Best Practices in Preventing Botulism

  • • Use appropriate therapy for botulism including supportive care, fluid and nutritional help, proper ventilation and treatment of complications, and passive immunization with an equine antitoxin which should be administered as quickly as possible.
  • • Test all possible food or water consumed by the patient.
  • • Antibiotics showed no known properties for altering or protecting against the toxin, however they may be used for secondary infections.


(See endnote 32)

Bubonic plague is caused by the organism Yersinia pestis which is carried by the Oriental rat flea. The reservoir of infection is rodents, prairie dogs, squirrels, and rabbits. Either the bite of the infected flea or touching or skinning an infective animal can cause disease transmission.

Pneumonic plague is transmitted from person to person when the bacteria affect the lungs and another person inhales the infected material. Symptoms of the disease include high fevers, chills, cough, difficulty in breathing, bloody mucus, and then death. An aerosolized weapon would cause fever and cough within 1-6 days and then a rapid move to septic shock with a substantial number of people dying.

Smallpox (See endnote 33)

Smallpox, which has been eradicated worldwide, may still be used as a bioweapon by terrorists if they have access to supplies of the variola virus. Although there are two designated World Health Organization repository laboratories, no one knows if terrorists have access to other sources of the virus. The mode of transmission is from person to person by inhaling infective droplets in close face-to-face contact. The symptoms usually begin in 12-14 days with high fever, malaise, severe headaches, and backaches followed by a rash all over the body. This is a highly infectious disease.

Best Practices for Controlling Smallpox

  • • Administer smallpox vaccine within 3 days after exposure, if smallpox is suspected, to prevent the disease or decrease the severity and reduce the risk of death.
  • • Obtain and utilize the most up-to-date version of the CDC Smallpox Response Plan.
  • • Identify and isolate as quickly as possible all smallpox cases to prevent disease spread.
  • • Identify, vaccinate, and monitor all known contacts of the individuals who have smallpox.
  • • If deemed necessary, vaccinate a larger population of people as soon as possible.
  • • Identify for vaccination and treatment individuals who had close face-to-face contact with the patient, those initially exposed to the virus release, household members of actual cases or potential cases, and healthcare personnel including first responders.
  • • Treat any individuals rapidly if they show adverse reactions to the vaccination.
  • • Use strict isolation procedures and quarantine on known or suspected cases.
  • • Inform the public by all sources of media of what has occurred and the necessity to look for symptoms and to immediately contact the appropriate authorities and be vaccinated.
  • • CDC should coordinate all activities in investigating the problem, and vaccination and treatment of patients with all state and local public health authorities.

Tularemia (See endnote 34)

Tularemia is a bacterial zoonosis caused by the microorganism Francisella tularensis. The disease can be caught by the bite of an infected tick, deer fly, or other insects, working with infected animal carcasses, eating or drinking contaminated food or water, or breathing in the bacteria especially from an aerosol. It is not spread person to person. It can be fatal if not treated rapidly with antibiotics. Airborne release of the organisms can cause primarily pleuropneumonitis and also possibly ocular tularemia. It can penetrate broken skin and cause glandular disease. People usually become infected 3-5 days after exposure and develop a variety of symptoms including hemorrhagic inflammation of the airways, life-threatening bronchopneumonia, fever, chills, progressive weakness, sore throat, and systemic infection. Since the organism which causes tularemia is highly infectious, a small number of bacteria will cause the disease. The bacteria are widely present in nature and therefore readily accessible. Therefore, it might make an excellent bioweapon used as an infectious aerosol.

Best Practices for Control of Tularemia as a Biological Weapon

  • • If exposure to tularemia is suspected, individuals should immediately be given vaccinations for the disease, appropriate antibiotics, and supportive therapy where necessary.
  • • Microbiological sampling should be handled in the appropriate biosafety cabinets.
  • • Avoid autopsies where possible of victims to prevent aerosols from entering the environment and causing a potential hazard for healthcare workers.
  • • Decontaminate and disinfect all linens and clothing containing the body fluids of the patient.

Viral Hemorrhagic Fever

(See the section “Ebola Virus” above) (See endnote 35)

Viral hemorrhagic fevers are a group of highly infectious organisms, one of which is the Ebola virus, from several distinct families of viruses. The viral hemorrhagic fever viruses affect multiple organ systems in the body, often accompanied by severe bleeding. Symptoms include fever, headaches, nausea, vomiting, diarrhea, and chest pain. Some of the viruses cause mild symptoms, while others are severe and cause a large number of deaths. Viruses are all RNA viruses and depend on an animal or arthropod host from a specific geographic area. Human cases occur when people come in contact with the animal or arthropod, which may be a mosquito or tick, and then the disease may be spread secondarily from person to person especially in a healthcare setting. Primary concerns are Ebola hemorrhagic fever, Marburg hemorrhagic fever, Lassa fever, and Argentine hemorrhagic fever.

Best Practices for Control of Bioterrorism and Potential Agents

Note: Other than the specific Best Practices listed under Ebola, in order to avoid repetition general Best Practices will be given for all potential Category A, Category B, and Category C agents

of bioterrorism, based on the method of distribution of the microorganism or toxin.

  • • Healthcare providers need to be taught the symptoms of the illnesses and best techniques for diagnosing the effects of agents of bioterrorism when a cluster of patients with similar symptoms appear in either their offices, clinics, or hospitals, and this should be reported immediately to local, state, and federal public health authorities and the FBI. Laboratory samples should be used only for confirmation and identification purposes while immediate precautions need to be taken based on the symptoms.
  • • Healthcare providers should be looking for unexplained fevers, sepsis, which is a life- threatening complication of an infection where chemicals are released into the bloodstream to fight an infection and trigger inflammatory responses throughout the body which then causes multiple organ system damage or failure, pneumonia, respiratory failure, or severe rashes especially in apparently very healthy people. Information concerning individuals with these symptoms aids in the identification of potential use of bioterrorism agents.
  • • Healthcare providers should be looking for what appears to be chickenpox among adults as possible use of smallpox as a weapon.
  • • Healthcare workers should be looking for cases of acute flaccid paralysis with prominent bulbar palsies (extreme loss of muscle tone that affects the lower cranial nerves) suggesting exposure to botulism toxin.
  • • Physicians treating individuals contaminated with various biological agents should consider the use of antibiotics, appropriate vaccines, and antitoxins.
  • • Clinical laboratory personnel should be alert to a large number of samples of blood or stool cultures or a request for analysis of a large number of these samples, as potential outbreaks of a serious disease or a bioterrorism agent.
  • • Use personal protective equipment when dealing with suspected highly infectious material, handle all samples in the appropriate biological safety cabinets, and immediately inform appropriate public health authorities. After determining the causative agent, a priority immediate report should be given to the public health agencies as well as to the practicing healthcare worker. All laboratory equipment and facilities should be immediately decontaminated after suspicion of a highly infectious agent.
  • • Infection control personnel should be constantly upgraded in their knowledge and skills concerning potential biological agents and it should be top priority protocol that current phone numbers for notifying appropriate public health officials, the CDC, and the FBI are prominently posted for use by healthcare workers.
  • • State health departments should have current plans and means of implementing them to quickly respond to any outbreaks of disease including use of biological agents. They should have appropriate educational programs and reminders to all healthcare workers about each of the potential disease outbreaks as well as use of biological agents.
  • • Since aerosol dissemination of biological agents is extremely hard to detect, if individuals become aware of a suspicious substance in the air, they should immediately cover their mouths and noses with layers of cloth to act as a filter, get away from the area as quickly as possible, wash and rinse thoroughly with soap and water, wash all clothing carefully, notify the proper authorities, and if told to get a specific vaccination, do it immediately. Seek immediate medical treatment since antitoxins exist for biotoxins and supportive therapy may be needed immediately to preserve life because of biological weapon use.
  • • If the aerosol release occurs in an enclosed environment, shut off the ventilation system to the building, trains, aircraft, or subways where terrorist groups in the past have released anthrax and botulism toxin. Thoroughly clean and disinfect the ventilation system, repeatedly if necessary, to remove all microorganisms or toxins. Chlorine dioxide may be excellent for this purpose.
  • • Monitor the level of biological agents to determine the quantity and specific type and perform the necessary cleanup and decontamination of the area by properly equipped personnel based on the organisms released.
  • • Where arthropods including insects are purposely infected with biological agents and an outbreak of disease occurs, there should be a determination of the type and nature of the organism, immediate public warnings for necessary precautions including vaccinations, immediate spraying campaign to destroy the insects, destruction of potential resting places and harborage, and in the case of mosquitoes staying indoors at dawn and dusk.
  • • If the biological weapon is a form of a contagious disease, immediately institute isolation procedures in healthcare centers, quarantine all suspected cases, have medical personnel use personal protective equipment of the appropriate kind depending on the disease under close supervision, and in all cases use appropriate hand-washing techniques.
  • • If the release of the biological substance is into water and cases of a disease start to track to a water source, immediately issue a boil water order to the public for any water used in drinking, eating, preparation of food, brushing teeth, or other essential personal needs, bathing, etc. for people and pets. Bottled water may be used for these purposes or the water may be disinfected by using bleach with 1/8 teaspoon of bleach per gallon of water, shaking the container and letting it stand for 30 minutes before using. After the boil water notice is withdrawn, thoroughly flush all water outlets including those for swimming pools, hot tubs, spas, icemakers, etc. All swimming areas need to be thoroughly cleaned using gloves and masks if necessary, disinfected, and restocked with treated water.
  • • If the release of the biological substances is into the food, as has been done in salad bars by a terrorist group, as soon as cases of a disease are tracked to the food source, there should be an immediate halting of all activities, thorough evaluation by the appropriate health authorities, and intensive cleaning and decontamination of all surfaces, vessels physical facilities, and equipment. All contaminated and potentially contaminated food should be disposed of in an appropriate manner. (See Chapter 7, “Food Security and Protection.”)
  • • If human carriers are involved in the distribution of biological substances, as soon as the disease symptoms appear, the individual should be put into isolation and treated.
  • • If infected animals are involved in the distribution of biological substances, as soon as the disease symptoms appear, the animals should be examined by veterinarians and a determination made as to the nature of the disease and then the animal should be destroyed and incinerated. All other animals should be given necessary protection including appropriate vaccinations. All areas where the infected animal lived should be thoroughly cleaned and disinfected, and the bedding and other materials including contaminated food should be incinerated.
  • • For mail attacks see below.
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