About the Center


The mission of the Center of Excellence for the Study of High Consequence Event Preparedness and Response is to investigate the risks, vulnerabilities and consequences of potential terrorist events employing weapons of mass destruction to specifically examine the preparedness and response posture of the United States, identifying and redressing gaps in the technical understanding of the deterrence, detection, use, response and long-term recovery from such weapons by a program of focused research.

Research at the center


Research ranges from highly technical engineering (e.g., state-of-the-art sensor development) and modeling/simulation to practical qualitative measures of response-plan adequacy. The research program is tightly coupled with both broad-based and specialized education programs for undergraduates, graduate students and scholars. The center is a direct resource to the Department of Homeland Security and in addition to research and education functions, provides independent assessments and expertise as requested.

Learning Materials


Practicing health practitioners are responsible for a range of health services. Depending upon the discipline, professionals in health disciplines may be involved in one or more of the following:
  • Diagnosis and treatment
  • Health maintenance and disease prevention
  • Community/public health
  • Health education
  • Research
  • Health information management
In the event of an act of bioterrorism, health professionals will have a central role in the identification, management and communication efforts necessary to minimize impact. In some cases, they may be the first to encounter victims of bioterrorist acts and thus fall into the category of “first responders.”  In order to effectively function in these roles, it is important the health professionals be knowledgeable in content areas related to the extent of the threat, potential agents of bioterrorism, clinical and laboratory evidence, epidemiology and patient treatment/management, as well as the suitable processes, protocols and policies regarding communication of suspected events to institutional, local, regional, state and federal authorities.

E-Modules


The purpose of the e-modules contained in this site is to provide information to a wide range of health professionals. They can be used individually to provide information quickly, as a refresher or compiled to provide a comprehensive training session. The agents are representative of the various types bioterrorism agents and not comprehensive. The cases are designed to introduce the knowledge, skills and attitudes needed to appropriately respond to a bioterrorist event. They can be used to train a wide variety of health professionals and to teach the interdisciplinary communications necessary to effectively manage the event.

Module Sections



Agents

Agents

Agents

The agents of bioterrorism discussed on this site have been chosen to be representative of the various types bioterrorism agents and not comprehensive. They were also chosen because studying them would introduce trainees to the general concepts needed to manage bioterrorist events.

Anthrax

Overview

Anthrax is a bacterial zoonosis1 caused by the spore2-forming bacteria Bacillus anthracis. There are three forms of anthrax: cutaneous, gastrointestinal and inhalation. Humans acquire unintentional anthrax infections by handling infected animal products such as wool or hides, or by eating undercooked meat or dairy products from infected animals. Anthrax is not contagious, meaning that it is not transmitted from person to person.

Anthrax has been recognized as a disease in animals and in humans for centuries3. Anthrax has been investigated as a potential biological weapon for approximately 80 years.

The cutaneous form of anthrax is the most common form of the disease. Deaths are rare when patients are treated with the appropriate antimicrobial therapy, and 80% of untreated cases do not result in death. Gastrointestinal anthrax results in death in 25 to 60% of diagnosed cases. Inhalation anthrax is the most severe form, with as many as 75% of treated cases resulting in death.

The first symptom of cutaneous anthrax is a small sore that develops into a blister, and then into a skin ulcer with a black center. Symptoms of gastrointestinal anthrax include nausea, loss of appetite, abdominal distress, diarrhea and fever. The initial symptoms of inhalation anthrax are cold or flu-like symptoms including a sore throat, mild fever and muscle aches. These symptoms are generally followed by chest discomfort, a dry cough, shortness of breath and fatigue. Unlike the common cold and flu, anthrax symptoms do not include a runny nose. Early identification and treatment are important in all three types of anthrax.
1Zoonosis: a disease that can be acquired by humans from an animal source.

2A bacterial spore is a dormant form of the bacteria that, under appropriate conditions, can cause the disease.

3Anthrax is known to have caused disease as long ago as 1500 BC when it is thought to have caused the Fifth Egyptian Plague. An anthrax outbreak in Iran in 1945 killed one million sheep. Anthrax was first developed as a potential biological warfare agent by Germany in WWI.

Epidemiology

The spores of B anthracis are typically found in soil, are highly resistant to chemical agents and environmental stresses, and can survive in the soil for decades. Spores can be found in soil world wide, but most commonly in temperate agricultural regions. Cattle, goats, sheep, pigs and horses contract the disease from spores in contaminated soil. In the United States, B anthracis spores are most prevalent in Texas, Oklahoma, parts of the lower Mississippi valley and in western states4.

The natural reservoirs of the organism are soil and infected animals. Humans can be infected5 by handling contaminated hides, wool, leather or hair, by ingesting the undercooked meat or dairy products of infected animals or by inhaling aerosolized spores.

Between 1944 and 2000, 225 cases of cutaneous anthrax were reported in the United States, and 12 cases in 2001 following September 11. Inhalation anthrax cases in the United States were rare leading up to September 2001, with the last case reported in 1976. Ten cases were reported in late 2001 after the first intentional release of B. anthracis spores in the United States6.

The infective dose of B. anthracis is approximately 8,000-10,000 spores, which equates to one deep breath of contaminated air. The disease is not transmitted from person to person7. Communicability is not a concern in managing patients with inhalation anthrax.
4The highest number of reported cases are in the western states.

5Laboratory workers are at particular risk for anthrax infection due to potential exposure to aerosols and open culture plates and the potential for needle injuries.

6A total of 23 confirmed cases of bioterrorism-related anthrax (10 inhalation, 13 cutaneous) occurred in the United States in the anthrax attacks following September 11.

Potential as a Biological Weapon/Events that Might Take Place

The Working Group on Civilian Biodefense considers B anthracis to be a potential biological weapon8 for several reasons – it causes an acute illness with a high fatality rate, it's relatively easy to manufacture and develop as a weapon, spores can be stored for long periods without losing infectivity and the spores can be easily disseminated as an aerosol. The CDC considers B anthracis to be a category A agent.

The most likely scenario for the intentional use of B anthracis as a biological weapon would more than likely be an aerosol release according to the Working Group on Civilian Biodefense. Such a release in a populated environment would result in large numbers of casualties with a high mortality rate9. A report by the U.S. Congressional Office of Technology Assessment estimated that between 130,000 and three million deaths could follow the aerosolized release of 100 kg of anthrax spores upwind of the Washington, DC area. The subsequent economical impact of such an incident exceeds $25 billion.

Following an aerosolized release of anthrax spores, exposed individuals would begin to exhibit symptoms within seven days, although the incubation period can be as long as six weeks10. While treatment should begin immediately following an exposure, the impact of a delay in post-exposure treatment on mortality rates are not known.
8Germany first developed anthrax as a potential biological weapon in 1915. The U.S. began to develop anthrax weapons in 1943. In the 1970s, the U.S. ceased the development of biological weapons, although defense research continues today.

9The accidental release of anthrax spores at a military facility in the Soviet Union in 1979 resulted in 79 anthrax cases with 68 deaths.

10The incubation period for the disease is one to 42 days.

Recognition/Diagnosis

Any first responder or health care worker exposed to acutely ill patients may be the first to recognize the potential threat of an anthrax exposure11. These individuals could include public health officials, police and fire personnel, medical technologists, radiologic technologists, respiratory therapists, nurses and physicians.

Cutaneous anthrax begins as a small sore that develops into a blister within one to two days. The blister further develops into an ulcer with a characteristic black, necrotic center. Gastrointestinal anthrax initially presents with nausea, loss of appetite and fever, followed by abdominal pain, vomiting and diarrhea.

The initial symptoms of inhalation anthrax can occur within six to 42 days of exposure. The symptoms resemble those of the common cold or flu, and include a sore throat, mild fever and muscle aches, but without a runny nose. These symptoms are generally followed by chest discomfort, a dry cough, shortness of breath and fatigue. Shortly thereafter, wheezing, cyanosis, shock, chest wall edema and meningitis can ensue. Chest x-ray and chest CT show a widened mediastinum, pleural effusions and/or pulmonary infiltrates. Death can occur rapidly.

Diagnosis of all three forms of anthrax begins by obtaining appropriate exposure history12. Microbiological culture and other types of laboratory procedures are used in definitive diagnosis13,14. Radiographic studies are used in the definitive diagnosis of inhalation anthrax.
11The initial symptoms of anthrax will vary depending upon the type of exposure.

12The exposure type will dictate the form of the initial symptoms.

13The organism can be successfully isolated using routine laboratory procedures.

14Laboratory workers are at high risk of infection and Biosafety Level 3 precautions must be used.

Treatment/Environmental Decontamination and Protection

Individuals that are exposed to anthrax and those who have been diagnosed are treated with antibiotics. FDA-approved drugs are ciprofloxacin, doxycycline and amoxicillin.

The CDC recommends that post-exposure and prophylactic antibiotic treatment continue for 60 days15. Prophylactic treatment is very effective in preventing anthrax following an exposure.

Isolation is not recommended for patients with anthrax. A vaccine for anthrax has been developed that protects against invasive disease, but it is currently recommended only for high-risk populations such as military, defense and biomedical research personnel.

Laboratory specimens should be handled using Biosafety Level 3 protocol and precautions16. Decontamination of an area or environment17 contaminated with anthrax spores can be a difficult proposition, depending upon the circumstances of the release.
15Anthrax spores may require an extended period of time to become infective in a host.

16Information on BSL precautions can be found on the following site: http://www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4s2.htm

17Details on environmental decontamination and infection control can be found at the following site: http://jama.ama-assn.org/cgi/content/full/281/18/1735

References and Notes

References

Anthrax, Disease Fact Sheet, Ohio Department of Health: http://www.odh.ohio.gov/ASSETS/D4144989BB0049D58305183A4F9655D7/forfs.PDF 

Epidemiology of Anthrax, World Wide Health Organization: http://www.who.int/topics/anthrax/en/ 

Emergency preparedness and response: Anthrax, CDC: http://www.bt.cdc.gov/agent/anthrax/ 

Bioterrorism alleging use of anthrax and interim guidelines for management-United States. CDC, MMWR, 48(4):69-74. 1999

Carroll K, Held M, Stombler R, Bryan J. Laboratory preparedness for bioterrorism: from the phlebotomist to the pathologist. Laboratory Medicine 24(3):169-182, March 2003.

Cieslak TJ, Eitzen EM. Clinical and Epidemiological principles of anthrax. Emerging and Infectious Diseases 5(4):552-555. 1999

Inglesby TV, Henderson DA, et al. Anthrax as a Biological Weapon. JAMA 281(18):1735-1745, May 12, 1999. 

Jernigan JA, Stephens DS, et al. Bioterrorism-Related Inhalational Anthrax: The First 10 Cases Reported in the United States. Emerging and Infectious Diseases 7(6):933-44. 2001

Notes

1Zoonosis : a disease that can be acquired by humans from an animal source.

2A bacterial spore is a dormant form of the bacteria that, under appropriate conditions, can cause the disease.

3Anthrax is known to have caused disease as long ago as 1500 BC when it is thought to have caused the Fifth Egyptian Plague. An anthrax outbreak in Iran in 1945 killed one million sheep. Anthrax was first developed as a potential biological warfare agent by Germany in WWI.

4The highest number of reported cases are in the western states.

5Laboratory workers are at particular risk for anthrax infection due to potential exposure to aerosols and open culture plates and the potential for needle injuries.

6A total of 23 confirmed cases of bioterrorism-related anthrax (10 inhalation, 13 cutaneous) occurred in the United States In the anthrax attacks following September 11.

7There are no known cases of person-to-person transmission. Isolation is an appropriate precaution until there is laboratory confirmation of the disease.

8Germany first developed anthrax as a potential biological weapon in 1915. The U.S. began to develop anthrax weapons in 1943. In the 1970s, the U.S. ceased the development of biological weapons, although defense research continues today.

9The accidental release of anthrax spores at a military facility in the Soviet Union in 1979 resulted in 79 anthrax cases with 68 deaths.

10The incubation period for the disease is one to 42 days.

11The initial symptoms of anthrax will vary depending upon the type of exposure.

12The exposure type will dictate the form of the initial symptoms.

13The organism can be successfully isolated using routine laboratory procedures.

14Laboratory workers are at high risk of infection and Biosafety Level 3 precautions must be used.

15Anthrax spores may require an extended period of time to become infective in a host.

16Information on BSL precautions can be found on the following site: http://www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4s2.htm

17Details on environmental decontamination and infection control can be found at the following site: http://jama.ama-assn.org/cgi/content/full/281/18/1735
Tularemia

Overview

Tularemia is a bacterial zoonosis1 resulting from infection with Francisella tularensis. Of note is the fact that Francisella tularensis is considered to be one of the most infectious bacterial agents known, requiring only a few organisms2 to cause disease. Humans can be exposed to the disease from a number of environmental sources.

Tularemia was first described as a disease of rodents in the early 20th century. Soon thereafter, the human form of the disease and the potential for epidemic outbreaks3 resulted in growing concern among the medical and public health community.

Symptoms of tularemia include such non-specific symptoms including fever, chills, headache, diarrhea, muscle and joint pain, non-productive cough and weakness. Depending upon the nature of exposure, other symptoms can include pneumonia, chest pain, ulcers of the skin or mouth, swollen lymph nodes, painful eyes and sore throat.
1Zoonosis: a disease that can be acquired by humans from an animal source.

2As few as 10 organisms can cause serious, potentially fatal disease.

3Waterborne outbreaks of tularensis occurred in Europe during the 1930s and '40s.

Epidemiology

Tularemia has been reported in every state except for Hawaii. Most cases are reported in the south-central and western states4. Tularemia is almost exclusively a rural disease.

The organism can be found in soil, water and vegetation. Natural reservoirs of the infection include a number of small mammals such as mice, rats, squirrels and rabbits. Humans can be infected5 in a number of ways including bites from arthropods, handling infective animal tissues, ingestion of contaminated food or water and inhalation of aerosols.

Most cases of tularemia occur in spring and summer when infectious arthropods are active. During the years 1985 to 1992, there were an average of 171 cases per year with a fatality rate of less than one and a half percent. Airborne cases6 in the U.S. are uncommon.

Although it is highly infective, there have been no reports of the transmission of tularemia from person to person7.
4The highest number of reported cases were in Missouri, Arkansas, Oklahoma, South Dakota and Montana.

5Laboratory workers are at particular risk for tularemia infection due to potential exposure to aerosols and open culture plates and the potential for needle injuries.

6There was an airborne epidemic in Sweden in 1966 through 1967 due to exposure to contaminated aerosols while farming.

7NOTE: Since there is no known cases of person-to-person transmission, confirmed cases of tularemia do NOT require isolation. Isolation is an appropriate precaution until there is laboratory confirmation of the disease.

Potential as a Biological Weapon/Events that Might Take Place

The Working Group on Civilian Biodefense considers F tularensis to be a potential biological weapon for three reasons including its high level of infectivity, ease of dissemination and capacity to cause severe disease. It is considered to be a Category A agent (CDC).

Historically, the organism has long been considered to have biological weapons potential8 since WWII.

F. Tularensis could be used as a biological weapon in a number of ways including contamination of food and water supplies. However, the Working Group on Civilian Biodefense considers that aerosol release would be the most probable. Such a release would result in the onset of large numbers of cases of acute febrile illness three to five days after release9.

In cases of exposure to F tularensis aerosols, illness would be expected to persist for several weeks with the potential for relapse. Immunization would only confer partial protection from infection. The impact10 in terms of morbidity and mortality and economic impact would be substantial.
8Japanese germ warfare units studied the organism in the 1930s and '40s. In the 1950s, the U.S. developed weapons that would disseminate F. tularensis aerosols. In the 1970s, development of biological weapons was terminated in the U.S. and stockpiles were destroyed.

9The incubation period for the disease is one to 14 days.

10A WHO expert estimated that an aerosol of 50 kg of F tularensis over a metropolitan area of five million persons would result in 250, 000 serious illnesses and 19,000 deaths. One estimate of the economic impact was $5.4 billion dollars per 100,00 exposed individuals.

Recognition/Diagnosis

Inhalation tularemia11 would be associated with the sudden onset of febrile illness progressing in some cases to acute respiratory illness including pharyngitis, bronchiolitis and pneumonitis. If untreated, the patient may become septic. Exposure to aerosols may also present result in eye contamination (ocular tularemia), skin penetration (glandular disease) or oropharyngeal disease with lymphadenitis.

Recognition by health care workers would most likely come from observing. A sudden unexplained increase in the number of cases of the disease, as well as cases in areas where the disease is not endemic, during times of the year when the incidence is generally low or in populations not generally considered to be at risk.

Any health care worker exposed to acutely ill patients may be the first to recognize the potential threat. This would include medical technologists, radiologic technologists, respiratory therapists, nurses and physicians. Early recognition is important to ensure that patients receive appropriate antibiotic therapy to minimize the deleterious effects of the disease12.

Definitive laboratory diagnosis is essential. Therefore, physicians who suspect tularemia should collect the appropriate laboratory specimens and alert the laboratory to the need for special diagnostic procedures13 and safety precautions14.
11Note: Tularemia has a number of forms, which differ based on the virulence of the organism, the dose and the site of the innoculum. The disease may present with ocular symptoms, skin lesions, lymphadenitis and GI symptoms.

12Untreated pneumonic and systemic forms of the disease have reported mortality rates of 30 to 60 percent. 

13The organism will not be successfully isolated using routine laboratory procedures.

14Laboratory workers are at high risk of infection and Biosafety Level 3 precautions must be used.

Treatment/Environmental Decontamination and Protection

The vaccine is an investigational drug currently under review by the FDA15. Patients infected with tularemia are treated with antibiotics. Streptomycin is the drug of choice. Other antibiotics used to treat tularemia include gentamicin, tetracyclines and chloramphenicol. Ciprofloxacin has been used off-label and has demonstrated promise in both children and adults.

Post-exposure treatment with antibiotics continued for 14 days may be protective. Isolation is not recommended for patients with tularemia. Laboratory specimens should be handled using BSL-3 precautions16. F tularensis may survive for extended period in cold, moist environments17.
15Research indicates that the vaccine is only partially protective against inhalation infection. Vaccine is not recommended for post-exposure protection.

16Information on BSL precautions can be found on the following site: http://www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4s2.htm

17Details on environmental decontamination and infection control can be found at the following site: http://jama.ama-assn.org/cgi/content/full/285/21/2763

References and Notes

References

Tularemia -- United States, 1990 – 2000. CDC, MMWR, 51(09):182-84, March 8, 2002. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5109a1.htm

Emergency preparedness and response: key facts about tularemia, CDC: http://www.bt.cdc.gov/agent/tularemia/facts.asp 

Infectious disease control manual, Ohio Department of Health: http://www.odh.ohio.gov/healthresources/infectiousdiseasemanual.aspx 

Recognition of illness associated with the intentional release of a biologic agent. CDC, MMWR, 50(41):893-97, October 19, 2001: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5041a2.htm

The Ohio State University Medical Center, Epidemiology Department, Annual Infection Control Education 2004.

Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia as a biological weapon. JAMA 285(21):2763 – 73, June 6, 2001, http://jama.ama-assn.org/cgi/content/full/285/21/2763

Carroll K, Held M, Stombler R, Bryan J. Laboratory preparedness for bioterrorism: from the phlebotomist to the pathologist. Laboratory Medicine 24(3):169-182, March 2003.

Notes

1Zoonosis: a disease that can be acquired by humans from an animal source.

2As few as 10 organisms can cause serious, potentially fatal disease.

3Waterborne outbreaks of tularensis occurred in Europe during the 1930s and '40s.

4The highest number of reported cases were in Missouri, Arkansas, Oklahoma, South Dakota and Montana.

5Laboratory workers are at particular risk for tularemia infection due to potential exposure to aerosols and open culture plates and the potential for needle injuries.

6There was an airborne epidemic in Sweden in 1966 and 1967 due to exposure to contaminated aerosols while farming.

7NOTE: Since there is no know cases of person-to-person transmission, confirmed cases of tularemia do NOT require isolation. Isolation is an appropriate precaution until there is laboratory confirmation of the disease.

8Japanese germ warfare units studied the organism in the 1930s and '40s. In the 1950s, the U.S. developed weapons that would disseminate F. tularensis aerosols. In the 1970s, development of biological weapons was terminated in the U.S. and stockpiles were destroyed.

9The incubation period for the disease is one to 14 days.

10A WHO expert estimated that an aerosol of 50 kg of F tularensis over a metropolitan area of five million persons would result in 250,000 serious illnesses and 19,000 deaths. One estimate of the economic impact was $5.4 billion dollars per 100,00 exposed individuals.

11Note: Tularemia has a number of forms, which differ based on the virulence of the organism, the dose and the site of the innoculum. The disease may present with ocular symptoms, skin lesions, lymphadenitis and GI symptoms.

12Untreated pneumonic and systemic forms of the disease have reported mortality rates of 30 to 60 percent. 

13The organism will not be successfully isolated using routine laboratory procedures.

14Laboratory workers are at high risk of infection and Biosafety Level 3 precautions must be used.

15Research indicates that the vaccine is only partially protective against inhalation infection. Vaccine is not recommended for post-exposure protection.

16Information on BSL precautions can be found on the following site: http://www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4s2.htm

17Details on environmental decontamination and infection control can be found at the following site: http://jama.ama-assn.org/cgi/content/full/285/21/2763

BNICE

BNICE

Lecture materials to provide a face-to-face overview of bioterrorism and appropriate response.

An introduction to the Threat of Bioterrorism- BNICE 101 (PDF)
An introduction to the Threat of Bioterrorism- BNICE 101 and Tularemia (PDF)

Cases

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