December 2001 volume 17 number 12 Division of Public Health http://health.state.ga.us Kathleen E. Toomey, M.D., M.P.H. Director State Health Officer Epidemiology Branch http://health.state.ga.us/epi Paul A. Blake, M.D., M.P.H. Director State Epidemiologist Mel Ralston Public Health Advisor Georgia Epidemiology Report Editorial Board Carol A. Hoban, M.S., M.P.H. - Editor Kathryn E. Arnold, M.D. Paul A. Blake, M.D., M.P.H. Susan Lance-Parker, D.V.M., Ph.D. Kathleen E. Toomey, M.D., M.P.H. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer Georgia Department of Human Resources Division of Public Health Epidemiology Branch Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588 Fax: (404) 657-7517 Please send comments to: Gaepinfo@dhr.state.ga.us The Georgia Epidemiology Report is a publication of the Epidemiology Branch, Division of Public Health, Georgia Department of Human Resources RECOGNIZING BIOTERRORISM Bioterrorism refers to the use of infectious agents to intentionally cause disease or inflict terror in a population. Motivations may include advancing social or political goals, creating mass hysteria, challenging government and community response efforts, and creating mass casualties that may overwhelm medical systems. Any infectious agent (bacteria, viruses, parasites) or their byproducts (toxins such as ricin) may be used in a bioterrorist attack. However, experts have designated anthrax, smallpox, botulinum toxin, plague, tularemia, and viral hemorrhagic fever agents to be of highest concern in terms of the widespread disease and devastation that may occur if intentional release occurred in a population. Biological agents can be dispersed to large numbers of people with little to no risk of immediate detection, and in some cases infected individuals can further disseminate the contagious organisms before they develop symptoms. In October 2001, a multi-state outbreak of human anthrax resulting from intentional release of anthrax spores via the mail delivery system has highlighted the reality of the threat of bioterrorism in the United States. The fact that the release of biological agents may be difficult to detect until cases of illness appear makes prevention or early intervention a formidable task for the public health community. In the event of a bioterrorist incident, health care personnel will be among the first to encounter victims seeking care. In fact, the index case in the human anthrax outbreak mentioned above was detected by an astute clinician in Florida who had a raised index of suspicion for anthrax (despite its rarity in the United States) and notified the local health department before ordering confirmatory diagnostic tests. By increased vigilance for unusual diseases and improved clinical recognition of syndromes potentially caused by bioterrorism agents, the medical community actually serves as "first responders" to bioterrorism events. In addition, by providing immediate notification to local or state public health officials, the medical community serves as the integral bridge to rapid epidemiologic investigation. This investigation (in coordination with criminal investigation if bioterrorism is being considered) will establish the potential source and/or risk factors of the outbreak, followed by determination of the at-risk population so that appropriate preventive measures (for example, immunization or administration of antibiotic prophylaxis) can be implemented. Role of the Medical Community in Recognizing Bioterrorism Illnesses potentially resulting from bioterrorism may be non-specific, especially in the early stages of the clinical course of infection. For example, clinical syndromes such as influenza-like illness, encephalitis, meningitis, pneumonia, rash with fever, or gastrointestinal symptoms such as nausea, vomiting, and diarrhea may be apparent. Victims of a bioterrorist event at a local public gathering may present with symptoms en masse to local health care facilities after the incubation period of the agent that was intentionally released. However, persons exposed to a biological agent at an airport may be spread across several states and countries when symptoms appear and they seek medical care. Therefore, whether encountering clusters of illnesses or seemingly sporadic cases of disease, medical practitioners must be able to recognize the possibility of intentional infection and alert public health officials. Most likely, a bioterrorist event will disproportionately affect people within a certain geographic area. Hospitals, urgent care clinics, individual healthcare providers, and even local pharmacies would presumably see numerous patients with similar illnesses or clinical syndromes in a short period of time. Such a scenario should send up a "red flag" of suspicion, which would prompt health care personnel to notify the local, district, or state public health agency before confirmation of an etiologic agent. Another scenario that may provide an "early warning" of a bioterrorist event is the discovery of one or more patients presenting with clinical syndromes consistent with very rare diseases or diseases not usually found in a given geographic area (for example, smallpox or pneumonic plague). Clues to possible bioterrorist events are listed in Table 1. Table 1. Clues to Possible Bioterrorism Unusual levels or patterns of disease in a population Unusual seasonal occurrence of a disease Unusual course of a disease not consistent with natural course Unusual syndromes with unknown etiology Unusual antibiotic resistance patterns in common pathogens Illness caused by unusual or unrecognized pathogens Incidents (continued from page 1) By law, Georgia physicians, laboratories, or other health care providers are required to report patients with designated conditions or diagnoses to the local, district, or state health department by mail or phone. Timeliness of this system will be improved with the advent of a new electronic webbased system for timely reporting of suspected or confirmed notifiable diseases, referred to as the State Electronic Notifiable Disease Surveillance System (SENDSS). This system will alert public health officials of disease occurrences more quickly than previous notifiable disease reporting systems so that unusual illnesses or clusters can be investigated rapidly. SENDSS may also allow public health personnel to identify seemingly unrelated cases of unusual illness that are occurring in various parts of the state but may have a common etiology. The system is expected to be available sometime next year. However, it will never replace the speed and sensitivity of immediate telephone reporting by care-givers' of large numbers of ill persons or highly suspicious individual cases should still be reported to the local, district, or state health department immediately by phone. Clinical Presentation of Bioterrorism Agents Routes for dissemination of infectious agents intentionally in a population may include via aerosol, food, water, insect vectors, blood products, etc. Aerosolization of agents (resulting in inhalation of the infectious organisms) may be accomplished using building air handling systems, crop dusters, individual sprayers, or even powder in envelopes. Many illnesses resulting from aerosol exposure will begin with "flu-like" symptoms, but each critical bioterrorism agent has a unique clinical presentation that may allow it to be differentiated from influenza. See Table 2 for comparison of signs and symptoms of influenza with those of other illnesses. If any of the agents in the chart are suspected, treatment should not be delayed if the clinical presentation does not exactly match that in the chart. For example, if Table 2. Differentiation of Influenza and Bioterrorism Agents Spread by Aerosol Signs and Symptoms Influenza Fever Y Chills Y Headache Y Anorexia Lymphadenopathy Nausea/vomiting Diarrhea Abdominal Pain Malaise/fatigue Y Myalgias Y Arthralgia Y Back Pain Y Chest Tightness Chest Pain Substernal Discomfort Shortness of Breath Cyanosis Cough Y Hemoptysis Rash* Purpura Hematochezia/melena Hematuria Blurred Vision Ptosis Diplopia Dysphonia Dysphagia Weakness Paralysis, descending Paralysis, ascending Ataxia Coma Gram + rods Gram ovoid bipolar Gram coccobacillus Mediastinal widening on CXR Elevated LFTs Thrombocytopenia Inhalation Anthrax Y Pneumonic Plague Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Q Fever Y Y Y Tularemia Ricin intoxication Y N Y Smallpox Y Y Y Hemorrhagic Fevers Y Y Y Y Botulism Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y * Centrifugal rash distribution, with lesions progressing through stages of macules, papules, vesicles, pustules, and crusted scabs; all lesions in a given area in the same stage of development. Adapted from the Texas Department of Health -2 - treatment for suspected inhalational anthrax is delayed until a widened mediastinum is visible on chest x-ray, the disease may have progressed too far for therapy to be beneficial. Table 3 also lists common signs and symptoms of potential bioterrorism agents. Virtually any infectious agent could be used in bioterrorism. In the past, common bacteria such as Salmonella and Shigella have been used intentionally to cause disease. While clusters of salmonellosis may not raise a "red flag," this illustrates why health care professionals should be suspicious of any clusters of illness and involve public health professionals as soon as possible. Additionally, a bioterrorist attack could occur using genetically modified agents, so that the clinical presentation is unfamiliar. Again, reporting unusual or unexplained cases immediately is vital. In this way, rapid investigation can begin in coordination with other community response partners (law enforcement, emergency management, environmentalists, pharmacists, other health care providers) to mitigate the consequences of a bioterrorist event and to learn valuable lessons in protecting community health in the future. To report a suspicious illness or cluster of illnesses, call the Georgia Division of Public Health Epidemiology Branch during regular business hours at 404-657-2588. On weekends, evenings, and holidays call 770-578-4104. You may also contact your local District Health Office and their phone numbers can be found at, http:// health.state.ga.us/epi/disease/report.shtml#District. The Georgia Division of Public Health has a bioterrorism website, http://health.state.ga.us/programs/emerprep/bioterrorism.shtml. The site contains links to general information about bioterrorism agents and resources for health care personnel, health facilities, and laboratories. This site is frequently updated with recent information released by state and federal agencies regarding bioterrorism. This article was written by: Cherie Drenzek, D.V.M., M.S. and Katherine Bryant, M.P.H. Table 3. Clinical Features of Potential Agents of Bioterrorism AGENT Bacillus anthracis (anthrax) Yersinia pestis (plague) CLINICAL FEATURES Cutaneous: Begins as itchy bump resembling insect bite Develops into painless vesicle or ulcer Characteristic black eschar appears in center Inhalation: Initial symptoms are flu-like, including fever, cough, headache, vomiting, chills, weakness, abdominal pain, and chest pain Rapid progression to dyspnea, diaphoresis, and shock Widened mediastinum is often visible on chest x-ray Gastrointestinal: Primary signs and symptoms include abdominal pain, nausea, vomiting, and fever Rapid progression to bloody diarrhea, acute abdomen, and sepsis Primary Pneumonic Plague: Primary signs include fever, dyspnea, headache, weakness, chest pain, cough with watery or bloody sputum production and possibly nausea, vomiting, abdominal pain, and diarrhea Rapid progression to respiratory failure, sepsis, and shock CONTAGIOUS NO YES Variola virus (smallpox) Initial prodrome of flu-like symptoms leading to high fever, malaise, prostra- YES tion, headache, and backache Development of centrifugal rash progressing through stages of macules, pap- ules, vesicles, pustules, and scabs Botulinum toxin from Clostridium botulism (botulism) Blurred vision, double vision, drooping eyelids, slurred speech, difficulty swal- lowing, muscle weakness, nausea, and vomiting NO Descending skeletal muscle weakness or paralysis Ricin toxin from Ricinus communis When ricin is inhaled, symptoms are similar to pneumonia and include fever, NO (castor plant) tightness in chest, cough, dyspnea, nausea, and arthralgia, followed by severe lung inflammation, cyanosis, and pulmonary edema When ingested, ricin causes abdominal pain, vomiting, diarrhea, and dehydra- tion -3 - The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186 PRESORTED STANDARD U.S. POSTAGE PAID ATLANTA, GA PERMIT NO. 4528 December 2001 Volume 17 Number 12 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for September 2001 Selected Notifiable Diseases Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis Total Reported for Sept 2001 2001 37 2274 16 1 74 1385 5 81 38 0 0 3 0 1 0 219 57 3 12 24 22 0 42 Previous 3 Months Total Ending in Sept 1999 2000 2001 183 181 205 8179 7821 7989 36 79 51 20 23 9 474 382 277 5989 5528 4673 8 7 13 127 127 282 77 100 119 2 1 1 0 0 0 11 6 5 3 0 0 23 17 4 0 1 0 795 680 705 90 94 133 48 29 28 71 88 67 153 118 104 198 195 110 4 9 1 160 178 119 Previous 12 Months Total Ending in Sept 1999 2000 2001 769 634 633 30412 27742 30389 175 190 147 46 51 30 1336 1288 1006 21328 18789 17472 83 77 100 638 341 843 204 305 413 2 10 12 0 0 0 75 61 50 5 2 7 48 59 20 0 1 0 1990 1786 1678 435 300 352 149 125 94 282 303 260 745 559 519 774 718 668 19 23 11 623 676 555 * The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia. ** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis. Report Period Latest 12 Months: 10/00 - 09/01 Five Years Ago: 10/95 - 09/96 Cumulative: 7/81 - 09/01 Total Cases Reported* Percent Female AIDS Profile Update Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown 1243 25.1 28.6 9.6 2.1 10.3 1.2 48.3 2414 18.7 46.9 17.7 5.2 18.6 1.3 10.3 23628 17.0 48.0 18.1 5.6 13.1 1.9 13.3 MSM - Men having sex with men IDU - Injection drug users HS - Heterosexual * Case totals are accumulated by date of report to the Epidemiology Section - 4 - Race Distribution (%) White Black Other 19.2 76.1 4.7 34.2 63.2 2.6 35.2 62.5 2.2