Arizona Department of Health Services Division of Public Health Services Office of Public Health Emergency Preparedness and Response 602-364-3289 Visit Our Website at http://www.azdhs.gov/phs/edc/edrp/index.htm Division of Public Health Services Office of the Assistant Director Public Health Preparedness Services th 150 N. 18 Avenue, Suite 150 JANET NAPOLITANO, GOVERNOR Phoenix, Arizona 85007 CATHERINE R. EDEN, DIRECTOR (602) 364-3289 (602) 364-3265 FAX Date: September 7, 2004 Dear Infection Control Personnel: Dear Health Care Professionals: Dear Public Health Professionals: Re: ZEBRA MANUAL: A REFERENCE HANDBOOK FOR BIOTERRORISM AGENTS Infection control personnel, healthcare providers and public health personnel need to know how to recognize symptoms of exposure to a bioterrorism agent. The Arizona Department of Health Services is distributing this updated version of the Zebra Manual to assist you in responding properly to a possible patient exposure to such an agent. The medical school adage, “when you hear hoof beats, think horses, not zebras” has a new twist in this age of threats of bioterrorism. We can learn how to recognize a zebra among the horses by increasing our awareness of the clinical syndromes associated with each potential bioterrorism agent. This enhanced Zebra Manual contains fact sheets, diagnostic guidelines, and infection control information for all Category “A” and “B” biological agents, as well as extensive smallpox information. If you have questions about specific diseases or about disease reporting, please contact your County Health Department or visit our web site: www.azdhs.gov/phs/edc/edrp/index.htm Sincerely, Sincerely, David M. Engelthaler, M.S. Karen Lewis, M.D. Office Chief Emergency Preparedness Medical Coordinator Office of Public Health Office of Public Health Emergency Preparedness and Response Emergency Preparedness and Response ZEBRA MANUAL Table of Contents About Zebra Manual i Section 1: Quick Reference Charts Bioterrorism Syndromes 1-1 American Medical Association’s Biological Weapons Quick Reference Guide 1-2 Characteristics of Bioterrorism Agents 1-7 Therapeutics, Prophylaxes and Vaccines for Agents of Bioterrorism 1-8 Medical Sample Collection for Agents of Bioterrorism 1-9 Section 2: Infection Control Information Infection Control Precautions for Bioterrorism Agents 2-1 Empiric Infection Control Precautions 2-3 Bioterrorism Infection Control Precautions 2-4 Section 3: Categories of Bioterrorism Agents Definition of Bioterrorism Categories 3-1 Public Health Assessment of Potential Biological Terrorism Agents 3-2 Section 4: Category A Agents Anthrax: Profile for Health Care Workers 4-1 Anthrax: Frequently Asked Questions 4-4 Botulism: Profile for Health Care Workers 4-6 Botulism: Frequently Asked Questions 4-8 Plague: Profile for Health Care Workers 4-10 Plague: Frequently Asked Questions 4-12 Smallpox: Profile for Health Care Workers 4-15 Smallpox: Frequently Asked Questions 4-18 Tularemia: Profile for Health Care Workers 4-20 Tularemia: Frequently Asked Questions 4-22 Viral Hemorrhagic Fevers: Profile for Health Care Workers 4-24 Viral Hemorrhagic Fevers: Frequently Asked Questions 4-27 Section 5: Category B Agents Brucellosis: Profile for Health Care Workers 5-1 Brucellosis: Frequently Asked Questions 5-3 Cholera: Profile for Health Care Workers 5-5 Cholera: Frequently Asked Questions 5-7 Cryptosporidiosis: Profile for Health Care Workers 5-9 Cryptosporidiosis: Frequently Asked Questions 5-11 Eastern Equine Encephalitis: Profile for Health Care Workers 5-13 Eastern Equine Encephalitis: Frequently Asked Questions 5-15 Epsilon Toxin of Clostridium perfringens: Profile for Health Care Workers 5-16 Epsilon Toxin of Clostridium perfringens: Frequently Asked Questions 5-18 Escherichia coli O157:H7: Profile for Health Care Workers 5-19 Escherichia coli O157:H7: Frequently Asked Questions 5-21 Glanders: Profile for Health Care Workers 5-23 Glanders: Frequently Asked Questions 5-25 Melioidosis: Profile for Health Care Workers 5-27 Melioidosis: Frequently Asked Questions 5-29 Psittacosis: Profile for Health Care Workers 5-31 Psittacosis: Frequently Asked Questions 5-32 Q Fever: Profile for Health Care Workers 5-34 Q Fever: Frequently Asked Questions 5-36 Ricin: Profile for Health Care Workers 5-38 Ricin: Frequently Asked Questions 5-40 Salmonellosis: Profile for Health Care Workers 5-42 Salmonellosis: Frequently Asked Questions 5-44 Shigellosis: Profile for Health Care Workers 5-47 Shigellosis: Frequently Asked Questions 5-49 Staphylococcal Enterotoxin B: Profile for Health Care Workers 5-51 Staphylococcal Enterotoxin B: Frequently Asked Questions 5-53 Trichothecene Mycotoxins: Profile for Health Care Workers 5-54 Trichothecene Mycotoxins: Frequently Asked Questions 5-56 Typhus Fever: Profile for Health Care Workers 5-58 Typhus Fever: Frequently Asked Questions 5-60 Venezuelan Equine Encephalitis: Profile for Health Care Workers 5-61 Venezuelan Equine Encephalitis: Frequently Asked Questions 5-63 Western Equine Encephalitis: Profile for Health Care Workers 5-65 Western Equine Encephalitis: Frequently Asked Questions 5-67 Section 6: CDC Smallpox Resources Disease Overview 6-1 Diagnosis and Evaluation Case Definition 6-3 Rash Testing Protocol 6-5 Evaluation Tools and Poster Chart 1. Acute, Generalized Vesicular or Pustular Rash Illness Protocol 6-6 Chart 2. Laboratory Testing for Acute, Generalized Vesicular or Pustular 6-7 Rash Illness in the United States Chart 3. Laboratory Testing for Suspected Smallpox Vaccine (Vaccinia) 6-8 Adverse Events or Monkeypox in the United States Chart 4. Laboratory Testing for Environmental Samples in the United States 6-9 Worksheet: Evaluating Patients for Smallpox 6-10 Evaluating Patients for Smallpox Poster 6-14 Vaccine Vaccine Components 6-15 Guidelines for Vaccine Packaging and Shipping 6-16 Vaccine Information Sheet (VIS) 6-41 Contraindications – Allergic Reactions 6-47 Vaccine Contraindications 6-48 Vaccination Site Care Fact Sheet 6-51 Evaluation of Takes and Non-Takes 6-52 Normal Primary Vaccination Reactions 6-54 More Examples of Major Reactions 6-55 Evaluation Tools for Adverse Reactions Dermatological Reactions – Localized to Vaccination Site 6-61 Dermatological Reactions – Nontoxic Appearance 6-62 Dermatological Reactions – Toxic Appearance 6-63 Opthalmologic Reactions – Inadvertent Inoculation 6-64 Opthalmologic Reactions – Eye Splash or Other Potential Exposure 6-66 Additional Resources for Adverse Reactions Medical Management of Vaccinia Adverse Reactions: VIG and Cidofovir 6-67 MMWR: Guidance for Clinicians, 2003 6-70 Guide F – Environmental Control of Smallpox Virus 6-113 CDC Smallpox Response Plan and Guidelines (Version 3.0) SSeeccttii oonn 11:: Quick Refere nce Charts Quick Refere nce Charts BIOTERRORISM SYNDROMES If an unusual illness is seen which leads you to suspect bioterrorism, IMMEDIATELY call your county health department to arrange for specialized lab testing, guidelines for treatment, and infection control guidance. You may also call the Arizona Department of Health Services at 602-364-3289 or the Centers for Disease Control and Prevention’s 24-hour bioterrorism response office at 770-488-7100 Syndrome Biological Threat Disease Differential Diagnosis Initial Laboratory and Other Immediate Public Health and Description Diagnostic Test Results Infection Control Actions Inhalational Anthrax Bacterial mediastinitis, Chest x-ray with widened mediastinum; Call Local Health Department. Alert Abrupt onset of fever, chest pain; coccidioidomycosis, influenza, gram-positive bacilli in sputum or blood; laboratory to possibility of anthrax. respiratory distress without radiographic Legionnaires’ disease, tularemia, definitive testing available through public Standard precautions. Contact precautions findings of pneumonia; no history of Q fever, psittacosis, histoplasmosis, health laboratory network for skin lesions. trauma or chronic disease; progression ruptured aneurysm, superior vena cava to shock and death within 24-36 hours. syndrome (SVC syndrome), SARS. Pneumonic Plague Severe bacterial or viral pneumonia, Gram-negative bacilli or coccobacilli in Standard and droplet precautions with a Severe community-acquired pneumonia inhalational anthrax, pulmonary infarct, sputum, blood, or lymph node; safety- regular surgical mask. Call hospital but with hemoptysis, cyanosis, pulmonary hemorrhage, hantavirus pin appearance with Wright or Giemsa infection control and Local Health gastrointestinal symptoms, shock. pulmonary syndrome, meningococcemia, stain; definitive testing available through Department. Family members/close rickettsiosis, influenza, mycoplasma public health laboratory network. contacts of patients may need pneumonia, SARS. chemoprophylaxis; get detailed address and phone number information. Alert laboratory of possibility of plague. Fever Ricin (aerosolized) Plague, tularemia, Q fever, Chest x-ray with pulmonary edema. Call Local Health Department. Acute onset of fever, chest pain, and Staphylococcal enterotoxin B, phosgene. Consult with Local Health Department Standard precautions. cough, progressing to respiratory regarding specimen collection and distress and hypoxemia; not improved diagnostic testing procedures. with antibiotics; death in 36-72 hours. Staphylococcal Enterotoxin B Influenza, adenovirus. Primarily clinical diagnosis. Consult with Call Local Health Department. Acute onset of fever, chills, headache, Local Health Department regarding Standard precautions. nonproductive cough, and myalgia specimen collection