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Agents of Bioterrorism. 4 th Intermountain Hazardous Materials Conference May 20-22, 2003 Kim Christensen Utah Department of Health Laboratory. Objectives. Public Health’s Role in BT LRN Bioterrorism Agents Specimen selection Specimen packaging Shipping/Transport

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Agents of bioterrorism

Agents of Bioterrorism

4th Intermountain Hazardous Materials Conference

May 20-22, 2003

Kim Christensen

Utah Department of Health Laboratory


Objectives
Objectives

  • Public Health’s Role in BT

  • LRN

  • Bioterrorism Agents

  • Specimen selection

  • Specimen packaging

  • Shipping/Transport

  • Training Opportunities

  • Contact Information


Udoh lab s core functions
UDOH Lab’s Core Functions

  • Disease Identification and Outbreak Investigation

  • Reference Services

  • Specialized Testing

  • Direct Services

  • Environmental Testing


Udoh lab s core functions1
UDOH Lab’s Core Functions

  • Rapid Testing

  • Laboratory Improvement

  • Applied Research

  • Support of Surveillance and Epidemiology Investigations

  • Emergency Preparedness and Response


Udoh lab testing

Newborn Screening

Rabies

Influenza

HIV

STDs

TB

Arbovirus Surveillance

Foodborne Organism Identification

OME

Molecular Biology

UDOH Lab Testing


Why is the udoh lab involved with bt
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


Laboratory response network lrn
Laboratory Response NetworkLRN

  • Test According to Consensus Protocols

  • Timely and Accurate Testing and Reporting

  • Linked with Local, State and Federal Agencies


Lrn laboratory levels
LRN Laboratory Levels

  • LEVEL A – Clinical Labs

  • LEVEL B – Public Health Labs

  • LEVEL C – Typing Labs, Public Health Labs

  • LEVEL D – CDC



Agents of highest concern category a
Agents of Highest ConcernCategory A

  • Bacillus anthracis (Anthrax)

  • Francisella tularensis (Tularemia)

  • Yersinia pestis (Plague)

  • Clostridium botulinum (Botulism)

  • Variola major (Smallpox)

  • Viral Hemorrhagic Fevers


Other possible agents category b
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)


Why these organisms
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


Smallpox variola 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

SmallpoxVariola major


Smallpox
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


Smallpox1
Smallpox

  • Disease Progression

    • Incubation Period

    • Initial Symptoms – Prodrome

    • Rash Development & Distribution


Smallpox rash

Rash

Begins on face, hands, forearms & spreads to lower extremities within 7 days

Lesions on palms & soles of feet

Smallpox - Rash


Smallpox rash1

Rash

Synchronous progression: maculesvesicles pustules scabs

Smallpox - Rash


Smallpox udoh testing
SmallpoxUDOH Testing

  • Vaccinia virus

    • Rule-out for Smallpox

  • Varicella zoster virus

    • Rule-out for Smallpox

  • Variola major virus

    • Smallpox beta testing lab


Smallpox specimen selection
Smallpox Specimen Selection

  • Tissue biopsy

  • Scabs

  • Vesicular fluid

    • Swab

    • Dried on slide (touch prep)



Anthrax bacillus anthracis

Bacillus anthracis –

Gram-positive, spore-forming bacillus (rod)

AnthraxBacillus anthracis


Anthrax bacillus anthracis1
AnthraxBacillus anthracis

  • Three forms of human anthrax occur:

    • Cutaneous

    • Gastrointestinal

      • Oropharyngeal

      • Abdominal

    • Inhalation


Anthrax bacillus anthracis2

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.

AnthraxBacillus anthracis



Cutaneous anthrax
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


Inhalation anthrax
Inhalation Anthrax

  • Inhalation Anthrax-

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


Inhalation anthrax1
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


Anthrax specimens

Inhalational

Sputum

Blood

Gastrointestinal

Blood

Stool

Cutaneous

Vesicles

Eschars

Swabs

Environmental

Powder

Evidentiary

Anthrax Specimens


Tularemia francisella tularensis
TularemiaFrancisella tularensis

  • Plague-like disease in rodents (California)

  • Deer-fly fever (Utah)

  • Glandular tick fever (Idaho and Montana)

  • Market men’s disease (Washington, DC)

  • Rabbit fever (Central States)

  • O’Hara’s disease (Japan)

  • Water-rat trappers disease (Russia)


Tularemia
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%


Tularemia clinical presentations

Pneumonic-

Incubation 3-5 days

Flu-like symptoms

Mortality –

30% untreated

<10% treated

Ulceroglandular

Ulcer w/adenopathy

Glandular

Adenopathy w/o lesion

Oculoglandular

Painful, purulent conjunctivitis

Typhoidal

Possible presentation for BT

Septicemia

TularemiaClinical Presentations


Tularemia specimen selection
Tularemia Specimen Selection

  • Blood

  • Tissue

  • Lesion aspirate, swab

  • Sputum

  • Serum

  • Environmental samples


Plague yersinia pestis
PlagueYersinia pestis

  • Distribution

    • Highest in 4 corners area – Western states

    • Prairie dog population


Plague yersinia pestis1
PlagueYersinia pestis

  • Transmission –

    • Inhalation

    • Direct contact

    • Fleas


Plague
Plague

  • Clinical presentations

    • Bubonic

      • Infected lymph nodes

    • Septicemic

      • Blood-borne organisms

    • Pneumonic

      • Transmissible by aerosol; deadliest


Plague1

Bubonic

Flu-like with painful buboes (lymph nodes)

Septicemic

Similar to bubonic

No swelling of lymph nodes

Plague


Plague2

Pneumonic

Highest mortality

Rapid transmission

Fever

Hemoptosis

Lymphadenopathy

Cough

Plague


Plague specimen selection

Specimen selection is Important!!

Bubonic

Bubo, lymph node aspirate

Septecemic

Blood

Pneumonic

Sputum

Bronchial washings/tracheal aspirate

Environmental

Fleas

powder

Plague Specimen selection


Botulism clostridium botulinum
BotulismClostridium 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)


Botulism
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


Botulism1

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

Botulism


Botulism specimen selection
BotulismSpecimen Selection

  • Clinical specimens –

    • Serum

    • Gastric contents or vomitus

    • Stool or sterile water enema return

    • Food samples

  • Autopsy specimens –

    • Serum

    • Gastric and intestinal contents


Botulism specimen selection1
BotulismSpecimen Selection

  • Bioterrorism – Intentional Release

    • Serum

    • Stool

    • Enema fluid

    • Gastric aspirate

    • Nasal swab

    • Food samples

    • Environmental samples


Brucellosis brucella species
BrucellosisBrucella species

  • Transmission

    • Unpasteurized dairy products

      • Most common mode

    • Direct skin contact

      • Occupational hazard for farmers, butchers, veterinarians, & lab personnel

    • Aerosols

      • Highly infectious


Brucellosis brucella species1
BrucellosisBrucella species

  • Infective dose = 10 -100 organisms

  • Incubation period = 5 days - > 6 months

  • Duration of illness = weeks to months

  • Fever, profuse sweating, malaise, headache and muscle/back pain.

  • Person to person transmission = no

  • Mortality = <5%

  • Persistence of organism = very stable


Brucella specimen selection
BrucellaSpecimen Selection

  • Blood or bone marrow

  • Serum

  • Tissue

    • Spleen

    • Liver

    • Abscess

  • Environmental & Evidentiary Samples


Ricin
Ricin

  • Castor bean waste

  • Many forms

    • Powder

    • Mist

    • Pellet

    • Dissolved in water or acid

  • Very stable substance


Ricin1

Medical uses (potential)

Bone marrow transplants

Cancer treatment

Ricin


Ricin2

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

Ricin


Ricin signs symptoms
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)


Ricin signs symptoms1

Ingestion

Internal bleeding (stomach, intestines)

Blood diarrhea and vomiting

Liver, spleen and kidney failure

Low/no urine output

Ingestion –

Pupil dilation

Fever

Thirst

Sore throat

Headache

Vascular collapse

Shock

RicinSigns & Symptoms


Ricin signs symptoms2
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


Ricin non clinical specimens only

Paper

Powder

Water

Soil

Food

Drink

Swabs (cotton, polyester, rayon or foam)

Wipes (non-cotton gauze, polyester blend – Handi-Wipes)

RicinNon-clinical specimens only!


Staphylococcus enterotoxin b
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


Staphylococcus enterotoxin b signs symptoms
Staphylococcus Enterotoxin BSigns & Symptoms

  • Non-specific flu-like symptoms-

    • Fever

    • Chills

    • Headache

    • Myalgia

    • Prostration


Staphylococcus enterotoxin b signs symptoms1

Inhalation specific

Non-productive cough, chest pain, dyspnea

Pulmonary edema & respiratory failure (severe cases)

Gastrointestinal

Ingestion specific –

Nausea

Vomiting

Diarrhea

Staphylococcus Enterotoxin BSigns & Symptoms


Staphylococcus enterotoxin b1
Staphylococcus Enterotoxin B

  • Toxins – No person to person transmission

  • Not dermally active

  • Secondary aerosols not a hazard

  • Significant morbidity

    • Inhalation 50-80% (untreated)


Staphylococcus enterotoxin b non clinical specimens only

Paper

Powder

Water

Soil

Food

Drink

Swabs (cotton, polyester, rayon or foam)

Wipes (non-cotton gauze, polyester blend – Handi-Wipes)

Staphylococcus Enterotoxin BNon-clinical specimens only!


Udoh lab process
UDOH Lab Process

  • Sample Check-in

    • Chain of Custody

    • Test request forms

    • Pre-screen

  • Testing

  • Reporting

    • Provider/designee, FBI, UDOH Epi


Chain of custody
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


Test request forms
Test Request Forms

  • UDOH Client Services Manual

    • Testing available

    • Test Request Forms

      • Bioterrorism specific

  • Available at

    • www.health.utah.gov/els/microbiology


Environmental samples please 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

Environmental SamplesPlease Pre-screen


Specimen packaging
Specimen Packaging

  • Clinical-

    • Containers:

      • Sterile, leak-proof

      • Blood collection tubes

      • Sterile swabs

    • Labeled, individually, with patient ID

    • According to institution’s protocols

    • www.health.utah.gov/els/microbiology


Specimen packaging1
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.


Local transport
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


Transporting
Transporting

  • Sample containers placed in leak-proof, unbreakable

    • Transport Box

      • Secure, tight-fitting cover

      • Biohazard label

  • Frozen specimens

    • Labeled, insulated box w/ice


Transporting1
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


Additional comments
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


Contact information
Contact Information


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