Table of Contents Introduction 8 History of Biological Warfare and Current Threat 9 Distinguishing Between Natural and Intentional Disease Outbreaks 13 Ten Steps in the Management of Biological Casualties on the Battlefield 15 Bacterial Agents 20 Anthrax 21 Brucellosis 26 Glanders and Melioidosis 30 Plague 35 Q Fever 40 Tularemia 44 Viral Agents 50 Smallpox 51 Venezuelan Equine Encephalitis 56 Viral Hemorrhagic Fevers 61 Biological Toxins 69 Botulinum 70 Ricin 76 Staphylococcal Enterotoxin B 80 T-2 Mycotoxins 84 Detection 88 Personal Protection 89 Decontamination 92 Appendix A: Glossary of Medical Terms Appendix B: Patient Isolation Precautions Appendix C: BW Agent Characteristics Appendix D: BW Agent Vaccines, Therapeutics and Prophylactics Appendix E: Medical Sample Collection for BW Agents Appendix F: Specimens for Laboratory Diagnosis Appendix G: BW Agent Laboratory Identification Appendix H: Differential Diagnosis - Toxins vs. Nerve Agents Appendix I: Comparative Lethality - Toxins vs. Chemical Agents Appendix J: Aerosol Toxicity Appendix K: References and Emergency Response Contacts 7 .
INTRODUCTION Medical defense against biological warfare or terrorism is an area of study unfamiliar to most military and civilian health care providers during peacetime. In the aftermath of Operations Desert Shield/Desert Storm, it became obvious that the threat of biological attacks against our soldiers was real. Increased incidents and threats of domestic terrorism (e.g., New York City World Trade Center bombing, Tokyo subway sarin release, Oklahoma City federal building bombing, Atlanta Centennial Park bombing) as well as numerous anthrax hoaxes around the country have brought the issue home to civilians as well. Other issues, including the disclosure of a sophisticated offensive biological warfare program in the Former Soviet Union (FSU), have reinforced the need for increased training and education of health care professionals on how to prevent and treat biological warfare casualties. Numerous measures to improve preparedness for and response to biological warfare or terrorism are ongoing at local, state, and federal levels. Training efforts have increased both in the military and civilian sectors. The Medical Management of Chemical and Biological Casualties Course taught at both USAMRIID and USAMRICD trains over 560 military medical professionals each year on both biological and chemical medical defense. The highly successful 3-day USAMRIID satellite course on the Medical Management of Biological Casualties has reached over 40,000 medical personnel over the last three years. Through this handbook and the training courses noted above, medical professionals will learn that effective medical countermeasures are available against many of the bacteria, viruses, and toxins, which might be, used as biological weapons against our military forces or civilian communities. The importance of this education cannot be overemphasized and it is hoped that our physicians, nurses, and allied medical professionals will develop a solid understanding of the biological threats we face and the medical armamentarium useful in defending against these threats. The global biological warfare threat is serious, and the potential for devastating casualties is high for certain biological agents. There are at least 10 countries around the world currently that have offensive biological weapons programs. However, with appropriate use of medical countermeasures either already developed or under development, many casualties can be prevented or minimized. The purpose for this handbook is to serve as a concise pocket-sized manual that will guide medical personnel in the prophylaxis and management of biological casualties. It is designed as a quick reference and overview, and is not intended as a definitive text on the medical management of biological casualties. 8 .
HISTORY OF BIOLOGICAL WARFARE AND CURRENT THREAT The use of biological weapons in warfare has been recorded throughout history. Two of the earliest reported uses occurred in the 6th century BC, with the Assyrians poisoning enemy wells with rye ergot, and Solon’s use of the purgative herb hellebore during the siege of Krissa. In 1346, plague broke out in the Tartar army during its siege of Kaffa (at present day Feodosia in Crimea). The attackers hurled the corpses of plague victims over the city walls; the plague epidemic that followed forced the defenders to surrender, and some infected people who left Kaffa may have started the Black Death pandemic, which spread throughout Europe. Russian troops may have used the same tactic against Sweden in 1710. On several occasions, smallpox was used as a biological weapon. Pizarro is said to have presented South American natives with variola-contaminated clothing in the 15th century, and the English did the same when Sir Jeffery Amherst provided Indians loyal to the French with smallpox-laden blankets during the French and Indian War of 1754 to 1767. Native Americans defending Fort Carillon sustained epidemic casualties which directly contributed to the loss of the fort to the English. In this century, there is evidence that during World War I, German agents inoculated horses and cattle with glanders in the U.S. before the animals were shipped to France. In 1937, Japan started an ambitious biological warfare program, located 40 miles south of Harbin, Manchuria, in a laboratory complex code-named “Unit 731”. Studies directed by Japanese General Ishii continued there until 1945, when the complex was burned. A post World War II investigation revealed that the Japanese researched numerous organisms and used prisoners of war as research subjects. Slightly less than 1,000 human autopsies apparently were carried out at Unit 731, mostly on victims exposed to aerosolized anthrax. Many more prisoners and Chinese nationals may have died in this facility - some have estimated up to 3,000 human deaths. Following reported overflights by Japanese planes suspected of dropping plague-infected fleas, a plague epidemic ensued in China and Manchuria. By 1945, the Japanese program had stockpiled 400 kilograms of anthrax to be used in a specially designed fragmentation bomb. In 1943, the United States began research into the use of biological agents for offensive purposes. This work was started, interestingly enough, in response to a perceived German biological warfare (BW) threat as opposed to a Japanese one. The United States conducted this research at Camp Detrick (now Fort Detrick), which was a small National Guard airfield prior to that time, and produced agents at other sites until 1969, when President Nixon stopped all offensive biological and toxin weapon research and production by executive order. Between May 1971 and May 1972, all stockpiles of biological agents and munitions from the now defunct U.S. program were destroyed in the presence of monitors representing the United States Department of Agriculture, the Department of Health, Education, and Welfare, and the states of Arkansas, Colorado, 9 .
DISTINGUISHING BETWEEN NATURAL AND INTENTIONAL DISEASE OUTBREAKS With a covert biological agent attack, the most likely first indicator of an event would be an increased number of patients presenting with clinical features caused by the disseminated disease agent. Therefore, health care providers must use epidemiology to detect and respond rapidly to a biological agent attack. A sound epidemiologic investigation of a disease outbreak, whether natural or human-engineered, will assist medical personnel in identifying the pathogen, as well as instituting the appropriate medical interventions. Documenting the affected population, possible routes of exposure, signs and symptoms of disease, along with rapid laboratory identification of the causative agents, will greatly increase the ability to institute an appropriate medical and public health response. Good epidemiologic information can guide the appropriate follow-up of those potentially exposed, as well as assist in risk communication and responses to the media. Many diseases caused by weaponized biological agents present with nonspecific clinical features that could be difficult to diagnose and recognize as a biological attack. The disease pattern that develops is an important factor in differentiating between a natural and a terrorist or warfare attack. Epidemiologic clues that can potentially indicate an intentional attack are listed in Table 1. While a helpful guide, it is important to remember that naturally occurring epidemics can have one or more of these characteristics and a biological attack may have none. Once a biological attack or any outbreak of disease is suspected, the epidemiologic investigation should begin. The conduct of the investigation will not differ significantly whether or not the outbreak is intentional. The first step is to confirm that a disease outbreak has occurred. A case definition should be constructed to determine the number of cases and the attack rate. The case definition allows investigators who are separated geographically to use the same criteria when evaluating the outbreak. The use of objective criteria in the development of a case definition is very important in determining an accurate case number, as additional cases may be found and some cases may be excluded, especially as the potential exists for hysteria to be confused with actual disease. The estimated rate of illness should be compared with rates during previous years to determine if the rate constitutes a deviation from the norm. Once the attack rate has been determined, the outbreak can be described by time, place, and person. These data will provide crucial information in determining the potential source of the outbreak. The epidemic curve is calculated based on cases over time. In a point-source outbreak, which is most likely in a biological attack or terrorism situation, the early parts of the epidemic curve will tend to be compressed compared with propagated outbreaks. The peak may be in a matter of days or even hours. Later phases of the curve may also help determine if the disease appears to spread from person to person, which can be extremely important for determining effective disease control measures. 13 .
TEN STEPS IN THE MANAGEMENT OF BIOLOGICAL CASUALTIES ON THE BATTLEFIELD Military personnel on the modern battlefield face a wide range of conventional and unconventional threats. Compared to conventional, chemical, and nuclear weapon threats, biological weapons are, perhaps, somewhat unique in their ability to cause confusion, disruption and panic. It is useful for medical care providers to understand the factors (Table 1) that account for this ability and for the difficulties they would be expected to face in dealing with biological casualties. Potential for massive numbers of casualties Ability to produce lengthy illnesses requiring prolonged and extensive care Ability of certain agents to spread via contagion Paucity of adequate detection systems Diminished role for self-aid & buddy aid, thereby increasing sense of helplessness Presence of an incubation period, enabling victims to disperse widely Ability to produce non-specific symptoms, complicating diagnosis Ability to mimic endemic infectious diseases, further complicating diagnosis Table 1. Characteristics of Biological Weapons and Warfare In light of these somewhat unique properties of biological weapons, medical personnel will require a firm understanding of certain key elements of biological defense in order to manage effectively the consequences of a biological attack amidst the confusion expected on the modern battlefield. Understanding the behavior, pathogenesis, modes of transmission, diagnostic modalities, and available treatment options for each of the potential agents thus becomes imperative. Acquiring such an understanding is relatively straightforward once the identity of the agent is known; many references (FM 8-9, FM 8-33, FM 8-284), including this handbook, exist to assist medical personnel in agent-based therapy. Proper and thorough evaluation and management of a potential biological attack, before a causative agent is identified, however, is likely to be complex and problematic. For this reason, we recommend a ten- step process to guide medical personnel in such evaluation and management. I. Maintain an index of suspicion. The health-care provider on the modern battlefield must first possess a high index of suspicion regarding the potential employment of biological weapons. This is due to the fact that, with many of the biological warfare (BW) diseases, very early treatment is mandatory if patients are to be salvaged. Anthrax, botulism, plague, and smallpox are readily prevented if patients are provided proper antibiotics, antisera, and/or immunization promptly following exposure. Conversely, all of these diseases may prove fatal if therapy or prophylaxis is delayed until classic symptoms develop. Unfortunately, symptoms in the early, or prodromal, phase of illness are non-specific, making diagnosis difficult. Moreover, many potential BW diseases, such as Brucellosis, Q-fever, and Venezuelan Equine Encephalitis (VEE), 15 .
BACTERIAL AGENTS Bacteria are unicellular organisms. They vary in shape and size from spherical cells - cocci - with a diameter of 0.5-1.0 m m (micrometer), to long rod-shaped organisms - bacilli - which may be from 1-5 m m in size. Chains of bacilli may exceed 50 m m in length. The shape of the bacterial cell is determined by the rigid cell wall. The interior of the cell contains the nuclear material (DNA), cytoplasm, and cell membrane, that are necessary for the life of the bacterium. Many bacteria also have glycoproteins on their outer surfaces which aid in bacterial attachment to cell surface receptors. Under special circumstances some types of bacteria can transform into spores. The spore of the bacterial cell is more resistant to cold, heat, drying, chemicals and radiation than the vegetative bacterium itself. Spores are a dormant form of the bacterium and, like the seeds of plants, they can germinate when conditions are favorable. The term rickettsia generally applies to very small, gram-negative coccobacillary organisms of the genera Rickettsia and Coxiella. Rickettsiae are unique from classical bacteria in their inability to grow (with rare exceptions) in the absence of a living host cell, but many are susceptible to treatment with antibiotics. Bacteria generally cause disease in human beings and animals by one of two mechanisms: by invading host tissues, and by producing poisons (toxins). Many pathogenic bacteria utilize both mechanisms. The diseases they produce often respond to specific therapy with antibiotics. It is important to distinguish between the disease- causing organism and the name of the disease it causes (in parentheses below). This manual covers several of the bacteria or rickettsiae considered to be potential BW threat agents: Bacillus anthracis (Anthrax), Brucella spp. (Brucellosis), Burkholderia mallei (Glanders), Burholderia pseudomallei (melioidosis), Yersinia pestis (Plague), Francisella tularensis (Tularemia), and Coxiella burnetii (Q Fever). 20 .
ANTHRAX SUMMARY Signs and Symptoms: Incubation period is generally 1-6 days, although longer periods have been noted. Fever, malaise, fatigue, cough and mild chest discomfort progresses to severe respiratory distress with dyspnea, diaphoresis, stridor, cyanosis, and shock. Death typically occurs within 24-36 hours after onset of severe symptoms. Diagnosis: Physical findings are non-specific. A widened mediastinum may be seen on CXR in later stages of illness. The organism is detectable by Gram stain of the blood and by blood culture late in the course of illness. Treatment: Although effectiveness may be limited after symptoms are present, high dose antibiotic treatment with penicillin, ciprofloxacin, or doxycycline should be undertaken. Supportive therapy may be necessary. Prophylaxis: Oral ciprofloxacin or doxycycline for known or imminent exposure. An FDA-licensed vaccine is available. Vaccine schedule is 0.5 ml SC at 0, 2, 4 weeks, then 6, 12, and 18 months (primary series), followed by annual boosters. Isolation and Decontamination: Standard precautions for healthcare workers. After an invasive procedure or autopsy is performed, the instruments and area used should be thoroughly disinfected with a sporicidal agent (hypochlorite). 21 .
BRUCELLOSIS SUMMARY Signs and Symptoms: Illness, when manifest, typically presents with fever, headache, myalgias, arthralgias, back pain, sweats, chills, and generalized malaise. Other manifestations include depression, mental status changes, and osteoarticular findings (i.e. Sacroiliitis, vertebral osteomyelitis). Fatalities are uncommon. Diagnosis: Diagnosis requires a high index of suspicion, since many infections present as non-specific febrile illnesses or are asymptomatic. Laboratory diagnosis can be made by blood culture with prolonged incubation. Bone marrow cultures produce a higher yield. Confirmation requires phage typing, oxidative metabolism, or genotyping procedures. ELISA, followed by Western blot are available. Treatment: Antibiotic therapy with doxycycline + rifampin or doxycycline in combination with other medications for six weeks is usually sufficient in most cases. More prolonged regimens may be required for patients with complications of meningoencephalitis, endocarditis, or osteomyelitis. Prophylaxis: There is no human vaccine available against brucellosis, although animal vaccines exist. Chemoprophylaxis is not recommended after possible exposure to endemic disease. Treatment should be considered for high-risk exposure to the veterinary vaccine, inadvertent laboratory exposure, or confirmed biological warfare exposure. Isolation and Decontamination: Standard precautions are appropriate for healthcare workers. Person-to-person transmission has been reported via tissue transplantation and sexual contact. Environmental decontamination can be accomplished with a 0.5% hypochlorite solution. 26 .
GLANDERS AND MELIOIDOSIS SUMMARY Signs and Symptoms: Incubation period ranges from 10-14 days after inhalation. Onset of symptoms may be abrupt or gradual. Inhalational exposure produces fever (common in excess of 102 F.), rigors, sweats, myalgias, headache, pleuritic chest pain, cervical adenopathy, hepatosplenomegaly, and generalized papular / pustular eruptions. Acute pulmonary disease can progress and result in bacteremia and acute septicemic disease. Both diseases are almost always fatal without treatment. Diagnosis: Methylene blue or Wright stain of exudates may reveal scant small bacilli with a safety-pin bipolar appearance. Standard cultures can be used to identify both B. mallei and B. pseudomallei. CXR may show miliary lesions, small multiple lung abscesses, or infiltrates involving upper lungs, with consolidation and cavitation. Leukocyte counts may be normal or elevated. Serologic tests can help confirm diagnosis, but low titers or negative serology does not exclude the diagnosis. Treatment: Therapy will vary with the type and severity of the clinical presentation. Patients with localized disease, may be managed with oral antibiotics for a duration of 60-150 days. More severe illness may require parenteral therapy and more prolonged treatment. Prophylaxis: Currently, no pre-exposure or post-exposure prophylaxis is available. Isolation and Decontamination: Standard Precautions for healthcare workers. Person-to-person airborne transmission is unlikely, although secondary cases may occur through improper handling of infected secretions. Contact precautions are indicated while caring for patients with skin involvement. Environmental decontamination using a 0.5% hypochlorite solution is effective. 30 .
PLAGUE SUMMARY Signs and Symptoms: Pneumonic plague begins after an incubation period of 1-6 days, with high fever, chills, headache, malaise, followed by cough (often with hemoptysis), progressing rapidly to dyspnea, stridor, cyanosis, and death. Gastrointestinal symptoms are often present. Death results from respiratory failure, circulatory collapse, and a bleeding diathesis. Bubonic plague, featuring high fever, malaise, and painful lymph nodes (buboes) may progress spontaneously to the septicemic form (septic shock, thrombosis, DIC) or to the pneumonic form. Diagnosis: Suspect plague if large numbers of previously healthy individuals develop fulminant Gram negative pneumonia, especially if hemoptysis is present. Presumptive diagnosis can be made by Gram, Wright, Giemsa or Wayson stain of blood, sputum, CSF, or lymph node aspirates. Definitive diagnosis requires culture of the organism from those sites. Immunodiagnosis is also helpful. Treatment: Early administration of antibiotics is critical, as pneumonic plague is invariably fatal if antibiotic therapy is delayed more than 1 day after the onset of symptoms. Choose one of the following: streptomycin, gentamicin, ciprofloxacin, or doxycycline for 10-14 days. Chloramphenicol is the drug of choice for plague meningitis. Prophylaxis: For asymptomatic persons exposed to a plague aerosol or to a patient with suspected pneumonic plague, give doxycycline 100 mg orally twice daily for seven days or the duration of risk of exposure plus one week. Alternative antibiotics include ciprofloxacin, tetracycline, or chloramphenicol. No vaccine is currently available for plague prophylaxis. The previously available licensed, killed vaccine was effective against bubonic plague, but not against aerosol exposure. Isolation and Decontamination: Use Standard Precautions for bubonic plague, and Respiratory Droplet Precautions for suspected pneumonic plague. Y. pestis can survive in the environment for varying periods, but is susceptible to heat, disinfectants, and exposure to sunlight. Soap and water is effective if decon is needed. Take measures to prevent local disease cycles if vectors (fleas) and reservoirs (rodents) are present. 35 .