1. Bioterrorist Agents: Brucellosis

2. Learning Objectives Become familiar with the following aspects of Brucellosis: Become familiar with the following aspects of Brucellosis: Epidemiology Epidemiology Transmission Transmission Clinical features Clinical features Diagnosis Diagnosis Treatment Treatment Prevention Prevention

3. Background Brucella melitensis discovered by Bruce in 1887 Brucella melitensis discovered by Bruce in 1887 Types: B. melitensis, abortus, suis, neotomae, ovis, canis, and types infecting marine mammals Types: B. melitensis, abortus, suis, neotomae, ovis, canis, and types infecting marine mammals Pathogenic types in humans - B. melitensis, abortus, canis and suis Pathogenic types in humans - B. melitensis, abortus, canis and suis Zoonotic disease Zoonotic disease

4. Brucellosis- definition A multisystem disease with a broad range of symptoms including acute or insidious onset of fever, night sweats, undue fatigue, anorexia, weight loss, headache and arthralgia

5. Epidemiology Incidence in US: <0.5 cases per 100,000 primarily B. melitensis Incidence in US: <0.5 cases per 100,000 primarily B. melitensis Most cases in the US are reported from California, Florida, Texas and Virginia Most cases in the US are reported from California, Florida, Texas and Virginia High risk areas: Mediterranean Basin, South and Central America, Eastern Europe, Asia, Africa, the Caribbean and the Middle East. High risk areas: Mediterranean Basin, South and Central America, Eastern Europe, Asia, Africa, the Caribbean and the Middle East.

6. Transmission Three methods of transmission: Three methods of transmission: 1. Ingestion – unpasteurized milk or dairy products. Ingestion is most common method of transmission. 2. Inhalation – breathing in the organism. Lab workers are high risk. 3. Wound contamination – high risk occupations include hunters, slaughterhouse workers, meat packing plant workers and veterinarians

7. Potential For Intentional Harm? CDC Category B agent CDC Category B agent Most likely route of intentional exposure: Respiratory Most likely route of intentional exposure: Respiratory Could also happen via contamination of food/drink Could also happen via contamination of food/drink Identify intentional exposures as any BT agent: Identify intentional exposures as any BT agent: Common Source Common Source Unlikely patients Unlikely patients Unlikely Season Unlikely Season Multiple Patients Multiple Patients Geographic correlation Geographic correlation

8. Case Definition Clinical illness with fever, night sweats, fatigue, anorexia, weight loss, headache and arthralgia Clinical illness with fever, night sweats, fatigue, anorexia, weight loss, headache and arthralgia Laboratory criteria for diagnosis: Laboratory criteria for diagnosis: Isolation of Brucella sp. from a clinical specimen, or Isolation of Brucella sp. from a clinical specimen, or Fourfold or greater rise in Brucella agglutination titer between acute- and convalescent-phase serum specimens obtained greater than or equal to 2 weeks apart and studied at the same laboratory, or Fourfold or greater rise in Brucella agglutination titer between acute- and convalescent-phase serum specimens obtained greater than or equal to 2 weeks apart and studied at the same laboratory, or Demonstration by immunofluorescence of Brucella sp. in a clinical specimen Demonstration by immunofluorescence of Brucella sp. in a clinical specimen

9. Case classification Probable: clinically compatible case with an epidemiologic link Probable: clinically compatible case with an epidemiologic link Confirmed: clinically compatible case that is laboratory confirmed Confirmed: clinically compatible case that is laboratory confirmed

10. Clinical Features Flu-like symptoms:"undulant" fever, headache, chills, myalgias, arthralgias, weakness and malaise Flu-like symptoms:"undulant" fever, headache, chills, myalgias, arthralgias, weakness and malaise Most recover entirely within 3 to 12 months Most recover entirely within 3 to 12 months Some develop ill-defined chronic syndrome Some develop ill-defined chronic syndrome Possible complications: arthritis, uveitis, sacroiliitis, spondylitis (10% of cases), meningitis (5%), and epididymoorchitis Possible complications: arthritis, uveitis, sacroiliitis, spondylitis (10% of cases), meningitis (5%), and epididymoorchitis

11. Treatment Six week course of a combination of antibiotics. Six week course of a combination of antibiotics. Doxycycline and rifampin or doxycyclin and streptomycin Doxycycline and rifampin or doxycyclin and streptomycin

12. Prevention/Infection Control Pasteurizing milk and dairy products Pasteurizing milk and dairy products Eradicating infection from herds and flocks Eradicating infection from herds and flocks Observing safety precautions for occupational exposures including Observing safety precautions for occupational exposures including rubber boots rubber boots wearing impermeable clothing, wearing impermeable clothing, gloves and face masks gloves and face masks practicing good personal hygiene practicing good personal hygiene

13. Case Reports Suspected Brucellosis Case Prompts Investigation of Possible Bioterrorism- Related Activity MMWR Morb Mortal Wkly Rep 2000: 49(23) MMWR Morb Mortal Wkly Rep 2000: 49(23) http://www.cdc.gov/mmwr/PDF/wk/mm4923.pdf

14. Resources CDC Emergency Preparedness and Response www.bt.cdc.gov/agent/brucellosis/index.asp USDA, APHIS, Veterinary Services www.aphis.usda.gov/vs/nahps/brucellosis Special thanks to Altoon Dweck, MD, MPH, Johns Hopkins Preventive Medicine Resident