Introduction and Objectives In this lesson you will learn about the clinical presentation of plague. Because it is likely that it will be an astute clinician who recognizes bioterrorism, it is important for you to understand and recognize the presentation of naturally occurring disease. We will look at the three major forms of plague- bubonic, pneumonic and septicemic, in more detail. At the end of this lesson you should be able to: Identify the distinctions between bubonic, pneumonic and septicemic plague with regard to symptoms and disease course.
Pharyngeal Plague Uncommon. Can resemble tonsillitis with peritonsillar abscess and cervical lymphadenopathy. There can be asymptomatic carriers of pharyngeal plague in close contacts of patients with other forms of plague. Plague Meningitis This form of plague is most common in children and is usually the end result of ineffective treatment for other forms of plague. Symptoms often mimic other forms of bacterial meningitis, such as headache, neck stiffness, and photophobia.
Infection Control In advanced stages, the sputum of pneumonic plague patients contains large numbers of plague bacilli, and the coughing patient can spread infection via respiratory droplets to persons in close direct contact. Therefore, respiratory droplet precautions should be taken with any suspect case. If you have reason to suspect you have a plague case, even in endemic areas, your health department should be contacted immediately so that control measures can begin
Medical Chart – Gary Indiana Hospital Patient – 12 month old from Gary Symptoms – Parents report acute onset fever, malaise and body aches x 2 days. Presenting with extremely tender lymph node under arm that has swollen to 2 inches in diameter. Patient is exhibiting some neurologic symptoms. You’re suspecting plague meningitis. What is your first step?
You suspect your patient has plague meningitis. What is your first step after thinking this? Call your local health department Rule out other diseases that could have the same symptoms Place the patient in isolation
The UCLA Center for Public Health and Disasters first developed this training for physicians in October of 2001. Since then, the fund of knowledge has grown considerably. We have attempted to incorporate these advances in this updated version of this presentation. Updated by: Gregory J. Moran, MD, Associate Professor of Clinical Medicine, David Geffen School of Medicine; Dept. of Emergency Medicine and Division of Infectious Diseases, Olive View-UCLA Medical Center ; Steven J. Rottman, MD, FACEP, Director, UCLA Center for Public Health and Disasters, Adjunct Professor, David Geffen School of Medicine, and UCLA School of Public Health; and Tamiza Z. Teja, MPH, Project Coordinator, Bioterrorism and Public Health Preparedness, UCLA Center for Public Health and Disasters Goal: To prepare physicians and other health providers for a bioterrorist incident in order to reduce morbidity and mortality. Learning Objectives: 1) Discuss why bioterrorism is a special concern to the health community 2) Identify key biological agents that could be used in a bioterrorism attack, and for each agent describe: Potential presenting symptoms Appropriate treatment of a patient Appropriate precautions to protect self and others from secondary infection 3) Describe the policy as well as the mechanism for reporting suspected cases 4) Describe the relationship between physicians in hospitals and private practice, the local public health department, state public health department, and federal agencies in the context of real or suspected cases of bioterrorism 5) Identify bioterrorism-related information and support resources for physicians and other health care providers Target Audience: This slide presentation was designed specifically for internists, family physicians, pediatricians, emergency physicians, and other clinical practitioners who would be most likely to encounter symptomatic patients presenting for evaluation and treatment in a bioterrorism incident. Time Required: Presenting the entire slide show to a group will take approximately 1-1/2 -2 hours. Please note: this estimated presentation time does not include time for questions and answers, or detailed discussion.
Bioterrorism definition of the Centers for Disease Control and Prevention. Even the threat, not just the actual use, is considered terrorism. Note the variety of agents that can be used: viruses, bacteria, fungi, and the toxins they may produce.
This slide summarizes a diagnostic approach to people with suspected inhalation anthrax. Note that this is for those with a history of suspected exposure or believed to be at significant risk for exposure. Blood culture is the test most likely to confirm anthrax. May see organism on gram stain of blood. Notify lab if suspected. Serologic testing is available through CDC, but not available in most labs.
Terrorists using botulism would probably not be spreading the bacterium itself. It is more likely they would be using the purified toxin. The most potent toxin known, botulinum is 100,000 times more toxic than sarin, the agent that was used in the Tokyo subway attacks by the Aum Shinrikyo cult in 1995 (Franz, 1997). The endospores of C. botulinum, when stained using the Malachite Green staining method, will appear as green spheres, while the bacilli themselves will turn purple in color. Article References: Arnon SS, et al. Botulinum toxin as a biological weapon. JAMA 2001; 285:1059-1070. Franz DR et al . Clinical recognition and management of patients exposed to biological warfare agents. JAMA . 1997;278(5):399-411. Photo Reference: CDC Public Health Image Library, Clostridium botulinum spores stained with Malachite Green Stain. http://phil.cdc.gov/phil/. Photo by: CDC/Courtesy of Larry Stauffer, Oregon State Public Health Laboratory.
Many of us have seen similar cases and probably didn’t think of bioterrorism as the causative agent. We would perhaps suspect sepsis, meningitis, or maybe Streptococcus pneumoniae . The first clue of a possible outbreak is that there is a similar case from the same building – this is a signal to call infection control and the local public health department immediately. Contact the local health department anytime there is an unusual or suspicious illness. When the lab returns the results days later, blood cultures are positive for? ( Bacillus anthracis) This scenario is used for FBI trainings: an anthrax attack on the New York Stock Exchange.
Preparing Physicians for Recognizing and Responding to Bioterrorism: A Needs-based Approach Stephen C. Alder, Ph.D. Melissa Vellinga October 20, 2004 Countering Bioterrorism 2004 Preparedness through Partnerships
“The public health community should acknowledge the substantial harm that bioterrorism preparedness has already caused and develop mechanisms to increase our public health resources and to allocate them to address the world’s real health needs”
Cohen HW, Gould RM, Sidel VW. The Pitfalls of Bioterrorism Preparedness: the Anthrax and Smallpox Experiences. American Journal of Public Health. 2004;94:1667-1670.
CDC's Health Alert Network has upgraded the capacity of state and local health agencies to detect and communicate different health threats—including bioterrorism, emerging infectious diseases, chronic diseases, and environmental hazards. This means that we reap the benefits of these investments every day, not just in the event of a bioterrorist attack.
CDC Programs in Brief: Bioterrorism and Public Health Preparedness http://www.cdc.gov/programs/bt.htm
“Terrorism presents many new challenges to the nation’s public health infrastructure. ……It is urgent that we now change and reinvest in our public health system to establish and maintain a strong disease-defense system- nationwide, competent, and modern.”
Levy BS, Sidel VW. Terrorism and Public Health: A Balanced Approach to Strengthening Systems and Protecting People. Oxford University Press; New York: 2003.
UCLA Center for Public Health and Disasters, Bioterrorism: Are you prepared slideshow presentation
Example of training resources from CDC for small group presentations to enable Primary Care physicians to recognize signs and symptoms of diseases caused by class A BT agents (learning objective 2)
Example of training resources from UCLA for small group presentations to enable Primary Care physicians to recognize signs and symptoms of diseases caused by class A BT agents (learning objective 2)
UCLA Center for Public Health and Disasters Bioterrorism Training for Physicians Updated March 2003 Over 1700 Downloads Since Going Online October 2001 Available at: http://www.ph.ucla.edu/cphdr/bioterrorism