Health

Update

THREAT LEVEL ORANGE – ALERT FOR MEDICAL COMMUNITY

The Department of Homeland Security issued a Code Orange – High Threat Alert today, May 20, 2003. The High Threat Alert informed all

states that intelligence reports indicate potential for terrorist attacks to related to an increase in terrorist attacks abroad. State

and local governments are advised to increase security at state and federal buildings, monuments, hospitals and high traffic locations.

NO SPECIFIC THREAT HAS BEEN RECEIVED AND NO SPECIFIC LOCATIONS OR WEAPONS HAVE BEEN INDICATED. Agents ranging from biological, chemical

and radiological remain on the threat list and require advance response preparation.

Delaware’s Division of Public Health (DPH) recommends heightened awareness by the Delaware medical community for patients that may

present with symptoms consistent with bio and chemical terrorist agents. This alert contains a chart that lists agents, clinical and

treatment information.

To report suspected illness resulting from terrorist activity, or to obtain technical assistance in evaluating and treating patients,

contact the Division of Public Health immediately at 1-888-295-5156. This number is operational 24 hours, seven days a week during the

High Threat Alert.

Further information about agents of bio and chemical terrorism can be obtained from the Centers for Disease Prevention and Control at:

http://www.bt.cdc.gov/ .

The Delaware Division of Public Health will provide further information about this threat as it becomes available through the Health

Alert Network.

Biological / Chemical Terrorism Agents

Agent	Incubation/Onset	Transmission Route	Clinical Effects	Need Decon?
Anthrax Pulm	1-6 days (up to 60)	Inhalation of Spores	Initially ILI: fever, malaise, fatigue, non-productive cough, chest discomfort. LATE: Severe respiratory distress, stridor, cyanosis. Septicemia and hemorrhagic meningitis.	Only if acutely exposed.
Anthrax Cut.	1-12 days (up to 60).	Spores enter through non-intact skin.	Begins as a papule then becomes a fluid filled vesicle. The vesicle dries and forms a dark black scab (eschar).	Only if acutely exposed.
Smallpox	7-17 days	Respiratory droplets and drainage from pustules.	Prodrome 2-4 days of ILI. Rash begins as papules which become deep vesicles then scab. Mostly face and extremities. DOES involve palms/soles.	Cleanse lesions and soiled material.
Plague Pneum.	2-3 days	Inhaled droplets Can follow bubonic.	Begins as ILI. Rapid progression over 24 hours to severe pneumonia, hemoptysis, then respiratory distress and failure.	Only if acutely exposed.
Plague Bubonic	2-10 days	Can be natural (endemic in Western US) Skin or inhaled.	High fever; painful, massively swollen lymph nodes (buboes).	Only if acutely exposed.
Tularemia	2-5 days (Range 1-14).	Inhaled for BW but also skin contact, GI or animal bites.	Begins as ILI. Progresses over several days to pneumonia with dyspnea and hilar adenopathy.	Only if acutely exposed.
Botulinum Toxin	24-72 hrs	Inhaled	Symmetric, descending flaccid paralysis. Eyes, bulbar muscles then respiratory and skeletal.	Possibly if toxin present.
VHF’s (Ebola, etc.)	2-10 days	Blood or secretions. Possibly aerosolized.	ILI prodrome. Day 3 Bleeding. Day 5 desquamation. Rapid progression to delirium, multi-system organ failure.	Linen, lesions.
Ricin	Ingestion 18-24 hrs Inhalation 8-36 hrs	Ingestion, Inhalation	Acute GI: Nausea/vomiting, diarrhea, fever, abd. pain Acute Pulm: Chest tightness, cough, wheeze, nausea, fever	Soap/water: Personnel, Equipment, Supplies.
Cyanides	Seconds – Minutes	Inhalation, Ingestion, Cutaneous absorption	Moderate exposure: hypotension, dizziness, nausea/vomiting, headache, eye irritation, “pink’ skin color, hyperventilation High exposure: LOC, seizures, cardio-pulm arrest	Soap/water: Personnel, Equipment, Supplies
Vesicants/Blister agents (mustard, lewisite, phosgene)	Lewisite: minutes Mustard: Hrs. – Days	Inhalation, Cutaneous absorption	Skin erythema, blistering, itchy red skin, mucosal irritation, tearing/burning/red eyes, nausea/vomiting, SOB, pulm. edema, metabolic failure	Soap/water: Personnel, Equipment, Supplies

Biological / Chemical Terrorism Agents (continued)

Agent	Treatment	Vaccinate?	Prophylaxis?	Morbidity
Anthrax Pulm	CIP OR Doxy. AND Clinda or Vanco AND Rifampin +/- Steroids All Intravenous	Patient: yes Exposed to release: possibly Other Contact: NO Health Care: NO	Only those exposed to actual release. Doxy or Cipro orally 28-60 days.	Treated early: LOW After onset of respiratory distress: HIGH (near 100%).
Anthrax Cut.	Cipro or Doxy for 7-10 days. Can be given PO. With systemic sx or risk of inhalation, treat as above.	Patient: yes Exposed to release: possibly Other Contact: NO Health Care: NO	Only those exposed to actual release. Doxy or Cipro orally 28-60 days.	Untreated: up to 25% Treated < 1%
Smallpox	Supportive Gancyclovir may help. Other antivirals unknown.	Vaccinate patient and all contacts or potential contacts. Vaccinate health care workers at facility.	See vaccination.	10-30% likely. Higher in (rare) hemorrhagic form up to 90%.
Plague Pneum.	IV doxycycline or gentamycin.	NOT effective on aerosolized form of disease.	Doxy or Tet. Strict respiratory and droplet precautions. Isolate pt. 72 hrs.	Untreated: 100% Treated: ?
Plague Bubonic	IV doxycycline or gentamycin.	Does not treat patient. May give to health care or family. Isolate pt. 48 hrs until lesions stop draining. Treat contacts as above.	Untreated: 7-30%. May be higher. Treated: < 2%
Tularemia	IV Streptomycin, gentamycin or ciprofloxacin	None		< 5%
Botulinum Toxin	Supportive. Antitoxin may lessen progress. No antibiotics.	Antitoxin from CDC or Public Health.	None: toxin not infection.	Uncertain. Long recovery.
VHF’s (Ebola, etc.)	Supportive care. Dialysis may help. Need transfusions and FFP.	None. Strict droplet precautions. Linen, etc. highly infectious.	None	High
Ricin	Inhalation & Ingestion: No antidote, Supportive care Charcoal lavage for ingestion	None	None	High
Cyanides	100% oxygen, intubation, Amyl nitrite via ambu, 1 ampule (0.2cc) q 5 min. Sodium nitrite 300mg IV over 5-10 min. Additional sodium nitrite based on hgb level and pt. wt.	None	See treatment.	HIGH without immediate antidotes.
Vesicants/Blister agents (mustard, lewisite, phosgene)	Mustards – NO antidote Lewisite – British Anti-Lewisite (BAL or Dimercaprol) IM Thermal burn therapy, supportive care, eye care	None	See treatment.	HIGH without early decon. for Mustard. HIGH without early antidote for Lewisite.