestinal
• Oropharyngeal
• Abdominal
• Inhalation

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AnthraxBacillus anthracis

• Cutaneous Exposure-
• A skin lesion evolving during a period of 2-6
  days from a papule, through a vesicular stage, to
  a depressed black eschar.

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Anthrax Lesion on Neck
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Cutaneous Anthrax

• Intense itching
• Painless skin sore
• Incubation 1-5 days (up to 60)
• 20 fatality if untreated (may spread to blood)
• Direct contact with skin lesion may result in
  cutaneous infection

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Inhalation Anthrax

• Inhalation Anthrax-
• A brief prodrome resembling a viral respiratory
  illness with radiograph evidence of mediastinal
  widening

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Inhalation Anthrax

• Flu-like symptoms
• Fever, fatigue, muscle aches, difficulty
  breathing, headache, chest pain
  non-productive cough
• 1-2 day improvement followed by respiratory
  failure, meningitis may develop
• No person-to-person spread

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Anthrax Specimens

• Inhalational
• Sputum
• Blood
• Gastrointestinal
• Blood
• Stool

• Cutaneous
• Vesicles
• Eschars
• Swabs
• Environmental
• Powder
• Evidentiary

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TularemiaFrancisella tularensis

• Plague-like disease in rodents (California)
• Deer-fly fever (Utah)
• Glandular tick fever (Idaho and Montana)
• Market mens disease (Washington, DC)
• Rabbit fever (Central States)
• OHaras disease (Japan)
• Water-rat trappers disease (Russia)

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Tularemia

• Person-to-person transmission NO
• Infective dose 10-50 organisms
• Incubation period 1-21 days (avg. 3-5)
• Duration of Illness 2 weeks
• Mortality low (treated), moderate (untreated)
• Persistence of organism months in moist soil
• Vaccine efficacy good 80

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TularemiaClinical Presentations

• Pneumonic-
• Incubation 3-5 days
• Flu-like symptoms
• Mortality
• 30 untreated
• lt10 treated
• Ulceroglandular
• Ulcer w/adenopathy

• Glandular
• Adenopathy w/o lesion
• Oculoglandular
• Painful, purulent conjunctivitis
• Typhoidal
• Possible presentation for BT
• Septicemia

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Tularemia Specimen Selection

• Blood
• Tissue
• Lesion aspirate, swab
• Sputum
• Serum
• Environmental samples

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PlagueYersinia pestis

• Distribution
• Highest in 4 corners area Western states
• Prairie dog population

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Plague Yersinia pestis

• Transmission
• Inhalation
• Direct contact
• Fleas

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Plague

• Clinical presentations
• Bubonic
• Infected lymph nodes
• Septicemic
• Blood-borne organisms
• Pneumonic
• Transmissible by aerosol deadliest

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Plague

• Bubonic
• Flu-like with painful buboes (lymph nodes)

• Septicemic
• Similar to bubonic
• No swelling of lymph nodes

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Plague

• Pneumonic
• Highest mortality
• Rapid transmission
• Fever
• Hemoptosis
• Lymphadenopathy
• Cough

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Plague Specimen selection

• Specimen selection is Important!!
• Bubonic
• Bubo, lymph node aspirate
• Septecemic
• Blood

• Pneumonic
• Sputum
• Bronchial washings/tracheal aspirate
• Environmental
• Fleas
• powder

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Botulism Clostridium botulinum

• A neuroparalytic illness
• Action of a potent toxin
• 7 types of botulinum toxin
• Types A, B, E and F (humans)
• Types C and D (birds mammals)
• Type G (not yet confirmed as cause)

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Botulism

• Foodborne
• Diplopia (double vision), blurred vision,
  flaccid, symmetric paralysis (rapid progression)
• Infant
• Constipation, poor-feeding, failure to thrive,
  weakness, impaired respiration and death
• Wound
• Same symptoms as foodborne w/infection through a
  wound
• Other
• Non-infant patient with no suspect food or wound

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Botulism

• Foodborne
• Incubation 18-36 hours
• Most likely presentation for BT event
• Mortality
• Currently 5-10
• Previously 60

• Wound
• Mortality 15
• Emerging problem of drug users
• Injecting Black Tar Heroin

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BotulismSpecimen Selection

• Clinical specimens
• Serum
• Gastric contents or vomitus
• Stool or sterile water enema return
• Food samples
• Autopsy specimens
• Serum
• Gastric and intestinal contents

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BotulismSpecimen Selection

• Bioterrorism Intentional Release
• Serum
• Stool
• Enema fluid
• Gastric aspirate
• Nasal swab
• Food samples
• Environmental samples

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Brucellosis Brucella species

• Transmission
• Unpasteurized dairy products
• Most common mode
• Direct skin contact
• Occupational hazard for farmers, butchers,
  veterinarians, lab personnel
• Aerosols
• Highly infectious

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Brucellosis Brucella species

• Infective dose 10 -100 organisms
• Incubation period 5 days - gt 6 months
• Duration of illness weeks to months
• Fever, profuse sweating, malaise, headache and
  muscle/back pain.
• Person to person transmission no
• Mortality lt5
• Persistence of organism very stable

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BrucellaSpecimen Selection

• Blood or bone marrow
• Serum
• Tissue
• Spleen
• Liver
• Abscess
• Environmental Evidentiary Samples

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Ricin

• Castor bean waste
• Many forms
• Powder
• Mist
• Pellet
• Dissolved in water or acid
• Very stable substance

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Ricin

• Medical uses (potential)
• Bone marrow transplants
• Cancer treatment

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Ricin

• Exposure
• Accidental unlikely
• Inhalation
• Mist or powder
• Ingestion
• Injection
• Absorption

• Exposure
• 500 micrograms
• Head of a pin
• Georgi Markov, 1978
• Iran-Iraq War
• Al Qaeda

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RicinSigns Symptoms

• Inhalation
• Coughing, chest tightness, nausea, difficulty
  breathing, muscle aches (1st few hours)
• Inflammed airways, excess fluid in lungs, blue
  skin, breathing more difficult (next few hours)

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RicinSigns Symptoms

• Ingestion
• Pupil dilation
• Fever
• Thirst
• Sore throat
• Headache
• Vascular collapse
• Shock

• Ingestion
• Internal bleeding (stomach, intestines)
• Blood diarrhea and vomiting
• Liver, spleen and kidney failure
• Low/no urine output

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RicinSigns Symptoms

• Injection
• Muscle and lymph node death (injection site)
• Liver, kidney and spleen failure
• Massive bleeding from stomach intestines
• Death multiple organ failure
• 36-48 hours after exposure

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RicinNon-clinical specimens only!

• Paper
• Powder
• Water
• Soil
• Food
• Drink

• Swabs (cotton, polyester, rayon or foam)
• Wipes (non-cotton gauze, polyester blend
  Handi-Wipes)

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Staphylococcus Enterotoxin B

• Exotoxin produced by Staphylococcus aureus
• Food poisoning
• Moderately stable
• Exposure
• Inhalation (incubation 3-12 hours)
• Ingestion (incubation 4-10 hours)
• Skin contact

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Staphylococcus Enterotoxin BSigns Symptoms

• Non-specific flu-like symptoms-
• Fever
• Chills
• Headache
• Myalgia
• Prostration

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Staphylococcus Enterotoxin BSigns Symptoms

• Inhalation specific
• Non-productive cough, chest pain, dyspnea
• Pulmonary edema respiratory failure (severe
  cases)
• Gastrointestinal

• Ingestion specific
• Nausea
• Vomiting
• Diarrhea

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Staphylococcus Enterotoxin B

• Toxins No person to person transmission
• Not dermally active
• Secondary aerosols not a hazard
• Significant morbidity
• Inhalation 50-80 (untreated)

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Staphylococcus Enterotoxin BNon-clinical
specimens only!

• Paper
• Powder
• Water
• Soil
• Food
• Drink

• Swabs (cotton, polyester, rayon or foam)
• Wipes (non-cotton gauze, polyester blend
  Handi-Wipes)

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UDOH Lab Process

• Sample Check-in
• Chain of Custody
• Test request forms
• Pre-screen
• Testing
• Reporting
• Provider/designee, FBI, UDOH Epi

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Chain of Custody

• Always observe a Chain of Custody
• Evidence
• Collector?Transporter ?Laboratory
• Each person to touch the sample must sign for it.
• Laboratory
• Signed for each time the sample is manipulated

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Test Request Forms

• UDOH Client Services Manual
• Testing available
• Test Request Forms
• Bioterrorism specific
• Available at
• www.health.utah.gov/els/microbiology

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Environmental SamplesPlease Pre-screen

• Credible Threat
• Determined by FBI/Local law enforcement
• Directly related to an event
• FBI 801-579-1400

• FBI or HAZMAT
• Pre-screen
• Bombs
• Incendiary Devices
• Radiological Materials
• Chemicals

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Specimen Packaging

• Clinical-
• Containers
• Sterile, leak-proof
• Blood collection tubes
• Sterile swabs
• Labeled, individually, with patient ID
• According to institutions protocols
• www.health.utah.gov/els/microbiology

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Specimen Packaging

• Non-clinical-
• Original containers if possible
• 1. Sample placed in sealed, clean, dry
  container Ziplock bags okay
• 2. Change/add gloves
• 3. Sample placed in 2nd container
• a. In a clean area
• b. Seal 2nd container
• 4. Change/add gloves
• 5. Decontaminate outer container with 10
• bleach solution OR add a 3rd container.

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Local Transport

• Usually courier service personal vehicle
• As important as air transport
• No possibility of contents escaping under normal
  transport conditions
• FedEx/Commercial carrier
• Strict regulations

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Transporting

• Sample containers placed in leak-proof,
  unbreakable
• Transport Box
• Secure, tight-fitting cover
• Biohazard label
• Frozen specimens
• Labeled, insulated box w/ice

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Transporting

• Transport box ?
• Carried to courier vehicle
• Secure in position for transport
• VERY IMPORTANT!!
• Courier Vehicle
• Should carry a spill kit with
• Absorbent material
• Disposable gloves
• Chlorine disinfectant
• Leak-proof waste disposal container

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Additional comments

• Call ahead of time 801-584-8400
• Clinical/Environmental
• Let lab know sample is on its way
• UDOH - 24/7 coverage 1-888-EPI-UTAH
• Training Opportunities
• Websites of Interest
• www.asmusa.org
• www.bt.cdc.gov

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Contact Information

• Utah Department of Health Lab Response
• Kim Christensen 801-584-8449 kchriste_at_utah.gov
• June Pounder 801-584-8449 jpounder_at_utah.gov
• Barbara Jepson 801-584-8595 bjepson_at_utah.gov
• Emergency Pager 888-EPI-UTAH
• FBI - 801-579-1400