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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
  • Utah Department of Health Lab Response
    • Kim Christensen – 801-584-8449 kchriste@utah.gov
    • June Pounder – 801-584-8449 jpounder@utah.gov
    • Barbara Jepson – 801-584-8595 bjepson@utah.gov
    • Emergency Pager – 888-EPI-UTAH
  • FBI - 801-579-1400