Biological Agents -- Bacteria

Anthrax
Description
Q: What is anthrax?
A: Anthrax is an infectious disease caused by spore-forming bacteria, which occurs most often in hoofed animals and can infect humans. Anthrax appears in three forms:

• Inhalational.
  
• Cutaneous (skin).
  
• Gastrointestinal.
  

Infection results from exposure to the SPORE form of the bacteria. The type of infection depends on how you are exposed. Inhalational anthrax is the deadliest form of the disease. Cutaneous anthrax is the most common and mildest form, and gastrointestinal anthrax is the rarest.

Q: Where is anthrax naturally found?
A: Anthrax is found globally. It most commonly occurs in wild and domestic hoofed animals (goats, cattle, sheep, camels, antelopes and other herbivores) and the soil where such animals have died. It can occur in humans when one is exposed to infected animals or tissue from infected animals. It is more common in developing countries or countries without veterinary public health programs. Anthrax is rarely found in U.S. animals or hides.

Transmission
Q: What is the difference between exposure to anthrax and infection with anthrax?
A: A person is exposed to anthrax when that person comes in contact with anthrax bacteria or its spores. A person can be exposed to anthrax, and spores can even be found in the person, without that person having the disease.

Infection occurs when there is some sign of illness, such as the skin lesion that appears with cutaneous anthrax.
Q: How would I know if I was exposed to anthrax?
A: There is no indication of exposure until you experience symptoms. There is no cloud or color. No odor. No taste. There is no indication of an attack when spores are dispersed by aerosol spray.

Q: Is anthrax contagious?
A: No, anthrax is not contagious. Anthrax is not spread from an infected person to others or animal-to-person.

Q: Can I be screened or tested to find out if I have been exposed to anthrax?
A: The only way exposure can be determined is through a public health investigation.

• There is not an effective screening test for anthrax.
  
• There is not an effective test that shows whether you’ve been exposed to or carry anthrax.
  
• Tests such as nasal swabs and environmental tests should not be used to determine whether an individual should be treated. These tests are used to provide a rough estimate to help determine the extent of exposure in a given building or workplace.
  

Q: If I suspect I’ve been exposed to anthrax, should I be quarantined? Should other family members be tested?
A: Since anthrax is not contagious, there is no need to quarantine individuals suspected of being exposed to anthrax. Family, friends or coworkers in close contact with anthrax patients do not need to be immunized unless they were also exposed to the same source of infection.

Q: How can I get inhalational anthrax?
A: You can contract inhalational anthrax from breathing anthrax spores. If they are the right size, these spores get deep into the lungs and cause a serious infection, which can be fatal if left untreated or not treated promptly.

Q: How much exposure causes inhalational anthrax?
A: It is not known how many spores are required to cause inhalational anthrax. It is thought that it takes several thousand naturally occurring spores of a particular size inhaled into the lungs to develop a clinical infection. Spores developed specifically for terrorism may be much smaller than those found in nature and smaller numbers of spores could cause disease.

Q: How can I get cutaneous (skin) anthrax?
A: Cutaneous anthrax occurs when anthrax spores enter a cut or abrasion on the skin. Usually, naturally occurring infection comes from handling contaminated hides or hair products from infected animals.

Q: How can I get intestinal anthrax?
A: Intestinal anthrax comes from eating the contaminated meat of infected animals that is not properly cooked. Intestinal anthrax is very rare.

Q: How long do anthrax spores live?
A: Anthrax spores can survive for decades in soil.

Symptoms
Q: What are the symptoms of inhalation anthrax?
A: Inhalational anthrax has two phases:

• Following an incubation period of one to seven days, initial symptoms usually include fever, chills, malaise, fatigue and a non-productive cough. Chest discomfort, nausea and vomiting may be present as well.
  
• The second phase develops suddenly with severe shortness of breath, continued fever and, if left untreated, eventual shock and death.
  

Q: What does cutaneous (skin) anthrax look like?
A: Cutaneous anthrax begins as a raised bump, which may or may not be itchy, on the skin that looks like a large spider bite. It develops into a painless ulcer within a few days and then forms a black, leathery scab. Lymph glands in the adjacent area may swell.

Q: What are the symptoms of intestinal anthrax?
A: Intestinal anthrax is characterized by inflammation of the intestinal tract. Initial signs can be a severe ulcer in the mouth or throat with swelling and swollen glands or can include nausea, loss of appetite, vomiting, bloody diarrhea and fever. Intestinal anthrax is very rare.

Treatment
Q: How is anthrax infection or exposure treated?
A: Antibiotics are used to treat both exposure and infection.

• If you are exposed to anthrax, prompt treatment with antibiotics can prevent infection.
  
• If you are infected, early recognition and treatment with antibiotics can be effective in preventing serious or fatal disease.
  
• Antibiotics, when given early after exposure, greatly reduce the likelihood of a fatal infection. Antibiotics most commonly effective are doxycycline, and fluoroquinolones.
  
• Tests should be conducted on the organism by medical authorities to see which antibiotics work best.
  

Q: Should I buy and stockpile antibiotics to use when there is an anthrax outbreak?
A: There is no need to buy or stockpile antibiotics. Under emergency plans, the state and federal government can provide appropriate antibiotics from stockpiles wherever they are needed. Stockpiling antibiotics can be detrimental to both the individual and to the community because:

• Only people who are exposed to anthrax should take antibiotics, and health authorities must make that determination.
  
• Individuals may not stockpile the correct antibiotic. Each organism requires a certain antibiotic. If a doctor hasn’t diagnosed your condition, the antibiotic you take may not be the right one to eliminate the organism causing the infection.
  
• The stored antibiotics may become outdated.
  
• Individuals may have severe adverse reactions to antibiotics.
  
• Organisms can become resistant to antibiotics if they are not taken properly or are taken when they are not needed. This will cause the antibiotics to not be useful when they are needed.
  

Q: Is there a vaccine to prevent anthrax? Can I get the vaccine?
A: While an anthrax vaccine does exist, it is currently not approved or recommended for the general public. It is used only in the military or for special at-risk groups.

Bioterrorist Threat
Q: What makes anthrax effective as a biological weapon?
A: Anthrax is considered a potentially effective biological weapon because:

• Spores can be reproduced in large quantities. However, making spores into an effective powder is difficult and requires very sophisticated technical knowledge and equipment.
  
• Spores can be easily spread in an aerosol spray.
  
• Inhalational anthrax can be deadly if not treated early.
  
• Spores can be stored for decades without losing potency.

Q: Can I be exposed to anthrax via the mail?
A: Letters containing the anthrax spores have been found in the mail in some areas in the U.S. In some instances, anthrax exposure and disease has occurred. To prevent such exposures and subsequent infection, all persons should learn how to recognize a suspicious package or envelope and take appropriate steps to protect themselves and others.

Q: What should I do if I receive a suspicious package or envelope?
A: Take the following steps:

• Do not shake or empty the contents of a suspicious package or envelope.
  
• Do not carry the package or envelope, show it to others or allow others to examine it.
  
• Put the package or envelope on a stable surface. Do not sniff, touch, taste or look closely at it or any contents that may have spilled.
  
• Alert others in the area about the suspicious package or envelope. Leave the area, close any doors and prevent others from entering the area. If possible, shut off the ventilation system.
  
• Wash hands with soap and water to prevent spreading potentially infectious material to face or skin. For exposed or potentially exposed persons seek additional instructions from local health officials.
  
• If at work, notify a supervisor, security officer or law enforcement official about a suspicious package. If at home, contact your local law enforcement agency.
  
• If possible, create a list of persons who were in the room or area when this suspicious letter or package was recognized and a list of persons who also may have handled this package or letter. Give the list to both the local public health authorities and law enforcement officials.
  

Q: What kind of mail or package should be considered suspicious?
A: Some characteristics of suspicious packages and envelopes include inappropriate or unusual labeling such as:

• Excessive postage.
  
• Handwritten or poorly typed addresses.
  
• Not addressed to a specific person.
  
• Strange return address or no return address.
  
• Incorrect titles or a title without a name.
  
• Misspellings of common words.
  
• Restrictive marks, such as "personal," "confidential," do not X-ray."
  
• Threatening language.
  
• Postmarked from a city or state that does not match the return address.
  

Appearance can also denote a suspicious package or envelope. Be suspicious of:

• Powdery substances felt through or appearing on the package or envelope.
  
• Oily stains, discolorations or odor.
  
• Lopsided or uneven envelopes or packages.
  
• Excessive packaging material such as masking tape or string.
  
• Excessive weight.
  
• Ticking sounds.
  
• Protruding wires or aluminum foil.
  

Q: How can I recognize anthrax in a package or letter?
A: Only specially trained personnel can distinguish between a real bioterrorist attack and a false one. If you suspect that a package, letter or anything else contains a harmful biological agent such as anthrax, notify local law enforcement authorities.

Q: Can microwaves, UV light or ironing kill anthrax spores on letters?
A: Some of these methods may kill anthrax spores, however, we do not know for sure exactly what works best. The correct length of time, or temperature setting required to effectively kill the spores is not known. Because there is little research on the efficiency of these methods, medical authorities do not recommend these techniques.

Q: What can I buy to protect myself against "germ" agents such as anthrax?
A: The CDC does not recommend that individuals buy any particular product to protect against biological or chemical attack. There is no universal protective product. During an attack, health and emergency officials may provide specific information about how best to protect yourself and your family.

Brucellosis
Description
Q: What is brucellosis?
A: Brucellosis is an infectious bacterial disease also known as undulant fever. This disease occurs in many different mammals. It is uncommon in the U.S. because it has been controlled in livestock.

Transmission
Q: How can I get brucellosis?
A: People usually become infected with brucellosis by coming in contact with animals or animal products contaminated with these bacteria. Infection occurs after eating or drinking something contaminated with the bacteria, through skin abrasions or by breathing in the organism (inhalation).

• The most common source of brucellosis infection is eating or drinking unpasteurized milk products, including cheese derived from an infected animal.
  
• Skin wound contamination can be a problem for veterinarians, hunters and people working in slaughterhouses or meat processing plants, in areas where brucellosis is common.
  
• Inhalation of the organisms is not a common natural route of infection, but it does occur. It is a significant hazard for people in laboratories where the organism is cultured and slaughterhouses where there are infected animals.
  

Q: Can I "catch" brucellosis from someone else who has the disease?
A: Direct person-to-person spread of brucellosis is extremely rare.

Symptoms
Q: What are the symptoms of brucellosis?
A: Symptoms of brucellosis are extremely variable. It can cause a range of initial symptoms similar to the flu including fever, sweats, headaches, back pains, weight loss and physical weakness. Brucellosis also causes long-lasting (chronic) symptoms that include recurrent fevers, joint pain and fatigue. Severe infections of the central nervous system, eyes, liver, blood cells or lining of the heart can also occur.

Q: Is brucellosis fatal to humans?
A: Case-fatality rates are low (5 percent of untreated cases). Fatalities are usually associated with infection of the lining of the heart (endocarditis).

Q: How soon do symptoms appear after exposure?
A: Incubation for brucellosis varies. Symptoms usually appear five to 60 days following exposure. The incubation period is commonly one to two months, and occasionally more than 2 months.

Q: How long can brucellosis symptoms last?
A: Symptoms can persist for months and even years with relapses and remissions.

Treatment
Q: Can brucellosis be treated?
A: Yes, effective treatment with antibiotics is sufficient for recovery in most cases. Depending on the timing of treatment, location of infection and severity of illness, treatment may be prolonged. Recovery can take a few weeks to several months.

Q: Is there a vaccine for brucellosis?
A: There is no vaccine available for humans.

Bioterrorist Threat
Q: Why is brucellosis considered a bioterrorist threat?
A: It is considered a threat because:

• The disease can be delivered as an aerosol or through the sabotage of a food or water supply.
  
• It is highly infectious via inhalation.
  
• Brucellosis was adapted for weapons in 1954.
  
• Although the disease is incapacitating and disabling, it rarely causes death and is not considered a primary biological warfare agent.
  

Cholera
Description
Q: What is cholera?
A: Cholera is an acute gastrointestinal illness caused by a bacterial infection of the intestinal tract. The infection is often mild or without symptoms, but sometimes it can be severe. If severe cases are untreated, 50 percent can be fatal.

Transmission
Q: How do people usually get cholera?
A: Cholera is contracted through contaminated drinking water or food. Large epidemics are often related to fecal contamination of either water or food. Cholera is occasionally transmitted through eating raw or undercooked shellfish, which acquire the bacteria from water contaminated with feces.

Q: Can cholera be spread person-to-person?
A: Cholera can be spread person-to-person only if people are not careful and allow a sick person to contaminate food or water or if proper hygiene is not used while taking care of a cholera patient. Casual contact with an infected person is not a risk.

Symptoms
Q: What are the symptoms of cholera?
A: About one in 20 infected people have profuse watery diarrhea, vomiting and leg cramps. Rapid loss of body fluids leads to dehydration and shock. Without treatment, death can occur within hours. The incubation period for cholera is from a few hours to 5 days.

Q: Why is cholera so dangerous?
A: Rapid loss of body fluids can lead to dehydration and shock. Without treatment, death can occur within hours.

Treatment
Q: What is the treatment for cholera?
A: Cholera is treated by immediate replacement of fluids and salts lost through diarrhea. Patients can be treated with an oral rehydration solution to replace fluids and electrolytes. With prompt rehydration, less than 1 percent of patients die.

In severe cases, patients may require intravenous fluid replacement.

Antibiotics shorten the course and diminish the severity of the illness.

Q: What should I do if I suspect I have contracted cholera?
A: Contact your doctor.

Q: Is there a vaccine for cholera?
A: The manufacture and sale of licensed cholera vaccine in the U.S. has been discontinued. The vaccine has not been recommended for travelers because of the brief and incomplete immunity it offers. Two recently developed vaccines for cholera that provide better immunity and fewer side-effects are licensed and available in other countries but are not recommended for travelers, nor are they available in the U.S.

Decontamination
Q: How can I avoid bacteria that cause cholera?
A: Observe good sanitary practices. The bacteria are readily killed by boiling, by exposure to ordinary disinfectants and by chlorination of water.

Bioterrorist Threat
Q: Is cholera a potential terrorist weapon?
A: Yes it could be used to sabotage food and water supplies.

Glanders
Description
Q: What is glanders?
A: Glanders is an infectious bacterial disease, primarily of horses, mules and donkeys that has disappeared from most areas of the world. It is rarely transmitted naturally to humans. When the disease was more common the fatality rate for humans ranged from 50 to 70 percent.

Q: Is glanders a common disease? I’ve never heard of it.
A: Glanders is rare in humans. Sporadic cases have been documented in veterinarians, horse caretakers and laboratorians and it has been highly infectious in people exposed to aerosols of the bacteria in laboratory situations. No naturally occurring cases have been diagnosed in the U.S. since the 1940s.

Q: Where is the bacterium that causes glanders found?
A: It can be found in horses or related species in limited areas of Asia and some eastern Mediterranean countries. The bacteria are not found in water, soil or plants.

Q: How serious is this disease?
A: Without treatment, glanders is usually fatal. However, naturally transmitted cases are very rare, even when there are epidemics in animal populations.

Transmission
Q: How do people get glanders?
A: Glanders is transmitted to people by direct contact with infected animals or contact with aerosols of the bacteria. It is not easily transmitted from animals to humans. Aerosol transmission is highly infectious.

Q: Can I catch glanders from another person?
A: Yes, a small number of human-to-human transmission cases have been reported. The route of exposure in secondary cases is presumed to be direct contact with infected body fluids via aerosol.

Symptoms
Q: What are the symptoms of glanders?
A: Glanders’ symptoms depend upon its route of infection. Symptoms appear 10 to 14 days following exposure and include fever, muscle aches, chest pain, muscle tightness and headache. Additional symptoms are excessive tearing of the eyes, light sensitivity, and diarrhea, blood streaked nasal discharge, a pustular rash, cutaneous and intramuscular abscesses on legs and arms, enlarged lymph nodes and pneumonia.

Q: What are the different ways that glanders occurs in humans?
A: Glanders occurs in four basic forms. Combinations of these syndromes often occur in human cases. The forms are:

• Localized, pus-forming cutaneous (skin) infection.
  
• Bloodstream infection.
  
• Chronic skin infection.
  
• Pulmonary (lung) infection.
  

Q: What is the skin infection form of glanders like?
A: If a break in the skin is exposed to glanders, a localized infection with ulceration will develop within 1 to 5 days at the place where the bacteria entered the body. Swollen lymph nodes may also be apparent.

If the infection involves the mucous membranes in the eyes, nose and respiratory tract there will be increased mucus production at those sites.

A chronic infection of the skin involves multiple abscesses within the muscles of the arms and legs or even in the spleen or liver.

Q: What are the other forms of glanders like?
A: With pulmonary infections, pneumonia and pulmonary abscesses can occur. Chest X-rays will show localized infection in the lungs.

Bloodstream infections (septicemic) begin suddenly with fever, sweats, muscle pain, chest pain and diarrhea and are usually fatal within 7 to 10 days.

Treatment
Q: What is the treatment for glanders?
A: Since the disease is rare in humans, there isn’t much information on the effectiveness of antibiotic treatment. However, sulfadiazine has been effective in both human and animal cases. Glanders is usually fatal if not treated.

Q: Is there a vaccine for glanders?
A: There is no vaccine available for glanders.

Bioterrorist Threat
Q: Could glanders be an effective bio-weapon?
A: Yes, very few organisms are required to cause disease, and it is easily inhaled. The U.S. and Soviet Union both studied its biological warfare potential. Since aerosols are efficient methods of dispersal and there are no vaccines or dependable treatment glanders is considered a potential bioterrorist weapon.

Plague
Description
Q: What is plague?
A: Plague is a disease caused by bacteria that live in rodents. It can occur in three distinct forms – bubonic, septicemic and pneumonic. Although it is rare in the U.S. it sometimes occurs in the western and southwestern parts of the country. If not treated, death can occur 50 to 90 percent of the time. That percentage decreases to 15 percent if treated.

Q: If plague bacteria are used in a weapon, how will they be dispersed?
A: The former biological weapons programs of the U.S. and Soviet Union both developed techniques to aerosolize plague. This method of delivery is considered the most effective. The Japanese reportedly used plague as a weapon in World War II, dropping plague-infected fleas over populated areas of China.

Transmission
Q: How do people get the plague?
A: In one of the following ways:

• Plague is spread to people by fleas from infected animals.
  
• People can also get the disease by handling tissues or fluids from infected animals.
  
• When the disease affects the lungs (pneumonic plague), it may be spread from animals or person-to-person by airborne droplets released when coughing.
  
• An aerosol spray can also spread plague.
  

Q: How would an outbreak of plague delivered by bioterrorists differ from a natural outbreak?
A: A plague outbreak from a biological weapon would have a different epidemiological pattern (onset of symptoms, rate of infection and reach) than naturally occurring plague. Naturally transmitted plague cases are rare in the U.S. and are limited to certain geographic areas. A large proportion of naturally occurring cases appear as bubonic plague infections. A deliberate release would have many pneumonic and septicemic cases.

The first sign of a bioterrorist plague attack would most likely be a sudden outbreak of illness showing symptoms such as severe pneumonia and sepsis (toxins in blood or tissue). Following an aerosol release these pneumonic cases would appear within one to two days with many people dying quickly after symptom onset. Human experience and animal studies suggest that the incubation period in this setting is one to six days.

Symptoms
Q: What are the symptoms of plague?
A: Generalized symptoms can include fever, chills, nausea, sore throat, headache and body aches. Symptoms appear anywhere from one to seven days after exposure. Symptoms specific to each particular route of plague infection are:

• Bubonic plague -- characterized by a swollen, red lymph node on the body near where the infected flea bit the person. Bubonic plague can progress to septicemic plague.
  
• Septicemic (bloodstream infection) plague -- symptoms include abdominal pain, shock and bleeding into skin and other organs.
  
• Pneumonic plague -- An infection of the lungs due either to inhalation of organisms or spread to the lungs from septicemia. Symptoms include high fever, headache, cough productive of bloody or watery sputum, difficult breathing and shock. The fatality rate for pneumonic plague is nearly 100 percent if untreated.
  

Treatment
Q: Is there any treatment for plague?
A: Several antibiotics are effective in the treatment of plague, if given within 24 hours of the onset of symptoms.

Q: Is plague fatal?
A: Yes, it can be fatal. Early treatment of plague is essential for recovery. Untreated pneumonic plague is usually 100 percent fatal. If bubonic plague is not treated the mortality rate can be 50 percent.

Q: Is there a vaccine for plague?
A: There is a vaccine that can be administered to those considered at risk; however, it is not routinely given to travelers.

Q: What should I do if I suspect that I have contracted plague?
A: Contact your doctor.

Q: How can the spread of plague be prevented?
A: Travelers to areas where plague is common should avoid contact with rodents, fleas and rodent-infested places. Sick or dead stray animals should also be avoided.

Decontamination
Q: If people around me have the plague, how can I keep from getting it?
Avoid contact with patients and seek medical assistance. Patients should be isolated and started on an antibiotic regime. Those who have close contact with patients should also be treated with antibiotics and observed for any signs of illness.
Plague bacteria are very susceptible to the action of sunlight and heating, but can remain viable for weeks in water or at near freezing temperatures. A plague aerosol is only effective for approximately one hour following release.

Bioterrorist Threat
Q: Is it a probability or even a possibility that the plague could be used as a biological weapon?
A: Technically, it is possible to use plague as a weapon. The technique for dispersal has been developed and large quantities of the agent, suitable for weaponry use, were manufactured in the Soviet Union. A biological attack with plague is a concern because of widespread availability, ease of production and dispersal and high fatality rate.

Q: Is this plague the same plague that caused mass death and confusion in early western history?
A: Yes. In AD 541, the first great, recorded plague pandemic began in Egypt and swept over the known world. In 1346, another pandemic, known as the Black Death, erupted and within five years ravaged the Middle East. Deaths totaled more than 13 million in China and 20 to30 million in Europe, one-third of the European population.

Q: Why don’t we have large naturally occurring outbreaks today?
A: Today, advances in living conditions, public health and antibiotic therapy make such natural pandemics of plague improbable.

Q fever
Description
Q: What is Q fever?
A: Q fever is a rickettsial disease (a type of bacteria) found in many domestic and some wild animals as well as in ticks. The disease has been found in all parts of the world but rarely in Virginia. It was first identified in Australia.

Q: Who can get Q fever?
A: Anyone can get Q fever. The human form of the disease is found most often in areas where rickettsia-infected animals live. Veterinarians, meat workers, sheep and dairy workers, farmers, and laboratory workers are most at risk.

Q: Why is Q fever considered a potential bioterrorist weapon?
A: The bacteria that cause Q fever are resistant to heat, drying and many disinfectants.

It is easily airborne and easily inhaled by humans. It is highly infectious when airborne.

In a susceptible person, a single organism can cause the disease.

Transmission
Q: How is Q fever spread?
A: Humans primarily contract the disease by inhaling bacteria-contaminated aerosols.

Bacteria can be inhaled in dust contaminated by placental tissues, birth fluids, and excreta of infected animals from places such as barnyards.

Direct contact with infected animals and other contaminated materials, such as wool, straw, fertilizer, and laundry of infected people has been associated with spread of the disease. Raw milk from infected cows may be responsible for some cases, but this has not been well documented. Direct transmission from blood or bone marrow transfusion has also been reported.

Q: Which animals can harbor the bacteria that cause Q fever?
A: The organisms are found in sheep, cattle, goats, cats, dogs, some wild animals, birds and ticks. Infected animals, including sheep and house cats, usually do not appear sick, but shed a lot of organisms when giving birth.

Q: How soon after exposure do symptoms of Q fever appear?
A: How quickly a person gets sick depends on the extent of exposure to the organism. The symptoms generally appear about two to three weeks after exposure.

Q: Do infected people need to be excluded from work or school?
A: Q fever rarely, if ever, is transmitted person-to-person. No isolation or exclusion from work or school is necessary.

Symptoms
Q: What are the symptoms of Q fever?
A: Most acute cases of Q fever begin with the sudden onset of one or more of the following: high fevers, severe headache, general malaise (hazy feeling), muscle aches, confusion, sore throat, chills, sweats, non-productive cough, nausea, vomiting, diarrhea, abdominal pain, and chest pain.

• Fever usually lasts for one to two weeks.
  
• Weight loss can occur and persist for some time.
  
• Pneumonia develops in 30 to 50 percent of patients.
  
• The majority of patients have abnormal results on liver function tests and may develop hepatitis.
  

Q: How serious is an acute case of Q fever?
A: Most patients recover to good health within several months without any treatment. Only 1 to 2 percent of people with acute Q fever die.

Q: Is there a more serious form of Q fever?
A: Yes, chronic Q fever is an uncommon, long-term, more serious form of the fever.

• It is characterized by an acute infection that persists for more than 6 months.
  
• It may develop in patients who had acute Q fever, as soon as 1 year or as long as 20 years after the initial infection.
  
• A serious complication of chronic Q fever is endocarditis (inflammation of interior heart membranes), generally involving the aortic heart valves.
  
• As many as 65 percent of patients with chronic Q fever can die of the disease.
  

Q: Is there any group that is more susceptible to the chronic form of Q fever?
A: Yes, most patients who develop chronic Q fever have pre-existing heart disease. Transplant recipients, cancer patients and those with chronic kidney disease are also at risk.

Treatment
Q: Is there any treatment for Q fever?
A: Q fever is treated with antibiotics. Antibiotic treatment is most effective when initiated within the first three days of illness. The chronic form of Q fever is much more difficult to treat effectively and often requires the use of multiple drugs.

Q: Is there a vaccine for Q fever?
A: A vaccine has been developed and has successfully protected humans in occupational settings in Australia. The vaccine is not commercially available in the U.S.

Q: Are there any risks associated with the vaccine?
A: A skin test should be given to determine prior exposure, since individuals who have previously been exposed could have severe reactions to the vaccine.

Q: What should I do if I suspect I’m exposed to Q fever?
A: Contact your doctor.

Tularemia
Description
Q: What is tularemia?
A: Tularemia (rabbit fever or deer fly fever) is a bacterial disease that can cause a variety of symptoms depending on how the organism enters the body. The organism that causes the disease is found in wild animals, ticks or the environment. Tularemia is known as rabbit fever because persons who hunt and trap wild rabbits are more at risk of getting the disease.

Q: How dangerous is tularemia?
A: It depends on the route of infection. The mortality rate is low for most naturally- transmitted cases of tularemia. It is more dangerous when inhaled.

Transmission
Q: How can I get tularemia?
A: Humans acquire infection from:

• The bite of an infected vector, most commonly ticks in the U.S., and mosquitoes or biting flies in other countries.
  
• Handling or ingesting infectious materials, like contaminated hay, water, infected carcasses, infected animals.
  
• Inhaling infected aerosolized particles.
  

Q: Is tularemia contagious?
A: No, there is no person-to-person transmission of the disease. Human cases typically occur individually, but outbreaks do occur.

Q: Where is tularemia found naturally?
A: The bacteria that cause tularemia are found in a variety of wild and some domestic animals, and also in contaminated water, soil and vegetation. A variety of small mammals, including voles, mice, water rats, squirrels, rabbits and hares are natural reservoirs of infection.

Symptoms
Q: What are the symptoms of tularemia?
A: Tularemia causes a skin lesion at the site of infection and swollen glands.

Ingestion of the organism may produce a throat infection, intestinal pain, diarrhea and vomiting.

Inhalation of the organism may produce a fever alone or combined with a pneumonia-like illness.

Symptoms generally appear between two and 10 days after exposure, but usually between 3 and 5 days.

Treatment
Q: What is the treatment for tularemia?
A: Tularemia is treatable with appropriate antibiotics, such as streptomycin and gentamycin.

Q: How effective is treatment for tularemia?
A: Appropriate and early treatment is usually effective.

Q: What should I do if I suspect I’ve been exposed to tularemia?
A: Contact your doctor.

Decontamination
Q: How do I get rid of any bacteria that may be in my house?
A: Under natural conditions, tularemia may survive for extended periods in a cold, moist environment.

Decontamination can be achieved by spraying the suspected contaminant with a 10 percent (9 parts water, 1 part bleach) bleach solution. After 10 minutes, a 70 percent (7 parts water, 3 parts alcohol) solution of alcohol can be used to further clean the area and reduce the corrosive action of the bleach.

• Soapy water can be used to flush away less hazardous contaminants.
  
• Persons with direct exposure to powder or liquid aerosols containing the bacteria should wash body surfaces and clothing with soapy water.
  
• Standard levels of chlorine in municipal water sources should protect against waterborne infection.
  

Bioterrorist Threat
Q: Could tularemia be an effective biological weapon?
A: Yes, it could be effective as an incapacitating weapon. While it would probably not kill large numbers of people, it could render many helpless. Patients can be incapacitated for days even after antibiotic treatment is begun. Untreated tularemia symptoms often persist for several weeks and sometimes months. Release in a densely populated area would be expected to result in a sudden outbreak of large numbers of cases.

Q: How would we know if tularemia was released intentionally?
A: Tularemia is usually not found in Virginia. More than one case in the same place would trigger a public health investigation. In the early stages, it would be difficult to distinguish from a natural outbreak of community-acquired infection, especially influenza. Released as a weapon, tularemia would be expected to have a slower progression of illness and a lower case-fatality rate than either inhalational plague or anthrax.

Q: Can tularemia be used as a biological weapon?
A: Tularemia has long been considered a potential biological weapon. It was one of a number of agents studied at Japanese germ warfare research units between 1932 and 1945. It was also examined for military purposes in the West in the 1950s and 1960s.

Q: How can tularemia be used as a weapon?
A: The agent could be used as a weapon in a number of ways with an aerosol release having the greatest adverse medical and public health consequences.

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