Tularemia

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2000

Benjamin, Georges C. “Chemical and Biological Terrorism: Planning for the WorstPhysician Executive Volume 26 Issue 1. 80. January/February 2000.

  1. Chemical or biological terrorism is the use of pathogenic microbes or toxins derived from plants, animals, microbes, or chemical agents to achieve terror.” – page 80
  2. ”Chemical and biological weapons, like nuclear weapons, are categorized as weapons of mass destruction (WMD) because of the high number of potential victims that can result from their use.” – page 80 *
  3. ”While any chemical can be weaponized, the chemical agents traditionally of concern fall into four categories: nerve agents like sarin, which create an anticholinergic-like syndrome; vesicants like mustard gas, that cause a blistering or burn-like syndrome; cyanide, which interrupts aerobic metabolism; and riot control agents such as mace, which generally cause incapacitation.” – page 80
  4. ”Biological agents act like chemical agents but have a slower onset of action. Agents of concern include Ricin.” – page 81
  5. ”The ideal bioweapon is hard to detect from the usual microbial flora, has person-to-person spread, and is easy to aerosolize. There are two groups of organisms of public health concern: those that cause a high morbidity or a high mortality.” – page 81
  6. ”Examples of high morbidity organisms include salmonella, cholera, or E. coli. The number of highly toxic organisms is fortunately quite low and includes anthrax, smallpox, and the viruses that cause hemorrhagic fevers, plague, brucellosis, and tularemia.” – page 81
  7. “Clues that biological terrorist events have occurred include an unexplained increase in respiratory cases or deaths, or dead and dying animals. Epidemiological clues include diseases with the wrong mode of transmission, which occur in an inappropriate geographic distribution or infect a new or novel population.” – page 81
  8. “Components of a biological/chemical terrorism disaster plan: plan how to identify the threat; develop an effective public health disease surveillance system; link the public health system and the traditional medical care delivery system; develop command and control systems; determine hospital bed availability; define disease containment, isolation, and quarantine procedures; plan how to obtain extra life support equipment such as respirators; plan how to train clinical staff to identify high-risk unusual diseases; ensure non-clinical staff are trained on the management of suspicious packages and mail; identify experts; plan simple handling and transport; plan how to communicate high risk information; manage medical examiner cases; and maintain a crime scene.” – page 81
  9. ”Effective disease control strategies such as case finding, decontamination, prophylaxis and vaccination, and quarantine must be defined.” – page 82

Chemical, WMD, Bioterrorism, Public Health, Military, Sarin, Japan, Ricin, E. coli, Cholera, Salmonella, Anthrax, Smallpox, Hemorrhagic fever, Plague, Brucellosis, Tularemia, Prophylaxis, Vaccination, Quarantine

2002

Shapiro, Daniel, S., & Schwartz, Donald, R.,  “Exposure of laboratory workers to Francisella tularensis despite a bioterrorism procedure,” J. of Clinical Microbiology, June 2002, pp. 2278-2281.  PubMed [http://www.ncbi.nlm.nih.gov/pubmed/12037110] last checked 12/16/15

  1. ”A rapidly fatal case of pulmonary tularemia in a 43-year-old man who was transferred to a tertiary care facility is presented. The microbiology laboratory and autopsy services were not notified of the clinical suspicion of tularemia by the service caring for the patient. Despite having a laboratory bioterrorism procedure in place and adhering to established laboratory protocol, 12 microbiology laboratory employees were exposed to Francisella tularensis and the identification of the organism was delayed due to lack of notification of the laboratory of the clinical suspicion of tularemia. A total of 11 microbiology employees and two persons involved in performing the patient’s autopsy received prophylactic doxycycline due to concerns of transmission. None of them developed signs or symptoms of tularemia. One microbiology laboratory employee was pregnant and declined prophylactic antibiotics. As a result of this event, the microbiology laboratory has incorporated flow charts directly into the bench procedures for several highly infectious agents that may be agents of bioterrorism. This should permit more rapid recognition of an isolate for referral to a Level B laboratory for definitive identification and should improve laboratory safety.” P. 2278.
  2. ”Despite the presence in the clinical microbiology laboratory of a written procedure for working with agents of bioterrorism, including F. tularensis, the identification of F. tularensis isolated from a fatal case of pulmonary tularemia was delayed, resulting in the manipulation of the organism at the bench by laboratory workers, many of whom subsequently began taking prophylactic antibiotics.” 2278
  3. ”Although tularemia is rare, with approximately 200 cases annually in the United States, in Pike’s study of 3,921 cases of laboratory-associated infections, it ranked second in the United States as a cause of laboratory-associated infections, behind only brucellosis, and third worldwide, behind brucellosis and typhoid (15).” P. 2278
  4. ”Although the medical service caring for this patient was concerned enough about the possibility of tularemia to give him intramuscular streptomycin, the microbiology laboratory and the autopsy service were not informed of this clinical suspicion. As a result, there was both a delay in sending the clinical isolate for definitive identification and an increased risk to the microbiology staff. Although a specific bioterrorism procedure was in place in the microbiology laboratory, it was separate from, and had not been sufficiently integrated into, the specific bench procedures for the workup of blood, respiratory, and sterile body fluid cultures. As a result, technologists working with the isolate on these benches did not suspect F. tularensis. It has been the standard procedure in our microbiology laboratory to subculture all positive blood cultures within a biological safety cabinet. This procedure, which involves a broth culture, is one that can potentially result in the production of an infectious aerosol.” P. 2280
  5. ”The clinical microbiology laboratory at Boston Medical Center is currently designated a Level A laboratory. This classification means that the laboratory should not attempt the identification of potential bioterrorism agents such as F. tularensis, but it does require the ability to rapidly rule out such agents and to forward those isolates which cannot be ruled out to a Level B laboratory (12, 13).” P. 2280
  6. ”The misidentification or preliminary identification of F. tularensis as a Haemophilus species has been noted in a number of published reports (2, 11, 18). F. tularensis is characteristically isolated as small, poorly staining gram-negative rods seen mostly as single cells which yield mostly pinpoint colonies on chocolate agar and often on sheep agar at 48 h, do not grow on either MacConkey or eosin-methylene blue agar, are oxidase negative, and have a weakly positive or a negative catalase test.”  P. 2280
  7. ”Although Yersinia pestis and Bacillus anthracis, two agents that have been classified as a Category A critical biological agents, have only rarely been reported to cause laboratory infections, we have incorporated flow charts for the identification of these organisms into our procedures in order to prevent a delay in their identification. In the clinical virology laboratory, we have incorporated a flow chart for those situations in which cytopathic effect is seen and which is consistently demonstrated upon passage but cannot be identified with our standard laboratory procedures.” P. 2280
  8. ”The role of performing autopsies in the possible detection of cases of bioterrorism is an important one (14). Under ideal circumstances, autopsies in cases of suspected bioterrorism should be performed in a specially designated morgue rather than in a routine hospital-based setting to minimize the risk of transmission of exotic agents, such as those causing viral hemorrhagic fevers.” P. 2281

Lab Safety, Biosafety, Tularemia, Anthrax, Plague, Biodetection

2003

Davis, Jim, “The Looming Biological Warfare StormAir & Space Power Journal, Volume 17, Issue 1. 57. Spring 2003.

  1. ”Until very recently, the lack of focus on this subject (biological warfare) has resulted in a lack of appropriate funding and accountability.” – page 58
  2. ”Unless we focus appropriate dollars and develop a coherent national plant to prepare for and prevent such actions, the United States will likely suffer an enormous economic loss that could even lead to our demise as a superpower.” – page 58
  3. ”A belief in one or more of at least six false assumptions or myths helps explain why individuals, including senior civilian and military leaders, do not believe that a mass-casualty biological warfare (BW) attack will occur.” – page 58
  4. ”Myth one: there never really has been a significant BW attack” – page 58
  5. ”Even before the fall 2001 anthrax terrorism in the United States, incidents of BW and bioterrorism have occurred on multiple occasions.” – page 58
  6. ”Today, more countries have active biological warfare programs than at any other time in history, which increases the likelihood that BW will be used again in the future.” – page 58
  7. ”Myth two: The United States has never been attacked by a BW agent” – page 59
  8. ”Myth three” you have to be extremely intelligent, highly educated, and well-funded to grow, weaponized, and deploy a BW agent” – page 59
  9. ”Dr. Tara O’Toole, deputy director for the Center for Civilian Biodefense Studies at Johns Hopkins University, believes we have probably crossed over the threshold from ‘too difficult’ to accomplish to ‘doable by a determined individual or group’” – page 59
  10. “Much of the technical information is readily available on the internet, in libraries, and through mail order channels that provide ‘how-to’ manuals.” – page 59
  11. ”Myth four: biological warfare must be too difficult because it has failed when it has been tried” – page 59
  12. ”Myth five: there are moral restraints that have kept and will keep BW agents from being used” – page 60
  13. ”Morality can be marshaled as a reason both to limit BW use and to advocate mass killings – depending on the decision maker’s values and perspectives” – page 60
  14. ”Myth six: the long incubation period required for BW agents before onset of symptoms makes BW useless to users” – page 60
  15. ”There have already been multiple BW attacks, and to a savvy weaponeer, the incubation period can be used as an advantage rather than a disadvantage.” – page 60
  16. ”There are two primary motivations that might drive an adversary to attack the United States with a BW agent. The first motivation is to gradually ‘erode US influence’ as a world superpower. The second is categorized as ‘revenge or hate’” – page 61
  17. ”The author believes that there are three most likely BW scenarios the United States and its allies might face in the future: an agroterrorist event against the United States, a BW attack on United States and allied troops in the Middle East, and/or a bioterrorist attack against a large population center in the United States or an allied state.” – page 61
  18. ”Such myths continue to inhibit the adequate funding of US and allied biodefense” – page 66

Military, Anthrax, Plague, Smallpox, Tularemia, Sarin, Japan, Iraq, Iran, Nonproliferation, WMD

 

Atlas, Ronald, “National Security and the LabMedical Laboratory Observer, Volume 35, Issue 9. 52. September 2003.

  1. ”The aftermath of anthrax attacks following the horrific 9/11 events increased fear that terrorists could acquire deadly pathogens from legitimate U.S. laboratories, which led to a series of laws and regulations directly impacting clinical microbiology laboratories.” – page 52
  2. ”Enhancement of clinical and public health laboratories is key to the nation’s biodefense capabilities, so the American Society for Microbiology (ASM) worked with the Centers for Disease Control and Prevention (CDC) to develop protocols for diagnostic laboratories to recognize and handle major biothreat agents.” – page 52
  3. ”Since clinical labs have been the sources of the agents used in prior acts of bioterrorism or biocrimes, (e.g., the 1989 use of salmonella by the Rajneesh cult in Dalles, OR), they must exercise appropriate oversight as to who is given access to any pathogen which can be misused to cause harm.” – page 52
  4. ”Clinical labs wishing to retain select agents as clinical specimens or reference standards must meet all of the registration requirements of the Biopreparedness Act, including imposing strict biosecurity procedures and obtaining Department of Justice clearance for all individuals with access to the select agents.” – page 52
  5. ”The CDC and USDA must maintain accurate tracking of the acquisition, transfer and possession of these select agents, and must establish safeguards and biosecurity procedures to be followed by institutions possessing select agents.” – page 52
  6. ”The FBI is responsible for conducting security risk assessments of individuals seeking access to listed agents and toxins, and individuals or entities seeking to register under the Act.” – page 52
  7. ”The Biopreparedness Act, a new regulatory burden, should have minimal impact. The greatest impact is likely to be on the labs in the western United States where plague, tularemia, and coccidioidomycoses occur.” – page 52

Public Health, Lab Security, Anthrax, Salmonella, Tularemia, Plague, CDC, Bioterrorism, Biodefense, Biosecurity

2004

King, Warren, “Washington State Bioterror Monitoring Expands To Animals,Knight Ridder Tribune Business News, pg. 1, Aug 30, 2004.

  1. “State health officials are expanding their early warning system for a bioterrorist attack by employing the help of rabbits, squirrels, mice and other critters.”
  2. “As part of the state’s biological-warfare defense, state veterinarians recently began monitoring unusual small-animal deaths for evidence of tularemia, plague or other diseases that could be cause by lethal agents.”
  3. “Small animals likely would show symptoms and die faster than humans after being exposed to a lethal biological agent.”
  4. “In the animal reporting system, plague and tularemia are receiving special emphasis because they are considered among the highest risks for an attack and can infect both animals and humans.  Anthrax, often mentioned as a threat, also could be detected in animals, especially cattle, sheep and goats, where it occurs naturally.”
  5. “Plague, tularemia and anthrax…can be easily disseminated or transmitted person to person, can cause many deaths, and can cause panic.”
  6. “Plague is usually fatal unless treated with antibiotics within 24 hours of onset.  Typically, those who are infected experience fever, weakness and rapidly developing pneumonia.”
  7. “If inhaled, tularemia bacteria can cause abrupt fever, headache, muscle aches and potentially fatal pneumonia, if not treated quickly with antibiotics.”
  8. “The new surveillance looks for ‘die-offs’ of vulnerable animals — a group of wild animals dying quickly without apparent explanation.”
  9. “Establishing a database of information on wildlife deaths will help veterinarians to determine quickly which infections are natural and which might be from bioterrorism.”
  10. “Unusual, unexplained symptoms may indicate the introduction of a disease from abroad, such as with the monkeypox outbreak a year ago.”

Biosurveillance, Monkeypox, Bioterrorism, Plague, Anthrax, Tularemia

2005

KAREN T. MORR, [the Acting Assistant Secretary for Office of Information Analysis in DHS] Statement, ”HEARING BEFORE THE SUBCOMMITTEE ON EMERGENCY PREPAREDNESS, SCIENCE, AND TECHNOLOGY OF THE COMMITTEE ON HOMELAND SECURITY HOUSE OF REPRESENTATIVES, ONE HUNDRED NINTH CONGRESS”, FIRST SESSION JULY 12, 2005. “PROJECT BIOSHIELD: LINKING BIOTERRORISM THREATS AND COUNTERMEASURE PROCUREMENT TO ENHANCE TERRORISM PREPAREDNESS.

  1. “Al-Qa’ida documents recovered from a training camp in Afghanistan show interest in a variety of biological agents and mentioned plague, anthrax, cholera and tularemia.”
  2. “To determine threat, we examine an actor’s capability and intent. We assess capability based on factors such as the actor’s level of skill or knowledge, their ability to acquire a biological agent, the materials necessary to grow the agent and their capacity to effectively disseminate a biological agent. For intent, in addition to the actor’s desire to simply use biological weapons, we discern which agents they are more likely to pursue, their preferred method of deployment and which targets they intend to attack.”
  3. “Last month one of our analysts provided some of the Committee members with a classified briefing on the specifics of the current bioterrorist threat to the Homeland.  I will not be able to revisit this classified threat assessment in this open forum but we would be happy to provide this information to additional members in a closed session.”
  4. “On occasion, we require quick access to information that does not reside within IA. In these cases, our analysts are supported to the Biodefense Knowledge Center (BKC)—a 24×7 support cell based at Lawrence Livermore National Laboratory and sponsored by the S&T Directorate. The BKC possesses vast repositories of biological technical information and is able to access SMEs from around the country, such as the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), the U.S. Army Medical Research Institute for Chemical Defense (USAMRICD), and the Armed Forces Medical Intelligence Center (AFMIC), in support of a tasking from IA. The BKC compiles the appropriate information and relays it to our analysts who integrate the information into their finished intelligence analysis.”
  5. “Our analysts regularly collaborate with other intelligence agencies, particularly NCTC, DIA, FBI, and CIA.  We also work with experts from government, academic, and private institutions and partner with scientists who keep us abreast of their potential areas of concern and the trends they see.  Interaction with outside public and private sector institutions keeps us well-informed of new and emerging technology that may be exploited or misused by malicious actors.  For example, IA recently hosted a workshop on emerging biotechnologies and the future biological threat.  This provided a forum for non-governmental experts to provide IA with information of which they believe we should monitor.”
  6. “Our analysts are broadly focused and access a wide array of information in gathering source material for our assessments. They use all-source intelligence, scientific and technical information, terrorist profiles, historical trends, and open source information such as media reports and scientific journal articles.”
  7. “We keep current on foreign State biological weapons program developments as these activities may have implications for future terrorist events. We look at the intent of the enemy, their capabilities, potential scenarios, and attack vectors. Working with counterterrorist experts in the Community, we develop link charts on potential associates here in the United States of operatives abroad who may have received training in WMD capabilities or have knowledge of WMD programs.”
  8. “we assessed the implications of the H2N2 influenza shipment in which a U.S. contractor sent a highly virulent strain of influenza to hundreds of laboratories worldwide. We also recently published an Information Bulletin advising State and local Law Enforcement officials of
    indicators of covert anthrax production. Generally, our products fall into two categories: threat assessments and feasibility assessments.”
  9. “Threat Assessments. Threat assessments are written on known actors and are based on specific intelligence. To determine threat, we examine an actor’s capability and intent. We calculate capability based on factors such as a particular actor’s level of skill or knowledge; their ability to acquire a biological agent and the materials necessary to grow the agent; and their capacity to effectively disseminate a biological agent. For intent, we consider more than just an actor’s desire to use biological weapons. We attempt to discern which agents they are more likely to pursue, their preferred method of deployment, and which targets they intend to attack.”
  10. “Feasibility Assessments. Intelligence is never complete or all-knowing and we cannot wait until intelligence is received in order to consider plausible scenarios or the impact of a particular technique or technology on a bioterrorist’s capability. To move beyond this limitation, IA, in partnership with S&T, conducts assessments of biological processes, emerging technologies, and techniques and determines their feasibility for use in a bioterrorism event.  These assessments include indicators that will help to identify if a particular scenario begins to unfold so we can prevent or disrupt events before they occur. In conjunction with the feasibility assessment, we are producing unclassified excerpts with the indicators which are distributed widely to local, State, Federal officials as well as the private sector to enhance awareness in the field and to increase suspicious activity reporting and trigger investigations where necessary.”
  11. “IA also has produced several bioterrorism-specific ‘‘red team’’ products, which explore issues from a terrorist’s perspective using nongovernmental experts and creative thinkers. These topics have included terrorist use of genetically modified food and recombinant DNA technologies to damage the U.S. food supply; possible terrorist exploitation of a U.S. flu vaccine shortage; and the safety and security impacts of a pandemic influenza outbreak.
  12. “Under the BioShield legislation, DHS is charged with assessing current and emerging threats of chemical, biological, radiological, and nuclear agents; and determining which of such agents present a material threat against the United States population. S&T, supported by IA, has been conducting Material Threat Assessments (MTAs) and Material Threat Determinations (MTDs) in order to guide near term BioShield requirements and acquisitions.”
  13. “MTAs … are speculative and represent a best estimate of how an adversary may create a high-consequence event using the agent/weapon in question. Currently, MTAs are drafted by the S&T and IA provides comments on the assessment before it is provided to HHS. In our review, we ensure that the assessment reflects what IA assesses is the general capability of terrorist groups that are pursuing biological weapons.”
  14. “MTAs result in an estimate of the number of exposed individuals, the geographical extent of the exposure, and other collateral effects. If these consequences are of such a magnitude to be of significant concern to our national security, the Secretary of DHS then issues a formal Material Threat Determination to the Secretary of HHS, which initiates the BioShield process. To date, one MTA has been completed for anthrax and MTAs for plague, botulinum toxin, tularemia, radiological devices and chemical nerve agents are underway and an MTA for viral hemorrhagic fevers will be initiated next month. MTDs have been approved for four agents: smallpox, anthrax, botulinum toxin, and radiological/nuclear devices.”
  15. “IA, in cooperation with NCTC and the FBI, is providing WMD outreach briefings around the country. These briefings outline the terrorist WMD threat, including descriptions of the types of weapons used and indicators and warnings aimed at increase awareness and reporting. In the near future, we hope to expand these briefings to other audiences such as academia and the private sector to further increase awareness and reporting.”
  16. “IA will be playing a key role in supplying current intelligence to the National Biosurveillance Integration System (NBIS) operations center once it begins operation later this summer. NBIS will fuse information on human, plant, and animal health with environmental monitoring of air, food, and water systems. This information will be integrated with threat and intelligence information to provide real-time situational awareness and identify anomalies or trends of concern to the Homeland Security Operations Center.”

Project Bioshield, Al-Qaeda, Information Policy, Academia, Lab Safety, Flu, Vaccination, Law Enforcement, WMD, Plague, Anthrax, Biosurveillance, Nuclear, Radiological Surveillance, Cholera, Tularemia

2009

Editors, “University of Pittsburgh Schools of the Health Sciences; Immune system quirk could lead to effective tularemia vaccineLife Science Weekly, NewsRx.com, November 10, 2009.

  1. “Immunologists…have found a unique quirk in the way the immune system fends off bacteria called Francisella tularensis, which could lead to vaccines that are better able to prevent tularemia infection of the lungs.”
  2. “…if we want to make an effective vaccine against tularemia, we must target ways to boost IL-17.”

Tularemia, Vaccination

2015

Uzun, Mustafa, et al. “Epidemiological and Clinical Characteristics and Management of Oropharyngeal Tularemia Outbreak.Turkish Journal of Medical Sciences, Volume 45 Issue 4. 902. 2015

  1. ”Tularemia is a zoonotic disease cause by the bacterium ”Francisella tularensis”. The infection is endemic in the northern hemisphere, including Turkey.” – page 902
  2. ”Oropharyngeal tularemia is the most common clinical form of the disease in East Europe, including Turkey.” – page 902
  3. ””Francisella tularensis” is quite a resistant bacterium, surviving in humid and cold environments for weeks. However, it is not resistant to high temperatures ad direct sunlight, and cannot survive in chlorinated water.” – page 902
  4. ”The wide range of reservoir hosts for humans include primarily rodents, such as rabbits, mice, and squirrels, and secondarily raccoons, cattle, cats, and dogs. Tularemia is transmitted mainly by arthropod vectors living on animals, such as ticks, and by consumption of contaminated food and water.” – page 902
  5. ”Tularemia may be misdiagnosed and treated for long periods as an upper respiratory tract infection. Furthermore, the complications of the infection may lead to prolonged treatment and patient discomfort.” – page 903
  6. ”The purpose of this study was to discuss the demographic, clinical, and epidemiological features of oropharyngeal tularemia in patients living in rural Amasya, who were diagnosed in our clinic.” – page 903
  7. ”The study included 31 patients referring to our clinic with complaints of fever, sore throat, and swelling in the neck in the time period between January 2009 and March 2011. Patients who referred to our clinic with ‘neck mass of unknown origin’ were hospitalized for further examination.” – page 903
  8. ”The most significant epidemiological findings were that animal husbandry was the most common means of livelihood in these areas, and that there had been increased rodent activity around the village. In the villages where tularemia was found, the main water system was not regularly chlorinated.” – page 904
  9. “In the management of tularemia, the first choice antibiotics are streptomycin and gentamicin.” – page 905

Tularemia, Public Health, Zoonotic