2025 Inpatient Prospective Payment System (IPPS) Proposed Rule
plague, anthrax.ppt
1. Plague
History & Significance
14th Century: “Black Death” responsible for
>20 million deaths in Europe
Used as a BW agent by Japan in WW II
Studied by Soviet and, to a smaller extent,
U.S. BW programs
1995: Larry Wayne Harris arrested for illicit
procurement of culture via mail
2. Plague
Epidemiology
Caused by Yersinia pestis
About 10-15 cases/year U.S.
Mainly SW states
Human plague occurs from bite of an infected flea
(bubonic)
Only pneumonic form of plague is spread person-
to-person
Last case of person-to-person transmission in U.S. occurred in 1924
3. Yersinia Pestis
Gram negative,
non-motile, non-
spore-forming
bacillus
Resistant to
freezing
temperature and
drying, killed by
heat and sunlight
Source: Centers for Disease Control and
Prevention, Division of Vector-Borne
Infectious Diseases, Fort Collins, CO
4. Plague
Case Definition
Characterized by fever, chills, headache,
malaise, prostration, & leukocytosis that
manifests in one or more of the following
clinical forms:
◦ Regional lymphadenitis (bubonic)
◦ Septicemia w/o evident bubo (septicemic)
◦ Plague pneumonia
◦ Pharyngitis & cervical lymphadenitis (pharyngeal)
MMWR 1997;46(RR-10)
5. Plague
Case Definition, cont.
Laboratory criteria for diagnosis:
Presumptive
Elevated serum antibody titers to Y. pestis F1 antigen (w/o
documented 4-fold change) in a patient with no history of plague
vaccination OR
Detection of F1 antigen in a clinical specimen by fluorescent
assay
Confirmatory
Isolation of Y. pestis from a clinical specimen OR
4-fold or greater change in serum antibody titer to Y. pestis F1
antigen
MMWR 1997;46(RR-10)
6. Plague: Case Classification
Suspected: Clinically compatible case w/o
presumptive or confirmatory lab results
Probable: Clinically compatible case with
presumptive lab results
Confirmed: Clinically compatible case with
confirmatory lab results
MMWR 1997;46(RR-10)
7. Plague
Clinical Forms
Bubonic plague
Most common naturally-occurring form
Mortality 60% untreated, <5% treated
Primary or secondary septicemic
plague
Pneumonic plague
Most likely BT presentation
From aerosol or septicemic spread to lungs
Survival unlikely if treatment not initiated
w/in 24 hours of the onset of symptoms
8. Pneumonic Plague
Clinical Presentation
Incubation: 1-6 days (usually 2-4 days)
Acute onset of fever with cough, dyspnea, and
chest pain
Hemoptysis characteristic; watery or purulent
sputum also possible
Prominent GI symptoms may be present, including
nausea, vomiting, diarrhea, and abdominal pain
12. Plague
Infection Control
Person-to-person transmission via
respiratory droplets
Standard respiratory droplet precautions
Treatment = 10 days antibiotics
Case isolation for at least the first 48 hrs of
antibiotic treatment
Bubonic plague - standard precautions
13. Plague
Infection Control
Antibiotic prophylaxis for close contacts
Duration: 7 days or duration of risk of
exposure + 7 days
Close contacts refusing prophylaxis:
Observe 7 days after last exposure and treat
if fever or cough develop
Bubonic contacts:
Observe 7d and treat if symptoms develop
14. Bacillus Species
The genus Bacillus includes large aerobic,
spore-forming, Gram-positive rods occurring in chains.
Most members of this genus are saprophytic organisms
prevalent in soil, water, air and on vegetation,
such as Bacillus subtilis & B. cereus .
Some are insect pathogens, such as B. thuringiensis . This
organism is also capable of causing disease in humans.
B. cereus can grow in foods and cause food poisoning by
producing either an enterotoxin (diarrhea) or an emetic toxin
(vomiting).
15. Morphology and identification
A. Typical Organisms
The typical cells, measuring 1 ×
3–4 μm, have square ends and
are arranged in long chains;
spores are located in the center
of the bacterial cell.
16. Colonies of B. anthracis are flat or slightly convex
with irregular edge and have a ground-glass
appearance in transmitted light.
B. Culture
Hemolysis is uncommon with
B anthracis but common with B cereus.
B. anthracis B. cereus
…..Morphology and identification
Gelatin is liquefied by B. cereus.
B. anthracis growth in gelatin stabs
resembles an inverted fir tree.
Bacillus cereus colonies are large flat and dry.
17. Diagnostic Laboratory Tests
Specimens to be examined are fluid or pus from a local lesion, blood,
pleural fluid, and cerebrospinal fluid in inhalational anthrax
associated with sepsis and stool or other
intestinal contents in the case of gastrointestinal anthrax.
• Stained smears
Gram stain show chains of large gram-positive rods
Culture
When grown on blood agar plates, the
organisms produce Non-hemolytic gray to white,
tenacious colonies with a rough texture and a
ground-glass appearance. Comma-shaped
outgrowths (Medusa head, “curled hair”) may project
from the colony.
In semisolid medium, anthrax bacilli are always non-
motile.
18. - Definitive identification requires lysis by a specific anthrax -
bacteriophage,
- Detection of the capsule by fluorescent antibody,
- identification of toxin genes by polymerase chain reaction
(PCR),
- Enzyme-linked immunoassay (ELISA)
Clinical laboratories that recover large gram-positive rods
from blood, cerebrospinal fluid, or suspicious skin lesions,
which phenotypically match the description of B anthracis
as mentioned, should immediately contact their public
health laboratory and send the organism for confirmation.
…..Diagnostic Laboratory Tests