Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis.

• Non-specific prodrome of flu-like symptoms follows inhalation of infectious spores
• Possible brief interim improvement
• Two to four days after initial symptoms, abrupt onset of respiratory failure and hemodynamic collapse, possibly accompanied by thoracic edema and a widened mediastinum on chest radiograph suggestive of mediastinal lymphadenopathy and hemorrhatic mediastinitis
• Gram-positive bacilli on blood culture, usually after the first two or three days of illness
• Treatable in early prodromal stage. Mortality remains extremely high despite antibiotic treatment if it is initiated after onset of respiratory symptoms

• Local skin involvement after direct contact with spores or bacilli
• Commonly seen on the head, forearms or hands
• Localized itching, followed by a popular lesion that turns vesicular, and within 2-6 days develops into a depressed black eschar
• Usually non-fatal if treated with antibiotics

• Abdominal pain, nausea, vomiting, and fever following ingestion of contaminated food, usually meat
• Bloody diarrhea, hematemesis
• Gram-positive bacilli on blood culture, usually after the first two or three days of illness. Usually fatal after progression to toxemia and sepsis

As a bioterrorism agent, it could be delivered as an aerosol. The modes of transmission for anthrax include:

• Inhalation of spores
• Cutaneous contact with spores or spore-contaminated materials
• Ingestion of contaminated food

One day to eight weeks (average 5 days), depending on exposure route and dose.

• 2-60 days following pulmonary exposure
• 1-7 days following cutaneous exposure
• 1-7 days following ingestion

Transmission from person to person is unlikely. Airborne transmission does not occur, but direct contact with skin lesions may results in cutaneous infection.

Pediatric use of fluoroquinolones and tetracyclines is associated with adverse effects that must be weighed against the risk of developing a lethal disease. If B. anthracis exposure is confirmed, the organism must be tested for penicillin susceptibility. If susceptible, exposed children may be treated with oral amoxicillin 40 mg per kg of body mass per day divided every 8 hours (not to exceed 500 mg, three times daily).

Prophylaxis should continue until B. Anthracis exposure has been excluded. If exposure is confirmed, prophylaxis should continue for 8 weeks.

Botulism is a rare but serious paralytic illness caused by a nerve toxin that is produced by the bacterium Clostridium botulinum.

Food borne botulism is accompanied by gastrointestinal symptoms. Inhalational botulism and food borne botulism are likely to share other symptoms including:

• Responsive patient with absence of fever
• Symmetric cranial neuropathies (drooping eyelids, weakened jaw clench, difficulty swallowing or speaking)
• Blurred vision and diplopia due to extra-ocular muscle palsies
• Symmetric descending weakness in proximal to distal pattern (paralysis of arms first, followed by respiratory muscles, then legs)
• Respiratory dysfunction from respiratory muscle paralysis or upper airway obstruction due to weakened glottis
• No sensory deficits

Botulinum toxin is generally transmitted by ingestion of toxin-contaminated food. Aerosolization of botulinum toxin may be a mechanism for bioterrorism exposure.

• Neurologic symptoms of food borne botulism begin 12-36 hours after ingestion
• Neurologic symptoms of inhalational botulism begin 24-72 hours after aerosol exposure

Botulism is not transmitted from person to person.

Intensive - Patients with suspected or confirmed botulism should be monitored carefully in an intensive care unit for neurologic and respiratory function.

Ventilator Care - Patients with botulism may develop respiratory failure and paralysis that may require use of a ventilator for several weeks.

Supportive Support - If diagnosed early, botulism can be treated with an antitoxin (available through the CDC). This can prevent patients from worsening, but recovery may still take many weeks. Early in the course of treatment, physicians may try to remove contaminated food still in the digestive system by inducing vomiting or by using enemas.

Plague is an infectious disease of animals and humans caused by a bacterium named Yersinia pestis.

• Fever, cough, chest pain
• Hemoptysis
• Muco-perulent or watery sputum with gram-negative rods on gram stain
• Radiographic evidence of bronchopneumonia

• Plague is normally transmitted from an infected rodent to man by infected fleas
• Bioterrorism-related outbreaks are likely to be transmitted through dispersion of an aerosol
• Person-to-person transmission of pneumonic plague is possible via large aerosol droplets

The incubation period for plague is normally 2 - 8 days if due to fleaborne transmission. The incubation period may be shorter for pulmonary exposure (1 - 3 days).

Patients with pneumonic plague may have coughs productive if infectious particle droplets. Droplet precautions, including the use of mask for patient care, should be implemented until the patient has completed 72 hours of antimicrobial therapy.

Pediatric use of tetracyclines and flouroquinolones is associated with adverse effects that must be weighed against the risk of developing a lethal disease.

Prophylaxis should continue for 7 days after last known or suspected Y.pestis exposure, or until exposure has been excluded.

Smallpox is an infectious disease caused by the Variola virus.

Acute clinical symptoms of smallpox resemble other acute viral illnesses, such as influenza. Skin lesions appear, quickly progressing from macules to papules to vesicles. Other clinical symptoms to aid in identification of smallpox include:

• 2 - 4 day, non-specific prodrome of fever, myalgias
• rash most prominent on face and extremities (including palms and soles) in contrast to the truncal distribution of varicella
• rash scabs over 1 - 2 weeks
• In contrast to the rash of varicella, which arises in "crops," variola rash has a synchronous onset

Smallpox is transmitted via both large and small respiratory droplets. Patient-to-patient transmission is likely from airborne and droplet exposure, and by contact with skin lesions or secretions. Patients are considered more infectious if coughing or if they have a hemorrhagic form of small pox.

The incubation period for smallpox is 7-17 days; the average is 12 days.

Unlike varicella, which is contagious before the rash is apparent, patients with smallpox become infectious at the onset of the rash and remain infectious until their scabs separate (approximately 3 weeks).

Smallpox infection was eradicated from the world in 1997 and vaccination is no longer routinely used. The US currently has an emergency supply of smallpox vaccine that is limited in quantity. Recommendations for prophylaxis are subject to change.

Treatment of smallpox is limited to supportive therapy and antibiotics as required for treating secondary bacterial infections. There are no proven antiviral agents effective in treating smallpox.

Cholera is an acute, diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholerae.

The range of severity of cholera varies from mild diarrhea to severe, dehydrating diarrhea. Patients with severe cholera infection develop severe diarrhea with rapid dehydration and excrete large volumes of rice-water stool, leading to hypovolemia and shock. The most severe syndrome, called cholera gravis, is a rapidly progressing, life-threatening condition that may be accompanied by:

• Nausea
• Vomiting
• Muscle cramps
• Shock

Cholera is spread by eating or drinking toxin-contaminated food or water. The disease is not likely to spread directly from one person to another.

Cholera occurs when the bacterium is ingested in sufficient quantity to pass through the gastric acid barrier and enter the small intestine and colonize there. The symptoms may appear from six hours to five days after exposure.

The disease is not likely to spread directly from one person to another.

Cholera can be treated by immediate replacement of the fluid and salts lost through diarrhea. Patients can be given large amounts of oral rehydration solution, a prepackaged mixture of sugar and salts to be mixed with water. Severe cases also require intravenous fluid replacement. Antibiotics shorten the course and diminish the severity of the illness.

Tularemia is an acute infectious disease caused by the aerobic, gram-negative bacillus Francisella tularensis.

Tularemia is classified into six clinical constellations:

• Ulceroglandular
• Glandular
• Oculoglandular
• Typhoidal
• Oropharangeal
• Pneumonic

Regardless of portal of entry, the mode of onset and general features remain the same. Symptoms include:

• Abrupt fever
• Chills
• Headache
• Cough
• Sore Throat
• Myalgia
• Vomiting

Tularemia can infect both animals and humans through the skin, mucous membranes, gastrointestinal tract and lungs. It is often spread naturally by ticks or mosquitoes. As a biological weapon, aerosol release would have the greatest adverse and public health consequences.

Nonspecific febrile illness begins within 3 to 5 days, with an incubation range of 1 to 14 days.
Illness may last 2-3 weeks.

Person-to-person transmission is rare.

Antibiotic treatment with Streptomycin is preferred, and Gentamicin is an widely available alternative.

Q Fever is an infection caused by the rickettsieal bacterium Coxiella burnetii.

Infection with C. burnetii can cause a wide spectrum of clinical conditions from no symptoms to acute illness. The most common symptoms of a severe infection include:

• Acute Onset Fever
• Chills
• Headache (severe)
• Myalgia
• Arthralgia
• Neck Pain and Stiffness
• Chest Pain
• Cough
• Nausea & Vomiting
• Jaundice

Q fever in humans is usually caused by inhalation of aerosolized particles. It also affects many species of animals. Ingestion of contaminated milk, followed by regurgitation and inspiration of the contaminated food, is a less common mode of transmission. Other modes of transmission to humans, including tick bites and human-to-human transmission, are rare.

The incubation period for Q fever varies depending on the number of organisms that initially infect the patient. Infection with greater numbers of organisms will result in shorter incubation periods. Most patients become ill within 2-3 weeks after exposure.

Person-to-person transmission is rare.

Tetracycline and its analogs are the treatment of choice for acute Q fever. Antibiotic treatment is most effective when initiated within the first 3 days of illness. A dose of 100 mg of Doxycycline taken orally twice daily for 15-21 days is a frequently prescribed therapy. Quinolone antibiotics have demonstrated good in vitro activity against C. burnetii and may be considered.

Venezuelan Equine Encephalitis (VEE) is caused by the virus Alphavirus togaviridae.

VEE can infect horses and humans, causing symptoms including:

• Abrupt Fever
• Chills
• Headache (severe)
• Myalgia
• Photophobia
• Nausea & Vomiting
• Sore Throat
• Conjunctivitis

Mosquitoes and air-borne particles naturally spread VEE from horses and burros to humans. As a biological weapon, aerosol release would have the greatest adverse and public health consequences.

The incubation period of VEE has been observed from laboratory and other outbreaks as less than 1 to 5 days, usually 2 to 3 days. Documented cases have had onset of symptoms 12 hours after exposure.

The onset of illness is abrupt and rapidly incapacitating. Symptoms diminish over several days with the lysis of fever. Person-to-person spread is seems possible but is not well documented.

There are currently no available antivirals to treat VEE. Treatment is usually symptomatic, with analgesics and bed rest. Anticonvulsant and other supportive therapy is also indicated. Pneumonia is the principal syndrome or secondary infection. Early antibacterial therapy should be considered in acutely ill patients.

The term viral hemorrhagic fever (VHF) refers to a group of illnesses that are caused by several distinct families of viruses. While some types of hemorrhagic fever viruses can cause relatively mild illnesses, many of these viruses cause severe, life-threatening disease.

Common symptoms of VHF's include:

• Fever
• Myalgia
• Headache
• Conjunctivitis
• Vomiting & Diarrhea
• Abdominal Pain
• Petechiae
• Bleeding from Gums, Vagina or GI Tract

Viruses causing hemorrhagic fever are initially transmitted to humans when the activities of infected reservoir hosts and humans overlap. The viruses carried in rodent reservoirs are transmitted when humans have contact with urine, fecal matter, saliva, or other body excretions from infected rodents. The viruses associated with arthropods are spread most often when an infected mosquito or tick bites a human, or when a human crushes a tick. However, infection may be spread to animals, like livestock. Humans then become infected when they care for or slaughter the animals. Some viruses that cause hemorrhagic fever can spread from one person to another, once an initial person has become infected. This type of secondary transmission of the virus can occur directly, through close contact with infected people or their body fluids. It can also occur indirectly, through contact with objects contaminated with infected body fluids.

(Varies according to specific virus)

(Varies according to specific virus)

Patients receive supportive therapy, but generally speaking, there is no other treatment or established cure for VHFs. Ribavirin, an anti-viral drug, has been effective in treating some individuals with Lassa fever or HFRS. Treatment with convalescent-phase plasma has been used with success in some patients with Argentine hemorrhagic fever.