Transcript HRSA BTCDP Site Visit 2/25/04

New Jersey Preparedness
Training Consortium
Continuing Education
for health care professionals
“modulebiov1”
Bioterrorism
Bioterrorism:
Who are 1st Responders?
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Primary Care Personnel
Hospital ER Staff
EMS Personnel
Public Health Professionals
Other Emergency Preparedness
Personnel
• Laboratory Personnel
• Law Enforcement
Indicators of BT Events
• Increasing Frequency of Cases
• Rare or Non-endemic Disease
• Trouble Identifying Cause of Symptoms
Scenarios
• Overt Event
– Announced
– Patients Fall ill or Die (Increased
Morbidity and Mortality)
– Microorganisms Unconfirmed
– Hoaxes Assumed to be Real
Scenarios
• Covert Event
– No Prior Warning - Unannounced
– Patients Fall ill or Die from Causes
of Unknown or Unusual Origin
– Unusual Cluster(s) of Cases - May
be Geographically Distributed
– Undetermined Causative Agent
Potential Bioterrorism Agents
• Bacterial Agents
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Anthrax
Brucellosis
Cholera
Plague,
Pneumonic
– Tularemia
– Q Fever
Source: U.S. A.M.R.I.I.D.
• Viruses
– Smallpox
– VEE
– VHF
• Biological Toxins
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Botulinum
Staph Entero-B
Ricin
T-2 Mycotoxins
Important
Report ALL suspected or confirmed illness
due to these agents to health authorities
immediately
In New Jersey:
• Local city/county LINCS agency
• NJDHSS
• 609-588-7500
• 609-392-2020 (after hours)
Advantages of Biologics
as Weapons
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Easy to obtain
Inexpensive to produce
Potential dissemination over large geographic area
Creates panic
Can overwhelm medical services
Susceptible civilian populations
High morbidity and mortality
Difficult to diagnose and/or treat
Some are transmitted person-to-person via aerosol
Routes of Infection
• Skin (cuts, abrasions, mucosal membranes)
• Gastrointestinal
– Food
• Potentially significant route of delivery
• Secondary to either purposeful or accidental
exposure to aerosol
– Water
• Capacity to affect large numbers of people
• Dilution factor
• Water treatment may be effective in removal of
agents
• Respiratory
– Inhalation of spores, droplets & aerosols
– Aerosols most effective delivery method
– 1-5F droplet most effective
Medical Response
• Pre-exposure
– active immunization
– prophylaxis
– identification of threat/use
• Incubation period
– detection and diagnosis
– active and passive immunization
– antimicrobial or supportive therapy
• Overt disease
– diagnosis
– treatment
• may not be available
• may overwhelm system
• may be less effective
– direct patient care will predominate
Biological Agents of
Highest Concern
• Francisella tularensis (Tularemia)
• Yersinia pestis (Plague)
• Filoviruses and Arenaviruses (Viral
hemorrhagic fevers)
• Botulinum toxin (Botulism)
• Bacillus anthracis (Anthrax)
• Variola major (Smallpox)
Francisella tularensis
Tularemia
Tularemia: Overview
• Disease of Northern Hemisphere
• In U.S., most cases associated with
rabbits/hares (winter) and ticks (summer)
• About 200 cases/year in U.S.
– most in South central and Western
states
– majority of cases in summer (tick
exposure)
Tularemia: Clinical Forms
• Ulceroglandular
– Ulcer with regional adenopathy
• Glandular
– Regional adenopathy without skin lesion
• Oculoglandular
– Painful purulent conjunctivitis with adenopathy
Reported Cases of Tularemia 1990-1998
Tularemia
• Contagious --- no person to person transmission
• Infective dose --- 10-50 organisms
• Incubation period --- 1-21 days (average=3-5
days)
• Duration of illness --- ~2 weeks
• Mortality --- treated : low
untreated: moderate
• Persistence of organism ---months in moist soil
• Vaccine efficacy --- good, ~80%
Yersinia pestis
Plague
Plague: Overview
• Natural vector - rodent
flea
• Mammalian hosts
– rats, squirrels,
chipmunks, rabbits, and
carnivores
• Enzootic or Epizootic
CDC: Wayson’s Stain of Y. pestis showing
bipolar staining
Plague Epidemiology
• Three Clinical Types:
– bubonic (infected lymph nodes)
– septicemic (blood-borne organisms)
– pneumonic (transmissible by
aerosol; deadliest)
Plague Epidemiology
• U.S. averages 13 cases/yr
• Bubonic most common form
• Pneumonic, only 1-2 cases/yr
• 30% of cases are in Native Americans
in the Southwest. 15% case fatality
rate
• Most cases occur in summer
Plague: Prophylaxis
• Bubonic contacts
– If common exposure, consider oral Doxycycline,
Tetracycline, or TMP/SMX for 7 days
– Other close contacts, fever watch for 7 days (treat
if febrile)
Plague: Prophylaxis
(continued)
• Pneumonic contacts
(respiratory/droplet exposure)
– Consider oral Doxycycline, Tetracycline,
or TMP/SMX
– Continue for 7 days after last exposure
• Vaccine no longer manufactured in
U.S.
– Not protective against pneumonic plague
Plague:
Medical Management
• Supportive therapy
• Isolation with droplet precautions for
pneumonic plague until sputum cultures
negative
• Antibiotic resistant strains have been
documented
Plague:
Medical Management
• Antibiotic therapy
– Gentamicin or Streptomycin
– Tetracyclines
– Sulfonamides
– Chloramphenicol (meningitis/pleuritis)
Plague: Septicemic
• Primary or secondary
– Secondary from bubonic or pneumonic forms
– 100% mortality if untreated
• Severe endotoxemia
• Systemic inflammatory response syndrome
• Shock, Disseminated intravascular
coagulopathy (DIC)
• Adult Respiratory Distress Syndrome (ARDS)
Differential Diagnosis
(cont)
• Septicemic
– Other gram-negative sepsis
– Meningococcemia
– Rocky Mountain Spotted Fever (RMSF)
– Thrombotic Thrombocytopenic Purpura (TTP)
Plague:
Differential Diagnosis
• Bubonic
Staph/streptococcal
adenitis
Glandular tularemia
Cat scratch disease
• Pneumonic
Other bioterrorism threats
• Anthrax
• Tularemia
• Melioidosis
Other pneumonias (CAP,
influenza, HPS)
Hemorrhagic leptospirosis
Plague: Pneumonic
• Pneumonic
– From aerosol or septicemic spread to lungs
– Person-to-person transmission by respiratory
droplet
– 100% mortality untreated
Plague: Pneumonic
(cont)
• Incubation: 1-3 days
• Sudden onset headache,
malaise, fever, myalgia, cough
• Pneumonia progresses rapidly
to dyspnea,
cyanosis, hemoptysis
• Death from respiratory
collapse/sepsis
USAMRICD: Pneumonic
infiltrate of pneumonic
plague
Plague: Clinical Forms
Bubonic
• Bubonic
– Inguinal, axillary, or cervical lymph nodes
most common
– 80% can become bacteremic
– 60% mortality if untreated
Plague: Bubonic
• Incubation: 2-6 days
• Sudden onset headache, malaise,
myalgia, fever, tender lymph
nodes
• Regional lymphadenitis (Buboes)
• Cutaneous findings
– possible papule, vesicle, or
pustule at inoculation site
– Purpuric lesions - late
USAMRICD:
Inguinal/femoral
buboes
Yersinia pestis
Specimen Selection
• Specimen selection is important
– Bubonic - bubo - lymph node
aspirate
– Septicemic - blood - Obtain three
sets 10-30 minutes apart
– Pneumonic
• Sputum/throat
• Bronchial washings
Hemorrhagic Fever Viruses
• Families Responsible for
VHF:
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Arenaviridae
Bunyaviridae
Filoviridae
Flaviviridae
Hemorrhagic Fever Viruses
• Arenaviruses
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Argentine Hemorrhagic Fever
Bolivian Hemorrhagic Fever
Sabia Associated Hemorrhagic Fever
Lassa Fever
Hemorrhagic Fever Viruses
• Bunyaviruses
– Crimean-Congo Hemorrhagic Fever
– Rift Valley Fever
– Hantavirus Pulmonary Syndrome
Hemorrhagic Fever
Hemorrhagic Fever Viruses
• Filoviruses
– Ebola Hemorrhagic Fever
– Marburg Hemorrhagic Fever
Hemorrhagic Fever Viruses
Ebola
Marburg
Hemorrhagic Fever Viruses
• Flaviviruses
– Tick-borne Encephalitis
– Kyasanur Forest Disease
– Omsk Hemorrhagic Fever
Viral Hemorrhagic Fevers
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Contagious --- Moderate
Infective dose --- 1-10 particles
Incubation period --- 4-21 days
Duration of illness --- 7-16 days
Mortality ---variable
Persistence of organism --- unstable
Non-endemic in U.S.
No vaccine
Clostridium botulinum
Botulism
FOODBORNE
BOTULISM
• Infective dose: 0.001 g/kg
• Incubation period: 18 - 36 hours
• Dry mouth, double vision, droopy
eyelids, dilated pupils
• Progressive descending bilateral
muscle weakness & paralysis
• Respiratory failure and death
• Mortality 5-10%, up to 25%
FOODBORNE
BOTULISM
• Among 309 persons with clinically
diagnosed botulism reported to CDC
from 1975 to 1988:
– Stool cultures for C. botulinum: 51% +
– Serum botulinum toxin testing: 37% +
– Stool botulinum toxin testing: 23% +
• Overall, at least one of the above
tests was positive for 65% of all
patients
Level A Procedures
for Botulism Event
• Properly collected specimens are to be
referred to designated testing
laboratories
• Prior to the shipment of any botulismassociated specimen, the designated
laboratory must be notified and
approved by the State Health
Department
Level A Procedures
for Botulism Event
• Clinical specimens to be collected:
1. Serum
2. Gastric contents or vomitus
3. Feces or return from sterile water
enema
4. Wound tissue
Bacillus anthracis
Anthrax
Anthrax: Basics
 Caused by the spore-forming bacterium,
Bacillus anthracis
 Zoonotic disease in herbivores (e.g., sheep,
goats, cattle) follows ingestion of spores in soil
 Human infection typically acquired through
contact with anthrax-infected animals or animal
products or atypically through intentional
exposure
 Three clinical forms
 Cutaneous
 Inhalational
 Gastrointestinal
Cases of Anthrax in the U.S., 1951–2000*
1990
1975
1960
Animal (Stern's) vaccination started in 1957, after OK enzootic.
Recommended for use in animals in endemic areas thereafter.
70 60
60
50 4745 39
38
40
w
2000
26
30
23
22
16
20
12 14
9
7
6
10
3 5 5 2 3 4 2 5 2 2 2 2 2
0 0 1 0 0 0 1 0 0 0 2 0 0 0 1 0 0 0 0 0 0 0 1
0
1951
Cases
(N = 409)
Year
*Only 18 of these cases were inhalational; the remainder were cutaneous.
wOne cultured case (cutaneous) reported in 2000 from North Dakota.
Anthrax: Current Issues in the U.S.
 Anthrax remains an endemic public health
threat through annual epizootics.
 B. anthracis is one of the most important
pathogens on the list of bioterrorism threats
Aerosolized stable spore form
Human LD50 8,000 to 40,000 spores, or
one deep breath at site of release
Anthrax Bioterrorism Issues (1)
• Surveillance for cutaneous and
inhalational disease to identify attack
• Targeting prevention strategies
– Rapidly identify exposed populations
– Conduct epidemiologic investigation
with environmental testing
– Supply postexposure prophylaxis
– Trace route of vehicle of exposure
Anthrax Bioterrorism Issues (2)
• Environmental assessment to
determine exposures
• Decontamination
• Defining population at risk for
pre-exposure immunization
Anthrax:
Case Definition
Confirmed Case:
• Clinically compatible illness confirmed by
isolation of B. anthracis or other laboratory
evidence based on at least two supportive
laboratory tests
Suspected Case:
• Clinically compatible illness with one
supportive lab test or linked to a confirmed
environmental exposure
Anthrax:
Exposure Classification
Exposure, laboratory-confirmed:
• Epidemiologically linked to a plausible
environmental exposure, with laboratory
evidence of B. anthracis from a nasal swab or
other clinical sample
Exposure, not laboratory-confirmed:
• Epidemiologically linked to a plausible
environmental exposure, without laboratory
evidence of B. anthracis
Cutaneous anthrax
Vesicle development, day 2 Eschar formation, day 4
www.who.int/emc/
Anthrax:
Cutaneous
 Begins as a papule, progresses through a
vesicular stage to a depressed black necrotic
ulcer (eschar)
 Edema, redness, and/or necrosis without
ulceration may occur
 Form most commonly encountered in
naturally occurring cases
 Incubation period: 1–12 days
 Case-fatality:
 Without antibiotic treatment—20%
 With antibiotic treatment—1%
Anthrax: Cutaneous
Vesicle
development
Day 2
Day 6
Day 4
Day 10
Eschar
formation
Differential Diagnosis
of Cutaneous Anthrax
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Spider bite
Ecthyma gangrenosum
Ulceroglandular tularemia
Plague
Staphylococcal or streptococcal cellulitis
Herpes simplex virus
Anthrax:
Diagnosis
Cutaneous
 Gram stain, polymerase chain
reaction (PCR), or culture of
vesicular fluid, exudate, or eschar
 Blood culture if systemic symptoms
present
 Biopsy for immunohistochemistry,
especially if person taking
antimicrobials
Anthrax: Inhalational
Mediastinal widening
JAMA 1999;281:1735–1745
Mediastinal Widening and Pleural Effusion
on Chest X-Ray in Inhalational Anthrax
Inhalational Anthrax
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Infective dose = 8,000 - 15,000 spores
Incubation period = 1-6 days
Duration of illness = 3-5 days
Fever, malaise, and fatigue
Short period of improvement = up to 2 days
Abrupt respiratory distress…death <24hrs
No person to person transmission
Anthrax:
Inhalational (1)
 A brief prodrome resembling a “viral-like”
illness, characterized by myalgia, fatigue,
fever, with or without respiratory
symptoms, followed by hypoxia and
dyspnea, often with radiographic evidence
of mediastinal widening.
 Meningitis in 50% of patients
 Rhinorrhea (rare)
Anthrax:
Inhalational (2)
 Extremely rare in United States
(20 reported cases in last century)
 Incubation period: 1–7 days (possibly
ranging up to 42 days)
 Case fatality:
 Without antibiotic treatment—97%
 With antibiotic treatment—75%
Differential Diagnosis
of Inhalational Anthrax
• Mycoplasmal
pneumonia
• Legionnaires’
disease
• Psittacosis
• Tularemia
• Q fever
• Viral pneumonia
• Histoplasmosis
(fibrous
mediastinitis)
• Coccidioidomycosis
• Malignancy
Anthrax:
Diagnosis
Inhalational
 Chest X-ray—widened mediastinum,
pleural effusions, infiltrates, pulmonary
congestion
 Affected tissue biopsy for
immunohistochemistry
 Any available sterile site fluid for Gram
stain, PCR, or culture
 Pleural fluid cell block for
immunohistochemistry
Anthrax: Gastrointestinal
(continued)
• Intestinal eschar similar
to cutaneous anthrax
lesion
– hemorrhagic
• Progression to
generalized toxemia
• Mortality rate 50 -100%
despite treatment
CDC: Intestinal lesion of GI
anthrax
Anthrax:
Gastrointestinal
 Abdominal distress, usually accompanied
by bloody vomiting or diarrhea, followed
by fever and signs of septicemia
 Gastrointestinal illness sometimes seen
as oropharyngeal ulcerations with cervical
adenopathy and fever
 Develops after ingestion of contaminated,
poorly cooked meat.
 Incubation period: 1–7 days
 Case-fatality: 25–60% (role of early
antibiotic treatment is undefined)
Differential Diagnosis of
Gastrointestinal Anthrax
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Acute appendicitis
Ruptured viscus
Diverticulitis
Diseases that cause acute cervical
lymphadenitis or acute gastritis
• Dysentery
Anthrax:
Diagnosis
Gastrointestinal
• Blood cultures
• Oropharyngeal (OP) swab collection
Exposure Situation Management:
B. anthracis in Envelope
• Antimicrobial prophylaxis for those
potentially exposed
• Environmental samples
– Surface swabs
– Nasal swabs of potentially exposed
persons (if <7 days)
• Refine list of potentially exposed persons
– Not exposed: stop treatment
– Likely exposed: continue treatment for
60 days total
Anthrax: Specimen
Selection
• Inhalation: Sputum and Blood
• Cutaneous: Vesicles and Eschar
• Gastrointestinal: Stool and Blood
Anthrax: PostExposure Treatment
• Start oral antibiotics as soon as possible
after exposure
– Ciprofloxacin or Doxycycline or
Amoxicillin/Penicillin (if known PCN
sensitive)
Post-Exposure Treatment (continued)
• Antibiotics for 60 days without vaccine
• Antibiotics for 30 days with 3 doses of
vaccine (animal studies)
• Long-term antibiotics necessary
because of spore persistence in
lung/lymph node tissue
Recommended Postexposure Prophylaxis to
Prevent Inhalational Anthrax
Initial Therapy
Duration
Adults
Ciprofloxacin
60 days
(including pregnant
500 mg PO BID
women and
OR
immunocompromised)
Doxycycline
100 mg PO BID
Children
Ciprofloxacin*
60 days
10–15 mg/kg PO Q 12 hrs
Change to
OR
amoxicillin
Doxycycline:
if susceptible
>8 yrs and >45 kg: 100 mg PO BID
>8 yrs and <45 kg: 2.2 mg/kg PO BID
<8 yrs: 2.2 mg/kg PO BID
*Ciprofloxacin not to exceed 1 gram daily in children
Patient information sheets at www.bt.cdc.gov
Anthrax: Treatment
• Antibiotics
– Penicillin or Doxycycline (FDA
approved), or Ciprofloxacin (animal and
in vitro studies)
• Supportive care
• Standard precautions, no quarantine
needed
Anthrax: Treatment
(continued)
• Duration of treatment dependent on form
of anthrax and/or vaccine use
• Early treatment improves prognosis
• Antibiotic susceptibility testing to help
guide therapy
Cutaneous Anthrax Treatment Protocol* for Cases
Associated with Bioterrorist Events
Category
Initial Therapy (Oral)
Adults
Ciprofloxacin
(Including pregnant women
500 mg BID
and immunocompromised)
OR
Doxycycline
100 mg BID
Children
(including immunocompromised)
Duration
60 daysw
Ciprofloxacin**
60 daysw
10–15 mg/kg Q 12 hrs
OR
Doxycycline:
>8 yrs and >45 kg: 100 mg BID
>8 yrs and <45 kg: 2.2 mg/kg BID
<8 yrs: 2.2 mg/kg BID
**Ciprofloxacin not to exceed 1 gram daily in children.
w60-day duration is to prevent inhalational anthrax.
Patient information sheets at www.bt.cdc.gov
*Source MMWR 2001;50:909–19
Inhalational Anthrax Treatment Protocol* for Cases Associated
with Bioterrorist Events (1)
Category
Initial therapy (intravenous)
Adults
Ciprofloxacin
(Including pregnant
400 mg Q 12 hrs
women** and
OR
immunocompromised)
Doxycycline
100 mg Q 12 hrs
AND
One or two additional
antimicrobials
Duration
Switch to oral
therapy when
clinically
appropriate:
Ciprofloxacin 500 mg BID
OR
Doxycycline 100 mg BID
Continue for 60 days
(IV and PO combined)
**High death rate from infection outweighs risk of antimicrobials
Patient information sheets at www.bt.cdc.gov
*Source MMWR 2001;50:909–19
Inhalational Anthrax Treatment Protocol* for Cases Associated
with Bioterrorist Events (2)
Category
Children
(including immunocompromised
Initial therapy (intravenous)
Duration
Ciprofloxacin
10–15 mg/kg Q 12 hrs
OR
Doxycycline
>8 yrs and >45 kg:
100 mg Q 12 hrs
>8 yrs and <45 kg:
2.2 mg/kg Q 12 hrs
<8 yrs:
2.2 mg/kg Q 12 hrs
AND
One or two additional
antimicrobials
Switch to oral
therapy when
clinically
appropriate:
Ciprofloxacin
10–15 mg/kg Q 12 hrs
OR
Doxycycline
>8 yrs and >45 kg:
100 mg BID
>8 yrs and <45 kg:
2.2 mg/kg BID
<8 yrs: 2.2 mg/kg BID
**Ciprofloxacin not to exceed 1 gram daily
wContinue
for 60 days (IV and po combined)
Patient information sheets at www.bt.cdc.gov
*Source MMWR 2001;50:909–19
Anthrax: Vaccine
• Current U.S. vaccine (FDA Licensed)
– FDA approved for persons 18-65 year of age
– Active component is Protective Antigen (PA)
from attenuated non-encapsulated strain
– Protective against cutaneous (human data)
and possibly inhalational anthrax (animal
data)
Anthrax: Vaccine
(continued)
• Current U.S. vaccine (FDA Licensed) continued
– FDA approved for 6 dose regimen over
18 months
– 3 dose regimen (0, 2, and 4
weeks) may be effective for postexposure treatment (animal studies)
– Limited availability
Smallpox: Overview
• 1980 - Global
eradication
• Humans were only
known reservoir
• Person-to-person
transmission
(aerosol/contact)
• Up to 30% mortality in
unvaccinated
CDC: Electron
micrograph of
Variola major
Smallpox:
Clinical Features
• Prodrome (incubation 7-17 days)
– Acute onset fever, malaise, headache,
backache, vomiting
– Transient erythematous rash
Smallpox:
Clinical Features
(continued)
• Exanthem (Rash)
– Begins on face, hands,
forearms spreads to lower
extremities then trunk over
~ 7 days
– Synchronous progression:
macules  vesicles 
pustules  scabs
– Lesions on palms /soles
USAMRICD: ater stage
facial lesions of
smallpox
Smallpox: Complications
• Encephalitis1
– 1 in 2,000 cases Variola minor
– 1 in 500 cases Variola major
• Keratitis, corneal ulceration2
– Blindness in 1% of cases
1 Marsden,
2 Hughes,
JP. Bulletin of Hygiene. 1948; 23: 735-46
K. Geneva, Switzerland: 1978. WHO/SE78.101
Smallpox: Complications (continued)
• Infection in pregnancy3
– High perinatal fatality
– Congenital infection
Marsden, JP, Greenfield CRM. Arch
Dis Child. 1934;9:309-14.
3
Smallpox vs. Chickenpox
Variola
Incubation
Prodrome
Distribution
Progression
Scab formation
Scab separation
Varicella
7-17 days
14-21 days
2- 4 days
minimal/none
centrifugal
centripetal
synchronous asynchronous
10-14 d p rash
4-7 d p rash
14-28 d p rash
<14 d p rash
Level A Procedures
Smallpox virus
• Rule out chickenpox (PCR)!
• Specimen of choice is lesion material from
pustules
• Contact your State Public Health
Laboratory for guidance
Smallpox:
Current Vaccine
• Made from live Vaccinia
virus
• Intradermal inoculation
with bifurcated needle
(scarification)
– Pustular lesion/induration
surrounding central scab/ulcer
6-8 days after vaccination
WHO: Smallpox vaccine vials
Smallpox:
Current Vaccine (continued)
– Low grade fever, axillary lymphadenopathy
– Scar (permanent) demonstrates successful
vaccination
– Immunity not life-long
Smallpox: Vaccination
Complications
• Most common
– Inadvertent inoculation (skin, eye)
• Less Common
– Generalized vaccinia (242/million) †
– Post-vaccination encephalitis (2.9/million)*
* Lane, et al., NEJM, 1969;281:1201
†Lane, et al., J Infect Dis., 1970; 122:303
Smallpox: Vaccination
Complications (continued)
• Less common (continued)
– Fetal vaccinia
– Eczema vaccinatum (38/million) †
– Vaccinia necrosum (0.9/million) †
• Primary vaccination - 1
death/million*
• Revaccination - 0.1 deaths/million*
Smallpox: Vaccination
Complications
WHO: Eczema vaccinatum
WHO: Vaccinia necrosum
WHO: Inadvertent
inoculation below eye
Smallpox: Vaccinia
Immune Globulin (VIG)
• Used for treatment of adverse reactions (AR)
– Approximately 25AR’s/100,000 vaccinations*
– AR rate possibly increased in present day due to
higher immunocompromised population
*Ström J., Zetterberg B., ed. (1966) Smallpox outbreak and vaccination
problems in Stockholm, Sweden, 1963.
Acta Medica Scandinavica, supplementum, 464:1-171
Vaccine (continued)
• Post-exposure prophylaxis
– Pregnant patients (VIG + Vaccinia
vaccine)
– Eczema (VIG + Vaccina vaccine)
– Immunocompromised patients, No
consensus (VIG alone vs. VIG + Vaccinia
vaccine?)
• Current supplies limited
Ström J., Zetterberg B., ed. (1966) Smallpox outbreak and vaccination problems in
Stockholm, Sweden, 1963 .Acta Medica Scandinavica, supplementum, 464:1-171
Smallpox:
Medical Management
• Strict respiratory/contact isolation of
patient
– Patient infectious until all scabs have
separated
• Notify public health authorities
immediately for suspected case
• Identify contacts within 17 days of
the onset of case’s symptoms
Smallpox:
Management of Contacts
• Immediate vaccination (or boosting) of
ALL potential contacts including health
care workers
– Vaccination within 4 days of exposure may
prevent or lessen disease
– 17 day observation for fever or rash
Smallpox:
Management of Contacts (cont)
• Passive immunization (VIG)
– Potential use for contacts at high risk for
vaccine complications (pregnancy,
dermatoses, immunosuppression)
Bioterrorism:
What Can Be Done?
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Awareness
Laboratory Preparedness
Plan in place
Individual & collective protection
Detection & characterization
Emergency response
Measures to Protect the Public’s Health and
Safety
• Treatment
• Safe practices