1. Northwest Center for Public Health Practice University of Washington School of Public Health and Community Medicine, December 2002 Preparing for and Responding to Bioterrorism: Information for Primary Care Clinicians

2. UW Northwest Center for Public Health Practice AcknowledgementsAcknowledgements This presentation, and the accompanying instructor’s manual (current as of 12/02), were prepared by Jennifer Brennan Braden, MD, MPH, at the Northwest Center for Public Health Practice in Seattle, Washington, and Jeff Duchin, MD with Public Health – Seattle & King County, and the Division of Allergy & Infectious Diseases, University of Washington, for the purpose of educating primary care clinicians in relevant aspects of bioterrorism preparedness and response. Instructors are encouraged to freely use all or portions of the material for its intended purpose. The following people and organizations provided information and/or support in the development of this curriculum. A complete list of resources can be found in the accompanying instructor’s guide. Patrick O’Carroll, MD, MPH The Centers for Disease Control & Prevention Project Coordinator Judith Yarrow Health Policy & Analysis, University of WA Design and Editing Jane Koehler, DVM, MPH Communicable Disease Control, Epidemiology and Immunization section, Public Health - Seattle & King County Ed Walker, MD; University of WA Department of Psychiatry

3. UW Northwest Center for Public Health Practice Diseases of Bioterrorist Potential Smallpox CDC, AFIP

4. UW Northwest Center for Public Health Practice Diseases of BT Potential Learning Objectives Be familiar with the agents most likely to be used in a biological weapons attack and the most likely mode of dissemination Be familiar with the agents most likely to be used in a biological weapons attack and the most likely mode of dissemination Know the clinical presentation(s) of the Category A agents and features that may distinguish them from more common diseases Know the clinical presentation(s) of the Category A agents and features that may distinguish them from more common diseases Be familiar with diagnosis, treatment recommendations, infection control, and preventive therapy for management of infection with or exposure to Category A agents. Be familiar with diagnosis, treatment recommendations, infection control, and preventive therapy for management of infection with or exposure to Category A agents. Be familiar with the agents most likely to be used in a biological weapons attack and the most likely mode of dissemination Be familiar with the agents most likely to be used in a biological weapons attack and the most likely mode of dissemination Know the clinical presentation(s) of the Category A agents and features that may distinguish them from more common diseases Know the clinical presentation(s) of the Category A agents and features that may distinguish them from more common diseases Be familiar with diagnosis, treatment recommendations, infection control, and preventive therapy for management of infection with or exposure to Category A agents. Be familiar with diagnosis, treatment recommendations, infection control, and preventive therapy for management of infection with or exposure to Category A agents.

5. Biological Agents of Highest Concern Category A Agents Easily disseminated, infectious via aerosol Easily disseminated, infectious via aerosol Susceptible civilian populations Susceptible civilian populations Cause high morbidity and mortality Cause high morbidity and mortality Person-to-person transmission Person-to-person transmission Unfamiliar to physicians – difficult to diagnose/treat Unfamiliar to physicians – difficult to diagnose/treat Cause panic and social disruption Cause panic and social disruption Previous development for BW Previous development for BW Easily disseminated, infectious via aerosol Easily disseminated, infectious via aerosol Susceptible civilian populations Susceptible civilian populations Cause high morbidity and mortality Cause high morbidity and mortality Person-to-person transmission Person-to-person transmission Unfamiliar to physicians – difficult to diagnose/treat Unfamiliar to physicians – difficult to diagnose/treat Cause panic and social disruption Cause panic and social disruption Previous development for BW Previous development for BW

6. Biological Agents of Highest Concern Category A Agents Variola major (Smallpox) Variola major (Smallpox) Bacillus anthracis (Anthrax) Bacillus anthracis (Anthrax) Yersinia pestis (Plague) Yersinia pestis (Plague) Francisella tularensis (Tularemia) Francisella tularensis (Tularemia) Botulinum toxin (Botulism) Botulinum toxin (Botulism) Filoviruses & Arenaviruses (Viral hemorrhagic fevers) Filoviruses & Arenaviruses (Viral hemorrhagic fevers) Report ANY suspected illness due to these agents to Public Health immediately. Report ANY suspected illness due to these agents to Public Health immediately. Variola major (Smallpox) Variola major (Smallpox) Bacillus anthracis (Anthrax) Bacillus anthracis (Anthrax) Yersinia pestis (Plague) Yersinia pestis (Plague) Francisella tularensis (Tularemia) Francisella tularensis (Tularemia) Botulinum toxin (Botulism) Botulinum toxin (Botulism) Filoviruses & Arenaviruses (Viral hemorrhagic fevers) Filoviruses & Arenaviruses (Viral hemorrhagic fevers) Report ANY suspected illness due to these agents to Public Health immediately. Report ANY suspected illness due to these agents to Public Health immediately.

7. Biological Agents of 2nd Highest Concern Category B Agents Coxiella burnetti (Q-fever) Coxiella burnetti (Q-fever) Brucella species (brucellosis) Brucella species (brucellosis) Burkholderia mallei (glanders) Burkholderia mallei (glanders) Alphaviruses (Venezuelan, Western and Eastern encephalomyelitis viruses) Alphaviruses (Venezuelan, Western and Eastern encephalomyelitis viruses) Ricin toxin from Ricinus communis (castor bean) Ricin toxin from Ricinus communis (castor bean) Epsilon toxin from Clostridium perfringens Epsilon toxin from Clostridium perfringens Staphlococcus enterotoxin B Staphlococcus enterotoxin B Coxiella burnetti (Q-fever) Coxiella burnetti (Q-fever) Brucella species (brucellosis) Brucella species (brucellosis) Burkholderia mallei (glanders) Burkholderia mallei (glanders) Alphaviruses (Venezuelan, Western and Eastern encephalomyelitis viruses) Alphaviruses (Venezuelan, Western and Eastern encephalomyelitis viruses) Ricin toxin from Ricinus communis (castor bean) Ricin toxin from Ricinus communis (castor bean) Epsilon toxin from Clostridium perfringens Epsilon toxin from Clostridium perfringens Staphlococcus enterotoxin B Staphlococcus enterotoxin B

8. Biological Agents of 2nd Highest Concern Food- or Water-borne Category B Agents Salmonella species Salmonella species Shigella dysenteriae Shigella dysenteriae Escherichia coli 0157:H7 Escherichia coli 0157:H7 Vibrio cholera Vibrio cholera Cryptosporidium parvum Cryptosporidium parvum Salmonella species Salmonella species Shigella dysenteriae Shigella dysenteriae Escherichia coli 0157:H7 Escherichia coli 0157:H7 Vibrio cholera Vibrio cholera Cryptosporidium parvum Cryptosporidium parvum

9. UW Northwest Center for Public Health Practice Biological Agents of 3rd Highest Concern Category C Agents Emerging pathogens that could be engineered for mass dissemination in the future Emerging pathogens that could be engineered for mass dissemination in the future Nipah virus Nipah virus Hantaviruses Hantaviruses Tick-borne hemorrhagic fever viruses Tick-borne hemorrhagic fever viruses Tickborne encephalitis viruses Tickborne encephalitis viruses Yellow fever Yellow fever Multidrug-resistant tuberculosis Multidrug-resistant tuberculosis Emerging pathogens that could be engineered for mass dissemination in the future Emerging pathogens that could be engineered for mass dissemination in the future Nipah virus Nipah virus Hantaviruses Hantaviruses Tick-borne hemorrhagic fever viruses Tick-borne hemorrhagic fever viruses Tickborne encephalitis viruses Tickborne encephalitis viruses Yellow fever Yellow fever Multidrug-resistant tuberculosis Multidrug-resistant tuberculosis

10. UW Northwest Center for Public Health Practice Smallpox Overview Two strains: variola major and variola minor Two strains: variola major and variola minor Variola minor – milder disease with case fatality typically 1% or less Variola minor – milder disease with case fatality typically 1% or less Variola major – more severe disease with average 30% mortality in unvaccinated Variola major – more severe disease with average 30% mortality in unvaccinated Person-to-person transmission Person-to-person transmission Two strains: variola major and variola minor Two strains: variola major and variola minor Variola minor – milder disease with case fatality typically 1% or less Variola minor – milder disease with case fatality typically 1% or less Variola major – more severe disease with average 30% mortality in unvaccinated Variola major – more severe disease with average 30% mortality in unvaccinated Person-to-person transmission Person-to-person transmission

11. Overview Smallpox Overview Killed approximately 300,000,000 persons in 20th century Routine smallpox vaccination in the U.S. stopped in 1972 WHO declared smallpox eradicated in 1980 Vaccine has significant adverse effects No effective treatment Killed approximately 300,000,000 persons in 20th century Routine smallpox vaccination in the U.S. stopped in 1972 WHO declared smallpox eradicated in 1980 Vaccine has significant adverse effects No effective treatment

12. Overview Smallpox Overview Person-to-person transmission Average 30% mortality from variola major in unvaccinated A single case is considered a global public health emergency Person-to-person transmission Average 30% mortality from variola major in unvaccinated A single case is considered a global public health emergency

13. Smallpox Pathogenesis Virus implants on oropharynx or respiratory mucosa and is transported to regional lymph nodes Virus implants on oropharynx or respiratory mucosa and is transported to regional lymph nodes Day 3-4: asymptomatic viremia followed by viral multiplication in spleen, bone marrow, lymph nodes, lung Day 3-4: asymptomatic viremia followed by viral multiplication in spleen, bone marrow, lymph nodes, lung Day 8: secondary viremia leads to fever and toxemia on day 12-14 Day 8: secondary viremia leads to fever and toxemia on day 12-14 Virus implants on oropharynx or respiratory mucosa and is transported to regional lymph nodes Virus implants on oropharynx or respiratory mucosa and is transported to regional lymph nodes Day 3-4: asymptomatic viremia followed by viral multiplication in spleen, bone marrow, lymph nodes, lung Day 3-4: asymptomatic viremia followed by viral multiplication in spleen, bone marrow, lymph nodes, lung Day 8: secondary viremia leads to fever and toxemia on day 12-14 Day 8: secondary viremia leads to fever and toxemia on day 12-14

14. Smallpox Pathogenesis Virus localizes in small blood vessels of respiratory and pharyngeal mucosa, then dermis = characteristic rash and case communicability Virus localizes in small blood vessels of respiratory and pharyngeal mucosa, then dermis = characteristic rash and case communicability Toxemia: circulating immune complexes and variola antigens Toxemia: circulating immune complexes and variola antigens Virus localizes in small blood vessels of respiratory and pharyngeal mucosa, then dermis = characteristic rash and case communicability Virus localizes in small blood vessels of respiratory and pharyngeal mucosa, then dermis = characteristic rash and case communicability Toxemia: circulating immune complexes and variola antigens Toxemia: circulating immune complexes and variola antigens

15. Smallpox Transmission Infectious dose extremely low Infectious dose extremely low Spread primarily by droplet nuclei >aerosols > direct contact Spread primarily by droplet nuclei >aerosols > direct contact Maintains infectivity for prolonged periods out of host Maintains infectivity for prolonged periods out of host Contaminated clothing and bedding can be infectious Contaminated clothing and bedding can be infectious Infectious dose extremely low Infectious dose extremely low Spread primarily by droplet nuclei >aerosols > direct contact Spread primarily by droplet nuclei >aerosols > direct contact Maintains infectivity for prolonged periods out of host Maintains infectivity for prolonged periods out of host Contaminated clothing and bedding can be infectious Contaminated clothing and bedding can be infectious

16. Smallpox Transmission Transmission does not usually occur until after febrile prodrome Transmission does not usually occur until after febrile prodrome Coincident with onset of rash Coincident with onset of rash Slower spread through the population than chickenpox or measles Slower spread through the population than chickenpox or measles Large outbreaks in schools were uncommon Large outbreaks in schools were uncommon Less transmissible than measles, chickenpox, influenza Less transmissible than measles, chickenpox, influenza Transmission does not usually occur until after febrile prodrome Transmission does not usually occur until after febrile prodrome Coincident with onset of rash Coincident with onset of rash Slower spread through the population than chickenpox or measles Slower spread through the population than chickenpox or measles Large outbreaks in schools were uncommon Large outbreaks in schools were uncommon Less transmissible than measles, chickenpox, influenza Less transmissible than measles, chickenpox, influenza

17. Smallpox Transmission Secondary cases primarily household, hospital, and other close contacts Secondary cases primarily household, hospital, and other close contacts Secondary attack rate 37-87% among unvaccinated contacts Secondary attack rate 37-87% among unvaccinated contacts Patients with severe disease or cough at highest risk for transmission Patients with severe disease or cough at highest risk for transmission Greatest infectivity from rash onset to day 7-10 of rash Greatest infectivity from rash onset to day 7-10 of rash Infectivity decreases with scab formation and ceases with separation of scabs Infectivity decreases with scab formation and ceases with separation of scabs Secondary cases primarily household, hospital, and other close contacts Secondary cases primarily household, hospital, and other close contacts Secondary attack rate 37-87% among unvaccinated contacts Secondary attack rate 37-87% among unvaccinated contacts Patients with severe disease or cough at highest risk for transmission Patients with severe disease or cough at highest risk for transmission Greatest infectivity from rash onset to day 7-10 of rash Greatest infectivity from rash onset to day 7-10 of rash Infectivity decreases with scab formation and ceases with separation of scabs Infectivity decreases with scab formation and ceases with separation of scabs

18. Smallpox Clinical Features Prodrome ( incubation 7-19 days ) Prodrome ( incubation 7-19 days ) Acute onset of fever, malaise, headache, backache, vomiting, occasional delirium Acute onset of fever, malaise, headache, backache, vomiting, occasional delirium Transient erythematous rash Transient erythematous rash Exanthem (2-3 days later) Exanthem (2-3 days later) Preceded by enanthem on oropharyngeal mucosa Preceded by enanthem on oropharyngeal mucosa Begins on face, hands, forearms Begins on face, hands, forearms Spread to lower extremities then trunk over ~ 7 days Spread to lower extremities then trunk over ~ 7 days Prodrome ( incubation 7-19 days ) Prodrome ( incubation 7-19 days ) Acute onset of fever, malaise, headache, backache, vomiting, occasional delirium Acute onset of fever, malaise, headache, backache, vomiting, occasional delirium Transient erythematous rash Transient erythematous rash Exanthem (2-3 days later) Exanthem (2-3 days later) Preceded by enanthem on oropharyngeal mucosa Preceded by enanthem on oropharyngeal mucosa Begins on face, hands, forearms Begins on face, hands, forearms Spread to lower extremities then trunk over ~ 7 days Spread to lower extremities then trunk over ~ 7 days CDC Synchronous progression: macules  vesicles  pustules  scabs Synchronous progression: macules  vesicles  pustules  scabs Lesions most abundant Lesions most abundant on face and extremities, on face and extremities, including palms/soles including palms/soles

19. UW Northwest Center for Public Health Practice Smallpox Clinical Course WHO

20. Smallpox Clinical Presentation CDC

21. Smallpox Clinical Presentation WHO This link will take you away from the educational site

22. Smallpox Clinical Presentation WHO

23. Smallpox Clinical Progression WHO

24. UW Northwest Center for Public Health Practice Smallpox Clinical Progression Thomas, D. Day 14Day 10Day 21

25. UW Northwest Center for Public Health Practice Smallpox Clinical Progression

26. Smallpox Clinical Types Ordinary smallpox: 90% of cases Ordinary smallpox: 90% of cases Case-fatality average 30% Case-fatality average 30% Occurs in non-immunized persons Occurs in non-immunized persons Modified smallpox Modified smallpox Milder, rarely fatal Milder, rarely fatal Occurs in 25% of previously immunized persons and 2% of non-immunized persons Occurs in 25% of previously immunized persons and 2% of non-immunized persons Fewer, smaller,more superficial lesions that evolve more rapidly Fewer, smaller,more superficial lesions that evolve more rapidly Ordinary smallpox: 90% of cases Ordinary smallpox: 90% of cases Case-fatality average 30% Case-fatality average 30% Occurs in non-immunized persons Occurs in non-immunized persons Modified smallpox Modified smallpox Milder, rarely fatal Milder, rarely fatal Occurs in 25% of previously immunized persons and 2% of non-immunized persons Occurs in 25% of previously immunized persons and 2% of non-immunized persons Fewer, smaller,more superficial lesions that evolve more rapidly Fewer, smaller,more superficial lesions that evolve more rapidly

27. Smallpox Clinical Types Hemorrhagic smallpox: <3% of cases Hemorrhagic smallpox: <3% of cases Immunocompromised persons and pregnant women at risk Immunocompromised persons and pregnant women at risk Shortened incubation period, severe prodrome Shortened incubation period, severe prodrome Extensive viral multiplication, coagulopathy Extensive viral multiplication, coagulopathy Dusky erythema followed by petechiae and hemorrhages into skin and mucous membranes Dusky erythema followed by petechiae and hemorrhages into skin and mucous membranes Almost uniformly fatal within 7 days Almost uniformly fatal within 7 days Hemorrhagic smallpox: <3% of cases Hemorrhagic smallpox: <3% of cases Immunocompromised persons and pregnant women at risk Immunocompromised persons and pregnant women at risk Shortened incubation period, severe prodrome Shortened incubation period, severe prodrome Extensive viral multiplication, coagulopathy Extensive viral multiplication, coagulopathy Dusky erythema followed by petechiae and hemorrhages into skin and mucous membranes Dusky erythema followed by petechiae and hemorrhages into skin and mucous membranes Almost uniformly fatal within 7 days Almost uniformly fatal within 7 days

28. Smallpox Clinical Types Malignant, or flat-type smallpox: 7% of cases Malignant, or flat-type smallpox: 7% of cases Slowly evolving lesions that coalesce without forming pustules Slowly evolving lesions that coalesce without forming pustules Associated with cell-mediated immune deficiency Associated with cell-mediated immune deficiency Usually fatal Usually fatal Variola sine eruptione Variola sine eruptione Occurs in previously vaccinated persons or infants with maternal antibodies Occurs in previously vaccinated persons or infants with maternal antibodies Asymptomatic or mild illness Asymptomatic or mild illness Transmission from these cases has not been documented Transmission from these cases has not been documented Malignant, or flat-type smallpox: 7% of cases Malignant, or flat-type smallpox: 7% of cases Slowly evolving lesions that coalesce without forming pustules Slowly evolving lesions that coalesce without forming pustules Associated with cell-mediated immune deficiency Associated with cell-mediated immune deficiency Usually fatal Usually fatal Variola sine eruptione Variola sine eruptione Occurs in previously vaccinated persons or infants with maternal antibodies Occurs in previously vaccinated persons or infants with maternal antibodies Asymptomatic or mild illness Asymptomatic or mild illness Transmission from these cases has not been documented Transmission from these cases has not been documented

29. UW Northwest Center for Public Health Practice Malignant Smallpox Thomas, D.

30. Smallpox Complications Encephalitis Encephalitis 1 in 500 cases Variola major 1 in 500 cases Variola major 1 in 2,000 cases Variola minor 1 in 2,000 cases Variola minor Keratitis, corneal ulceration Keratitis, corneal ulceration Blindness in 1% of cases Blindness in 1% of cases Infection in pregnancy Infection in pregnancy High perinatal fatality rate High perinatal fatality rate Congenital infection Congenital infection Encephalitis Encephalitis 1 in 500 cases Variola major 1 in 500 cases Variola major 1 in 2,000 cases Variola minor 1 in 2,000 cases Variola minor Keratitis, corneal ulceration Keratitis, corneal ulceration Blindness in 1% of cases Blindness in 1% of cases Infection in pregnancy Infection in pregnancy High perinatal fatality rate High perinatal fatality rate Congenital infection Congenital infection

31. UW Northwest Center for Public Health Practice CDC Major Smallpox Criteria Febrile prodrome Febrile prodrome Occurring 1-4 days before rash onset: fever >102°F and at least one of the following: prostration, headache, backache, chills, vomiting or severe abdominal pain Occurring 1-4 days before rash onset: fever >102°F and at least one of the following: prostration, headache, backache, chills, vomiting or severe abdominal pain Classic smallpox lesions Classic smallpox lesions Deep, firm/hard, round, well-circumscribed; may be umbilicated or confluent Deep, firm/hard, round, well-circumscribed; may be umbilicated or confluent Lesions in same stage of development on any one part of the body (e.g., face or arm) Lesions in same stage of development on any one part of the body (e.g., face or arm) Febrile prodrome Febrile prodrome Occurring 1-4 days before rash onset: fever >102°F and at least one of the following: prostration, headache, backache, chills, vomiting or severe abdominal pain Occurring 1-4 days before rash onset: fever >102°F and at least one of the following: prostration, headache, backache, chills, vomiting or severe abdominal pain Classic smallpox lesions Classic smallpox lesions Deep, firm/hard, round, well-circumscribed; may be umbilicated or confluent Deep, firm/hard, round, well-circumscribed; may be umbilicated or confluent Lesions in same stage of development on any one part of the body (e.g., face or arm) Lesions in same stage of development on any one part of the body (e.g., face or arm) More on CDC's response plan... This link will take you away from the educational site

32. UW Northwest Center for Public Health Practice CDC Minor Smallpox Criteria Centrifugal distribution: greatest concentration of lesions on face and distal extremities Centrifugal distribution: greatest concentration of lesions on face and distal extremities First lesions on oral mucosa or palate, face, forearms First lesions on oral mucosa or palate, face, forearms Patient appears toxic or moribund Patient appears toxic or moribund Slow evolution: lesions evolve from macules to papules to pustules over days Slow evolution: lesions evolve from macules to papules to pustules over days Lesions on palms and soles (majority of cases) Lesions on palms and soles (majority of cases) Centrifugal distribution: greatest concentration of lesions on face and distal extremities Centrifugal distribution: greatest concentration of lesions on face and distal extremities First lesions on oral mucosa or palate, face, forearms First lesions on oral mucosa or palate, face, forearms Patient appears toxic or moribund Patient appears toxic or moribund Slow evolution: lesions evolve from macules to papules to pustules over days Slow evolution: lesions evolve from macules to papules to pustules over days Lesions on palms and soles (majority of cases) Lesions on palms and soles (majority of cases)

33. UW Northwest Center for Public Health Practice CDC Criteria for Determining Risk of Smallpox High risk: report immediately High risk: report immediately All three major criteria Moderate risk: urgent evaluation Moderate risk: urgent evaluation Febrile prodrome and 1 major or  4 minor criteria Low risk: manage as clinically indicated Low risk: manage as clinically indicated No viral prodrome or Febrile prodrome and <4 minor criteria (no major criteria) High risk: report immediately High risk: report immediately All three major criteria Moderate risk: urgent evaluation Moderate risk: urgent evaluation Febrile prodrome and 1 major or  4 minor criteria Low risk: manage as clinically indicated Low risk: manage as clinically indicated No viral prodrome or Febrile prodrome and <4 minor criteria (no major criteria)

34. UW Northwest Center for Public Health Practice CDC Recommended Evaluation of Patients at High Risk of Smallpox Contact and airborne precautions Contact and airborne precautions Notify infection control Notify infection control Infectious disease and/or dermatology consult Infectious disease and/or dermatology consult Notify local/state health dept immediately Notify local/state health dept immediately Response team advises on management and specimen collection Specimen testing at CDC Specimen testing at CDC Contact and airborne precautions Contact and airborne precautions Notify infection control Notify infection control Infectious disease and/or dermatology consult Infectious disease and/or dermatology consult Notify local/state health dept immediately Notify local/state health dept immediately Response team advises on management and specimen collection Specimen testing at CDC Specimen testing at CDC

35. UW Northwest Center for Public Health Practice CDC Recommended Evaluation of Patients at Moderate Risk of Smallpox Contact and airborne precautions Contact and airborne precautions Notify infection control Notify infection control Infectious disease and/or Dermatology consult Infectious disease and/or Dermatology consult VZV and/or other lab tests as indicated VZV and/or other lab tests as indicated If cannot rule out smallpox, contact local/state health dept. immediately If cannot rule out smallpox, contact local/state health dept. immediately Contact and airborne precautions Contact and airborne precautions Notify infection control Notify infection control Infectious disease and/or Dermatology consult Infectious disease and/or Dermatology consult VZV and/or other lab tests as indicated VZV and/or other lab tests as indicated If cannot rule out smallpox, contact local/state health dept. immediately If cannot rule out smallpox, contact local/state health dept. immediately

36. UW Northwest Center for Public Health Practice CDC Recommended Evaluation of Patients at Low Risk of Smallpox Contact and airborne precautions Contact and airborne precautions Notify infection control Notify infection control Evaluate clinically for VZV Evaluate clinically for VZV Test for VZV and other conditions, as indicated Test for VZV and other conditions, as indicated Contact and airborne precautions Contact and airborne precautions Notify infection control Notify infection control Evaluate clinically for VZV Evaluate clinically for VZV Test for VZV and other conditions, as indicated Test for VZV and other conditions, as indicated

37. UW Northwest Center for Public Health Practice Differential Diagnosis of Smallpox Variola vs. Varicella Source: CDC

38. UW Northwest Center for Public Health Practice Differential Diagnosis of Smallpox Variola vs. Varicella Source: CDC

39. Variola vs. Varicella Lesion Distribution WHO Chickenpox Smallpox This link will take you away from the educational site

40. Variola vs. Varicella Lesion Distribution WHO Chickenpox Smallpox

41. UW Northwest Center for Public Health Practice Differential Diagnosis of Smallpox Varicella Varicella Disseminated herpes zoster Disseminated herpes zoster Drug eruptions and contact dermatitis Drug eruptions and contact dermatitis Disseminated herpes simplex Disseminated herpes simplex Varicella Varicella Disseminated herpes zoster Disseminated herpes zoster Drug eruptions and contact dermatitis Drug eruptions and contact dermatitis Disseminated herpes simplex Disseminated herpes simplex Impetigo Impetigo Erythema multiforme Erythema multiforme Scabies, insect bites Scabies, insect bites Bullous pemphigoid Bullous pemphigoid Secondary syphillis Secondary syphillis Molluscum contagiosum Molluscum contagiosum Enterovirus exanthem Enterovirus exanthem

42. Smallpox Diagnosis Clinical diagnosis = public health emergency Clinical diagnosis = public health emergency Laboratory confirmation: vesicular or pustular fluid on swab or biopsy Laboratory confirmation: vesicular or pustular fluid on swab or biopsy Seal in vacutainer and overpack - transport to state public health laboratory Seal in vacutainer and overpack - transport to state public health laboratory Culture (BSL-4 Lab) followed by PCR and RFLP Culture (BSL-4 Lab) followed by PCR and RFLP Clinical diagnosis = public health emergency Clinical diagnosis = public health emergency Laboratory confirmation: vesicular or pustular fluid on swab or biopsy Laboratory confirmation: vesicular or pustular fluid on swab or biopsy Seal in vacutainer and overpack - transport to state public health laboratory Seal in vacutainer and overpack - transport to state public health laboratory Culture (BSL-4 Lab) followed by PCR and RFLP Culture (BSL-4 Lab) followed by PCR and RFLP

43. Smallpox Diagnosis EM: characteristic “brick shaped” morphology distinct from HSV and VZV EM: characteristic “brick shaped” morphology distinct from HSV and VZV Light microscopy: Giemsa stain  aggregations of viral particles (Guarnieri bodies) Light microscopy: Giemsa stain  aggregations of viral particles (Guarnieri bodies) Gel diffusion test: vesicular fluid + hyperimmune globulin Gel diffusion test: vesicular fluid + hyperimmune globulin EM: characteristic “brick shaped” morphology distinct from HSV and VZV EM: characteristic “brick shaped” morphology distinct from HSV and VZV Light microscopy: Giemsa stain  aggregations of viral particles (Guarnieri bodies) Light microscopy: Giemsa stain  aggregations of viral particles (Guarnieri bodies) Gel diffusion test: vesicular fluid + hyperimmune globulin Gel diffusion test: vesicular fluid + hyperimmune globulin

44. UW Northwest Center for Public Health Practice Smallpox Specimen Collection Specimen collection by trained teams Specimen collection by trained teams Only recently, successfully vaccinated personnel (within 3yrs) wearing appropriate barrier protection should be involved in specimen collection Only recently, successfully vaccinated personnel (within 3yrs) wearing appropriate barrier protection should be involved in specimen collection Respiratory and contact precautions Respiratory and contact precautions Testing done by CDC; contact local HD before collecting clinical specimens Testing done by CDC; contact local HD before collecting clinical specimens Specimen collection by trained teams Specimen collection by trained teams Only recently, successfully vaccinated personnel (within 3yrs) wearing appropriate barrier protection should be involved in specimen collection Only recently, successfully vaccinated personnel (within 3yrs) wearing appropriate barrier protection should be involved in specimen collection Respiratory and contact precautions Respiratory and contact precautions Testing done by CDC; contact local HD before collecting clinical specimens Testing done by CDC; contact local HD before collecting clinical specimens More on CDC's response plan... This link will take you away from the educational site

45. UW Northwest Center for Public Health Practice Smallpox Specimen Collection If necessary, unvaccinated personnel without contraindications to vaccination may collect specimens If necessary, unvaccinated personnel without contraindications to vaccination may collect specimens If smallpox confirmed, will need immediate vaccination If smallpox confirmed, will need immediate vaccination If necessary, unvaccinated personnel without contraindications to vaccination may collect specimens If necessary, unvaccinated personnel without contraindications to vaccination may collect specimens If smallpox confirmed, will need immediate vaccination If smallpox confirmed, will need immediate vaccination

46. Smallpox Medical Management Respiratory and contact isolation for hospitalized cases Respiratory and contact isolation for hospitalized cases Negative pressure room; HEPA-filtered exhaust Negative pressure room; HEPA-filtered exhaust All health care workers employ aerosol and contact precautions regardless of immunization status All health care workers employ aerosol and contact precautions regardless of immunization status No specific therapy available No specific therapy available Supportive care: fluid and electrolyte, skin, nutritional Supportive care: fluid and electrolyte, skin, nutritional Respiratory and contact isolation for hospitalized cases Respiratory and contact isolation for hospitalized cases Negative pressure room; HEPA-filtered exhaust Negative pressure room; HEPA-filtered exhaust All health care workers employ aerosol and contact precautions regardless of immunization status All health care workers employ aerosol and contact precautions regardless of immunization status No specific therapy available No specific therapy available Supportive care: fluid and electrolyte, skin, nutritional Supportive care: fluid and electrolyte, skin, nutritional

47. Smallpox Medical Management Antibiotics for secondary infection Antibiotics for secondary infection Antiviral drugs under evaluation Antiviral drugs under evaluation Notify Public Health and hospital epidemiology immediately for suspected case Notify Public Health and hospital epidemiology immediately for suspected case Antibiotics for secondary infection Antibiotics for secondary infection Antiviral drugs under evaluation Antiviral drugs under evaluation Notify Public Health and hospital epidemiology immediately for suspected case Notify Public Health and hospital epidemiology immediately for suspected case

48. Smallpox Outbreak Management Case identification, isolation, and immunization Case identification, isolation, and immunization Rapid identification of contacts Rapid identification of contacts Immediate vaccination or boosting of ALL potential contacts including health care workers Immediate vaccination or boosting of ALL potential contacts including health care workers Vaccination within 4 days of exposure may prevent or lessen disease Vaccination within 4 days of exposure may prevent or lessen disease Isolation with monitoring for fever or rash Isolation with monitoring for fever or rash 18 days from last contact with case 18 days from last contact with case Respiratory isolation if possible for febrile contacts Respiratory isolation if possible for febrile contacts Passive immunization (VIG) Passive immunization (VIG) Potential use for contacts at high risk for vaccine complications Potential use for contacts at high risk for vaccine complications Case identification, isolation, and immunization Case identification, isolation, and immunization Rapid identification of contacts Rapid identification of contacts Immediate vaccination or boosting of ALL potential contacts including health care workers Immediate vaccination or boosting of ALL potential contacts including health care workers Vaccination within 4 days of exposure may prevent or lessen disease Vaccination within 4 days of exposure may prevent or lessen disease Isolation with monitoring for fever or rash Isolation with monitoring for fever or rash 18 days from last contact with case 18 days from last contact with case Respiratory isolation if possible for febrile contacts Respiratory isolation if possible for febrile contacts Passive immunization (VIG) Passive immunization (VIG) Potential use for contacts at high risk for vaccine complications Potential use for contacts at high risk for vaccine complications

49. Smallpox Outbreak Management Strategy for outbreak containment: Ring vaccination Strategy for outbreak containment: Ring vaccination Isolation of confirmed & suspected smallpox cases Isolation of confirmed & suspected smallpox cases Tracing, vaccination & close surveillance of contacts Tracing, vaccination & close surveillance of contacts Vaccination of contacts of contacts Vaccination of contacts of contacts Strategy for outbreak containment: Ring vaccination Strategy for outbreak containment: Ring vaccination Isolation of confirmed & suspected smallpox cases Isolation of confirmed & suspected smallpox cases Tracing, vaccination & close surveillance of contacts Tracing, vaccination & close surveillance of contacts Vaccination of contacts of contacts Vaccination of contacts of contacts

50. UW Northwest Center for Public Health Practice Isolation CDC Smallpox Response Plan Facility Categories Facility Categories Type C – Contagious Type C – Contagious Confirmed and probable cases Confirmed and probable cases Type X – Uncertain diagnosis Type X – Uncertain diagnosis Vaccinated febrile contacts without rash Vaccinated febrile contacts without rash Type R – Asymptomatic Type R – Asymptomatic Non-febrile contacts Non-febrile contacts Facility Categories Facility Categories Type C – Contagious Type C – Contagious Confirmed and probable cases Confirmed and probable cases Type X – Uncertain diagnosis Type X – Uncertain diagnosis Vaccinated febrile contacts without rash Vaccinated febrile contacts without rash Type R – Asymptomatic Type R – Asymptomatic Non-febrile contacts Non-febrile contacts

51. Smallpox Outbreak Management Priority Groups for Vaccination Persons exposed to an intentional release Persons exposed to an intentional release Direct (<6.5 feet) face-to-face contacts of case/suspect case Direct (<6.5 feet) face-to-face contacts of case/suspect case Persons involved in direct medical or public health management or transport of case/suspect case Persons involved in direct medical or public health management or transport of case/suspect case Persons exposed to an intentional release Persons exposed to an intentional release Direct (<6.5 feet) face-to-face contacts of case/suspect case Direct (<6.5 feet) face-to-face contacts of case/suspect case Persons involved in direct medical or public health management or transport of case/suspect case Persons involved in direct medical or public health management or transport of case/suspect case

52. Smallpox Outbreak Management Priority Groups for Vaccination Others at risk of contact with infectious materials Others at risk of contact with infectious materials Persons whose unhindered function is essential to support response activities Persons whose unhindered function is essential to support response activities Others at risk of contact with infectious materials Others at risk of contact with infectious materials Persons whose unhindered function is essential to support response activities Persons whose unhindered function is essential to support response activities

53. UW Northwest Center for Public Health Practice Smallpox Outbreak Management Pre-release Vaccination Select individuals vaccinated to enhance smallpox response capacity Select individuals vaccinated to enhance smallpox response capacity Smallpox Response Teams Smallpox Response Teams Designated public health, law enforcement, and medical personnel in each state/territory Designated public health, law enforcement, and medical personnel in each state/territory Investigate, evaluate, and diagnose initial suspect cases of smallpox Investigate, evaluate, and diagnose initial suspect cases of smallpox Select personnel at acute health care facilities (Smallpox Health Care Teams) Select personnel at acute health care facilities (Smallpox Health Care Teams) Select individuals vaccinated to enhance smallpox response capacity Select individuals vaccinated to enhance smallpox response capacity Smallpox Response Teams Smallpox Response Teams Designated public health, law enforcement, and medical personnel in each state/territory Designated public health, law enforcement, and medical personnel in each state/territory Investigate, evaluate, and diagnose initial suspect cases of smallpox Investigate, evaluate, and diagnose initial suspect cases of smallpox Select personnel at acute health care facilities (Smallpox Health Care Teams) Select personnel at acute health care facilities (Smallpox Health Care Teams) ACIP, June 2002

54. Smallpox Vaccine Made from live Vaccinia virus Made from live Vaccinia virus ~ 200 million doses in U.S. stores ~ 200 million doses in U.S. stores Intradermal inoculation with bifurcated needle (scarification) Intradermal inoculation with bifurcated needle (scarification) Pustular lesion or induration surrounding central lesion (scab or ulcer) 6-8 days post- vaccination Pustular lesion or induration surrounding central lesion (scab or ulcer) 6-8 days post- vaccination Low grade fever, axillary lymphadenopathy Low grade fever, axillary lymphadenopathy Scar (permanent) demonstrates successful vaccination (“take”) Scar (permanent) demonstrates successful vaccination (“take”) Immunity not life-long Immunity not life-long Made from live Vaccinia virus Made from live Vaccinia virus ~ 200 million doses in U.S. stores ~ 200 million doses in U.S. stores Intradermal inoculation with bifurcated needle (scarification) Intradermal inoculation with bifurcated needle (scarification) Pustular lesion or induration surrounding central lesion (scab or ulcer) 6-8 days post- vaccination Pustular lesion or induration surrounding central lesion (scab or ulcer) 6-8 days post- vaccination Low grade fever, axillary lymphadenopathy Low grade fever, axillary lymphadenopathy Scar (permanent) demonstrates successful vaccination (“take”) Scar (permanent) demonstrates successful vaccination (“take”) Immunity not life-long Immunity not life-long WHO

55. Smallpox Vaccine Administration WHO JAMA 1999;281:1735-45 Vaccine admin instructions This link will take you away from the educational site

56. Smallpox Vaccine “Take” WHO

57. Smallpox Complications Rates for Primary Vaccination Complication rates lower with revaccination Complication rates lower with revaccination Primary vaccination: ~1 death/million Primary vaccination: ~1 death/million Revaccination: ~0.2 deaths/million Revaccination: ~0.2 deaths/million Most common complication: Most common complication: Inadvertent auto- and secondary inoculation (skin, eye) Inadvertent auto- and secondary inoculation (skin, eye) 529/million (30% in one study were contacts) 529/million (30% in one study were contacts) Complication rates lower with revaccination Complication rates lower with revaccination Primary vaccination: ~1 death/million Primary vaccination: ~1 death/million Revaccination: ~0.2 deaths/million Revaccination: ~0.2 deaths/million Most common complication: Most common complication: Inadvertent auto- and secondary inoculation (skin, eye) Inadvertent auto- and secondary inoculation (skin, eye) 529/million (30% in one study were contacts) 529/million (30% in one study were contacts) Sources: MMWR June 22, 2001 / 50(RR10);1-25. Vaccinia (Smallpox) Vaccine Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001 Vaccines 3rd Ed. Plotkin SA, Orenstein WA. W.B. Saunders, Phila. 1999

58. Smallpox Complication Rates for Primary Vaccination Less common Less common Post-vaccination encephalopathy (7-42.3/million) * Post-vaccination encephalopathy (7-42.3/million) * Post-vaccination encephalitis (12.3/million) Post-vaccination encephalitis (12.3/million) 25% fatal; 23% neurological sequelae 25% fatal; 23% neurological sequelae Progressive vaccinia/vaccinia necrosum (1.5/million) Progressive vaccinia/vaccinia necrosum (1.5/million) Generalized vaccinia (241.5/million): severe in 10% Generalized vaccinia (241.5/million): severe in 10% Eczema vaccinatum (38.5/million) Eczema vaccinatum (38.5/million) Fetal vaccinia - rare Fetal vaccinia - rare Less common Less common Post-vaccination encephalopathy (7-42.3/million) * Post-vaccination encephalopathy (7-42.3/million) * Post-vaccination encephalitis (12.3/million) Post-vaccination encephalitis (12.3/million) 25% fatal; 23% neurological sequelae 25% fatal; 23% neurological sequelae Progressive vaccinia/vaccinia necrosum (1.5/million) Progressive vaccinia/vaccinia necrosum (1.5/million) Generalized vaccinia (241.5/million): severe in 10% Generalized vaccinia (241.5/million): severe in 10% Eczema vaccinatum (38.5/million) Eczema vaccinatum (38.5/million) Fetal vaccinia - rare Fetal vaccinia - rare Sourced: MMWR June 22, 2001 / 50(RR10);1-25. Vaccinia (Smallpox) Vaccine Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001 *Vaccines 3rd Ed. Plotkin SA, Orenstein WA. W.B. Saunders, Phila. 1999

59. Smallpox Vaccine Complications WHO

60. Smallpox Vaccine Complications WHO

61. Smallpox Vaccine Pre-exposure Contraindications Immunosuppression Immunosuppression Agammaglobulinemia Agammaglobulinemia Leukemia, lymphoma, generalized malignancy Leukemia, lymphoma, generalized malignancy Chemo- or other immunosuppressive therapy Chemo- or other immunosuppressive therapy HIV infection HIV infection History or evidence of eczema History or evidence of eczema Household, sexual, or other close contact with person with one of the above conditions Household, sexual, or other close contact with person with one of the above conditions Life-threatening allergy to polymixin B, streptomycin, tetracycline, or neomycin Life-threatening allergy to polymixin B, streptomycin, tetracycline, or neomycin Pregnancy Pregnancy Immunosuppression Immunosuppression Agammaglobulinemia Agammaglobulinemia Leukemia, lymphoma, generalized malignancy Leukemia, lymphoma, generalized malignancy Chemo- or other immunosuppressive therapy Chemo- or other immunosuppressive therapy HIV infection HIV infection History or evidence of eczema History or evidence of eczema Household, sexual, or other close contact with person with one of the above conditions Household, sexual, or other close contact with person with one of the above conditions Life-threatening allergy to polymixin B, streptomycin, tetracycline, or neomycin Life-threatening allergy to polymixin B, streptomycin, tetracycline, or neomycin Pregnancy Pregnancy

62. Smallpox Vaccinia Immune Globulin (VIG) Treatment of adverse reactions (AR) Treatment of adverse reactions (AR) Approximately 25 AR’s/100,000 vaccinations Approximately 25 AR’s/100,000 vaccinations AR rate may be increased in immunocompromised populations AR rate may be increased in immunocompromised populations Post-exposure prophylaxis (if available) Post-exposure prophylaxis (if available) Pregnant patients: VIG + vaccinia vaccine Pregnant patients: VIG + vaccinia vaccine Eczema: VIG + vaccinia vaccine Eczema: VIG + vaccinia vaccine Immunocompromised patients: no consensus on VIG alone vs. VIG + vaccinia vaccine Immunocompromised patients: no consensus on VIG alone vs. VIG + vaccinia vaccine Current supplies very limited, but new lots are being produced that conform to IV standards Current supplies very limited, but new lots are being produced that conform to IV standards Treatment of adverse reactions (AR) Treatment of adverse reactions (AR) Approximately 25 AR’s/100,000 vaccinations Approximately 25 AR’s/100,000 vaccinations AR rate may be increased in immunocompromised populations AR rate may be increased in immunocompromised populations Post-exposure prophylaxis (if available) Post-exposure prophylaxis (if available) Pregnant patients: VIG + vaccinia vaccine Pregnant patients: VIG + vaccinia vaccine Eczema: VIG + vaccinia vaccine Eczema: VIG + vaccinia vaccine Immunocompromised patients: no consensus on VIG alone vs. VIG + vaccinia vaccine Immunocompromised patients: no consensus on VIG alone vs. VIG + vaccinia vaccine Current supplies very limited, but new lots are being produced that conform to IV standards Current supplies very limited, but new lots are being produced that conform to IV standards

63. UW Northwest Center for Public Health Practice Smallpox Summary of Key Points The clinical diagnosis of smallpox is a public health emergency; the local or state health department and hospital infection control should be notified immediately for suspected cases, including cases that meet criteria of the CDC smallpox case definition. CDC criteria for determining the risk of smallpox can help differentiate smallpox from varicella and other rash illnesses. The clinical diagnosis of smallpox is a public health emergency; the local or state health department and hospital infection control should be notified immediately for suspected cases, including cases that meet criteria of the CDC smallpox case definition. CDC criteria for determining the risk of smallpox can help differentiate smallpox from varicella and other rash illnesses.

64. UW Northwest Center for Public Health Practice Smallpox Summary of Key Points Smallpox is transmitted person to person; standard contact and airborne precautions should be initiated in all suspected cases until smallpox is ruled out. Vaccine-induced immunity wanes with time; therefore most people today are considered susceptible to infection. Smallpox is transmitted person to person; standard contact and airborne precautions should be initiated in all suspected cases until smallpox is ruled out. Vaccine-induced immunity wanes with time; therefore most people today are considered susceptible to infection.

65. UW Northwest Center for Public Health Practice Smallpox Additional Images & Information Herron C. Smallpox — 26 Years Ago N Engl J Med 1996; 334:1304 Moses A. E. & Cohen-Poradosu R. Eczema vaccinatum — a timely reminder. N Engl J Med 2002; 346:1287. Herron C. Smallpox — 26 Years Ago N Engl J Med 1996; 334:1304 Moses A. E. & Cohen-Poradosu R. Eczema vaccinatum — a timely reminder. N Engl J Med 2002; 346:1287. World Health Organization This link will take you away from the educational site

66. UW Northwest Center for Public Health Practice Summary - Category A Critical Agents Modified from: USAMRIID’s Medical Management of Biological Casualties HandbookUSAMRIID’s Medical Management of Biological Casualties Handbook *infectious dose may be less in certain circumstances This link will take you away from the educational site

67. UW Northwest Center for Public Health Practice Summary Category A Critical Agents Decontamination of exposed persons Decontamination of exposed persons Showering or washing thoroughly with soap and water adequate for most; bleach not necessary Showering or washing thoroughly with soap and water adequate for most; bleach not necessary Infection control Infection control Standard precautions – all cases Standard precautions – all cases Airborne and contact precautions – smallpox and viral hemorrhagic fevers Airborne and contact precautions – smallpox and viral hemorrhagic fevers Droplet precautions – pneumonic plague Droplet precautions – pneumonic plague Decontamination of exposed persons Decontamination of exposed persons Showering or washing thoroughly with soap and water adequate for most; bleach not necessary Showering or washing thoroughly with soap and water adequate for most; bleach not necessary Infection control Infection control Standard precautions – all cases Standard precautions – all cases Airborne and contact precautions – smallpox and viral hemorrhagic fevers Airborne and contact precautions – smallpox and viral hemorrhagic fevers Droplet precautions – pneumonic plague Droplet precautions – pneumonic plague

68. UW Northwest Center for Public Health Practice ResourcesResources Centers for Disease Control and Prevention Centers for Disease Control and Prevention Bioterrorism Web page: Bioterrorism Web page: CDC Office of Health and Safety Information System (personal protective equipment) CDC Office of Health and Safety Information System (personal protective equipment) USAMRIID – includes link to online version of Medical Management of Biological Casualties Handbook USAMRIID – includes link to online version of Medical Management of Biological Casualties Handbook Johns Hopkins Center for Civilian Biodefense Studies fact sheets and links to other info, including JAMA series from Working Group on Civilian Biodefense and BT- related anthrax case studies Johns Hopkins Center for Civilian Biodefense Studies fact sheets and links to other info, including JAMA series from Working Group on Civilian Biodefense and BT- related anthrax case studies Centers for Disease Control and Prevention Centers for Disease Control and Prevention Bioterrorism Web page: Bioterrorism Web page: CDC Office of Health and Safety Information System (personal protective equipment) CDC Office of Health and Safety Information System (personal protective equipment) USAMRIID – includes link to online version of Medical Management of Biological Casualties Handbook USAMRIID – includes link to online version of Medical Management of Biological Casualties Handbook Johns Hopkins Center for Civilian Biodefense Studies fact sheets and links to other info, including JAMA series from Working Group on Civilian Biodefense and BT- related anthrax case studies Johns Hopkins Center for Civilian Biodefense Studies fact sheets and links to other info, including JAMA series from Working Group on Civilian Biodefense and BT- related anthrax case studies http://www.hopkins-biodefense.org http://www.usamriid.army.mil/ http://www.bt.cdc.gov/ http://www.cdc.gov/od/ohs/ These links will take you away from the educational site

69. UW Northwest Center for Public Health Practice ResourcesResources Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information St. Louis University Center for the Study of Bioterrorism and Emerging Infections – fact sheets and links St. Louis University Center for the Study of Bioterrorism and Emerging Infections – fact sheets and links Public Health - Seattle & King County Public Health - Seattle & King County Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information St. Louis University Center for the Study of Bioterrorism and Emerging Infections – fact sheets and links St. Louis University Center for the Study of Bioterrorism and Emerging Infections – fact sheets and links Public Health - Seattle & King County Public Health - Seattle & King County http://www.nbc-med.org http://www.metrokc.gov/health http://bioterrorism.slu.edu These links will take you away from the educational site

70. UW Northwest Center for Public Health Practice ResourcesResources American College of Physicians – links to BT resources, including decision support tools and palm documents American College of Physicians – links to BT resources, including decision support tools and palm documents Self-Assessment (case scenarios – chemical and biological) Self-Assessment (case scenarios – chemical and biological) MMWR Rec. and Rep. Case definitions under public health surveillance. MMWR Rec. and Rep. Case definitions under public health surveillance. American College of Physicians – links to BT resources, including decision support tools and palm documents American College of Physicians – links to BT resources, including decision support tools and palm documents Self-Assessment (case scenarios – chemical and biological) Self-Assessment (case scenarios – chemical and biological) MMWR Rec. and Rep. Case definitions under public health surveillance. MMWR Rec. and Rep. Case definitions under public health surveillance. http://www.acponline.org http://www.acponline.org/bioterro/self_assessment.htm 1997;46(RR-10):1-55 These links will take you away from the educational site

71. UW Northwest Center for Public Health Practice In Case of An Event… Web Sites with Up-to-Date Information and Instructions Centers for Disease Control and Prevention Centers for Disease Control and Prevention Saint Louis University, CSB & EI Saint Louis University, CSB & EI WA State Local Health Departments/Districts WA State Local Health Departments/Districts Level A Lab Protocols: Presumptive Agent ID Level A Lab Protocols: Presumptive Agent ID Centers for Disease Control and Prevention Centers for Disease Control and Prevention Saint Louis University, CSB & EI Saint Louis University, CSB & EI WA State Local Health Departments/Districts WA State Local Health Departments/Districts Level A Lab Protocols: Presumptive Agent ID Level A Lab Protocols: Presumptive Agent ID http://www.bt.cdc.gov/EmContact/index.asp http://bioterrorism.slu.edu/hotline.htm http://www.bt.cdc.gov/LabIssues/index.asp http://www.doh.wa.gov/LHJMap/LHJMap.htm These links will take you away from the educational site

72. UW Northwest Center for Public Health Practice In Case of An Event… Web Sites with Up-to-Date Information and Instructions FBI Terrorism Web Page FBI Terrorism Web Page WA State Emergency Mgt Division – Hazard Analysis Update WA State Emergency Mgt Division – Hazard Analysis Update Mail Security Mail Security Links to your state health department Links to your state health department NIOSH – Worker Safety and Use of PPE NIOSH – Worker Safety and Use of PPE FBI Terrorism Web Page FBI Terrorism Web Page WA State Emergency Mgt Division – Hazard Analysis Update WA State Emergency Mgt Division – Hazard Analysis Update Mail Security Mail Security Links to your state health department Links to your state health department NIOSH – Worker Safety and Use of PPE NIOSH – Worker Safety and Use of PPE http://www.fbi.gov/terrorism/terrorism.htm http://www.usps.com/news/2001/press/serviceupdates.htm http://www.cdc.gov/niosh/emres01.html http://www.wa.gov/wsem http://www.astho.org/state.html These links will take you away from the educational site