M21: Disease Transmission IV: Biodefense

Question 1

Policies Against Bioweapons

1. _ (1925): Prohibiting use of biological weapons in war
2. _ (BWC, 1972): prevents development, production and stockpile of biological weapons

Answer 1

The Geneva Convention

The Biological Weapons Convention

Question 2

Differences between biological agents vs. conventional weapons (5)

Answer 2

• Cheaper
• Ubiquitous
• Hard to detect
• Dual-use technology
• Potentially self-perpetuating

Question 3

Components of the US plan include:

_ which capture particles from the air and are analyzed for the presence of bioagents

the strategic national stockpile of _

_ teams

Answer 3

Biowatch detectors

vaccines/antimicrobials

national disaster medical system

Question 4

Epidemiologic clues:

The most likely scenario would be _ among people who are _.

The likely presenting symptoms would be _ because most infectious agents are distributed in _ form, but _ outbreaks through _ could also occur.

Another clue would be if an organism was identified that _.

Also _ around the country or organisms with an unusual pattern of _ would be suspicious.

Answer 4

a large epidemic with severe illness and high death rate
otherwise fairly healthy

respiratory
aerosolized

food borne
ingestion

wasn’t normally present in that part of the country or the world

multiple, simultaneous outbreaks
antibiotic resistance

Question 5

Natural Events

There have been several natural events which would be managed in a fashion similar to an act of bioterrorism. This is an example of an “_” approach to preparedness. Because the principles are the same, these natural events are often discussed along with bioterrorism.

These include such diseases as (4)

The strengths needed to respond to natural outbreaks would be harnessed in the response to an unnatural outbreak.

Answer 5

all hazards

pandemic influenza
SARS
monkeypox
West Nile Virus.

Question 6

Components

The first part of managing an outbreak is _. This can be done through laboratory and/or clinical reporting. This is important for containment but, most importantly, for better outcomes.

We generally rely on _ confirmation of the disease after which we focus on containing it through infection control measures.

This may involve (3) while monitoring for signs of infection.

Answer 6

early identification of it through surveillance

laboratory

isolating infected and contagious patients
finding close contacts
observing/quarantining individuals

Question 7

Category A Agents

1. _ (anthrax)
2. _ (tularemia)
3. _ (plague)
4. _ (smallpox)
5. _ and _ (Viral hemorrhagic fevers)
6. _ (botulism)

Answer 7

1. Bacillus anthracis (anthrax)
2. Francisella tularensis (tularemia)
3. Yersinia pestis (plague)
4. Variola major (smallpox)
5. Arenaviruses and filoviruses (Viral hemorrhagic fevers)
6. Clostridium botulinum toxin (botulism)

Question 8

Category A Agents

1. Bacillus anthracis (_)
2. Francisella tularensis (_)
3. Yersinia pestis (_)
4. Variola major (_)
5. Arenaviruses and filoviruses (_)
6. Clostridium botulinum toxin (_)

Answer 8

1. Bacillus anthracis (anthrax)
2. Francisella tularensis (tularemia)
3. Yersinia pestis (plague)
4. Variola major (smallpox)
5. Arenaviruses and filoviruses (Viral hemorrhagic fevers)
6. Clostridium botulinum toxin (botulism)

Question 9

Category A Agents are considered to be high priority agents because (5)

Answer 9

– They can be easily spread from one person to another
– High mortality rates
– Major public health impact
– Public panic & social disruption
– Special action required for public health preparedness

Question 10

Category B Agents

These are the 2nd highest priority. They are less likely to cause _ but they may be easier to _ and they are fairly easy to _.

Answer 10

fatal disease
obtain
disseminate

Question 11

Category B Agents (7)

Answer 11

E. coli
Salmonella
Burkholderia mallei (glanders)
Burkholderia 
pseaudomallei (melioidosis)
Rickettsia prowazekii (typhus fever)
ricin toxin

Question 12

Category C Agents

These are the third highest priority. This group includes pathogens that could be _ because of availability and ease of production and dissemination.

These agents have the potential for high _ and _ and major health impact

Answer 12

engineered for mass dissemination

morbidity and mortality rates

Question 13

Category C Agents (3)

Answer 13

Nipah virus
avian influenza virus
hantavirus

Question 14

Category A Agents:
Anthrax:
Bacillus anthracis

• Gram (positive / negative) _
• Readily forms _ –> Can persist in the soil for years
• Non-_, _ colonies on blood agar
• Anthrax occurs worldwide
• Reservoirs (3)

Answer 14

• Gram positive rod
• spores
• Non-hemolytic, medusa’s head/comet’s tail colonies on blood agar
• Anthrax occurs worldwide
• Reservoirs: cattle, sheep, goats

Question 15

Category A Agents:
Anthrax:

Naturally occurring anthrax is generally a disease of the _

Breakdown (? > ? >?): inhalational, gastrointestinal, cutaneous

Answer 15

skin

cutaneous > inhalational > gastrointestinal

Question 16

Category A Agents:
Anthrax:
Anthrax Infection

In humans, anthrax is fairly (common / rare).

It usually occurs after exposure to _ or _.

In 2001, it was also associated with _ exposure.

Other recent outbreaks of note include cases in _ in Scotland through contaminated _ and people handling _.

Answer 16

rare

infected animals or animal products

intentional

injection drug users
heroin

drums made with animal skins

Question 17

Category A Agents:
Anthrax:
Anthrax Infection

The infection begins with _ when it is in an environment conducive to vegetative growth.

It then _ and produces a _.

The organisms may stay contained in the _ or spread through both the _ and the _.

It causes severe inflammation of the _.

Answer 17

germination of the spore

multiplies
toxin

skin
bloodstream
lymphatics

lymph nodes

Question 18

Category A Agents:
Anthrax:
Virulence Factors

• Capsule: The organism is protected from the immune system by an _ capsule (a _ capsule) encoded on a plasmid.
• Exotoxins (2) encoded on a plasmid

Answer 18

antiphagocytic 
polyglutamic acid (PGA)

Edema Toxin (protectiv eantigen + edema factor)

Lethal Toxin (protective antigen + lethal factor)

Question 19

Category A Agents:
Anthrax:
Virulence Factors

a. Edema Toxin
i) an _ that increases intracellular _ concentrations and interferes with _
b. Lethal Toxin
i) _ that cleaves and inactivates multiple _ and interferes with _

Answer 19

adenylate cyclase
cyclic AMP
cell function

calmodulin-dependent zinc metalloprotease
mitogen-activated protein kinases
signal transduction

Question 20

Category A Agents:
Anthrax in 2001

There were 22 cases diagnosed between October and November 2001. Eleven of these were _ infections and all survived. The others were _ anthrax and among these 11 cases; 7 were postal workers, 2 had known exposure to contaminated mail and 2 had presumed exposure to contaminated mail. These infections were all limited _ to Florida, Washington DC, New York, New Jersey and Connecticut. This was consistent with an intentional release in certain geographic areas. However the fear was widespread.

Answer 20

cutaneous

inhalational

geographically

Question 21

Category A Agents:
Cutaneous (skin) anthrax

• Exposure _ to _ of anthrax
• Incubation period of _ days
• _ at site
• Vesicles –> _
• Lesion is usually (painful / painless)
• Enlarged _ in the region of the infection

Answer 21

• Exposure abraded/lacerated skin to spores of anthrax
• Incubation period of 1-7 days
• Pruritic papule at site
• VesiclesàBlack eschar
• Lesion is usually painless
• Enlarged lymph nodes in the region of the infection

Question 22

Category A Agents:
Gastrointestinal Anthrax

• From _
• 40% mortality
• _ day incubation period
• _, _, and _, followed by severe _. Many cases will be associated with _, massive _, and _.

Answer 22

• From uncooked meat
• 40% mortality
• 1-5 day incubation period
• Nausea, vomiting, and fever, followed by severe abdominal pain. Many cases will be associated with hematemesis, massive ascites, and bloody diarrhea.

Question 23

Category A Agents:
Inhalational Anthrax (“_ Disease”) 

• 45% mortality in 2001; Patients who survived were recognized and treated early in their course
• Incubation period of _ days
• _ illness (but no _)
• Does not cause _ but does cause _
• _ widening on chest x-ray (_)
• Dissemination from inhalational or GI anthrax can result in _ (“cardinal’s cap”)

Answer 23

Woolsorter’s

• 45% mortality in 2001; Patients who survived were recognized and treated early in their course
• Incubation period of 4-6 days
• Flu-like illness (but no rhinorrhea)
• Does not cause pneumonia but does cause bloody pleural effusions
• Mediastinal widening on chest x-ray (hemorrhagic mediastinitis)
• Dissemination from inhalational or GI anthrax can result in hemorrhagic meningitis (“cardinal’s cap”)

Question 24

Category A Agents:
Anthrax:
Diagnosis

The easiest way to make the diagnosis is by _

– _ cultures turn positive in 6-24 hours
– _ cultures may be used for epidemiologic purposes to see if someone has been exposed

Other diagnostic tests include:

– _
– stains
– Anthrax _ test
– Looking for a 4-fold increase in _ antibody level—this requires follow up antibody levels ( diagnosis)

Answer 24

culture of blood, CSF, effusion

Blood
Nasal swab

– PCR
– Immunohistochemical stains
– Anthrax IgM test
– Looking for a 4-fold increase in IgG antibody level—this requires follow up antibody levels (retrospective diagnosis)

Question 25

Category A Agents: Anthrax: Transmission-Isolation There is no _-to-_transmission of inhalational anthrax. It can be spread by _. No _ is required: “standard precautions”

Answer 25

There is no person-to-person transmission of inhalational anthrax. It can be spread by contact with an open, infected wound. No special isolation is required: “standard precautions”

Question 26

Category A Agents: Anthrax: Treatment The standard treatment was increased in duration in 2001 because of concerns that someone could have been exposed to a “weaponized” form of anthrax which could be easily aerosolized. So the current treatment recommendations are based on the assumption that _ in the lungs could be germinating long after inhalation exposure. Since manufactured anthrax may contain _, multiple antibiotics are recommended. Cutaneous anthrax: _ x 60 days or _ x 60 days Inhalational or gastrointestinal: _ or _ and 1-2 additional antibiotics x 60 days (7) Post-exposure prophylaxis: 3 doses of vaccine and _ x 60 days or _ x 60 days Monoclonal Antibody: • _: targeted toward protective antigen • To be used as an adjunct to antimicrobial treatment

Answer 26

spores antibiotic resistance genes doxycycline ciprofloxacin doxycycline ciprofloxacin * rifampin * vancomycin * penicillin/ampicillin * chloramphenicol * imipenem * clindamycin * clarithromycin doxycycline ciprofloxacin Raxibacumab

Question 27

Category A Agents: Anthrax: Vaccination The anthrax vaccine is called the _. It has historically been given with a series of 5 doses plus annual boosters. It results in antibodies against the “_” which is a component of both of the toxins produced by this organism. It is generally well tolerated but there are mild _ reactions in 30% of people and _ reactions in 0.2% of people. Other treatments: • _ (not FDA approved)

Answer 27

Anthrax Vaccine Adsorbed (AVA) protective antigen local systemic Anthrax Immune Globulin

Question 28

Category A Agents: Tularemia: Francisella tularensis * Gram-(positive / negative) _ * (Obligate / Facultative) (intracellular / extracellular) pathogen * Why category A: (#) organisms to cause disease, variety of _, substantial _ if untreated * _ experimented with it in WWII-era

Answer 28

* Gram-negative coccobacillus * Facultative intracellular pathogen * Why category A: 10 organisms to cause disease, variety of sources, substantial mortality if untreated * Japanese experimented with it in WWII-era

Question 29

Category A Agents: Tularemia: Epidemiology * (Common / rare) in the USA before 1950 * Now (more / less) common * Disease of the (northern / southern) hemisphere * Primarily a disease of _ * Peaks in the (summer / winter) (_) * Small peak in the (summer / winter) (_)

Answer 29

* Common in the USA before 1950 * Now less common * Disease of the northern hemisphere * Primarily a disease of animals * Peaks in the summer (ticks) * Small peak in the winter (hunters)

Question 30

Category A Agents: Tularemia: Naturally occurring infection This is a naturally occurring infection in the USA. It generally begins after the bite of an infected _. It is generally found in _ or _ and it may be inoculated directly into the wound. It can also be seen after contact with contaminated _ and it can be aerosolized (rarely) from contaminated _. Laboratory workers are at risk if it is in their laboratory so they should be notified if you suspect this infection.

Answer 30

tick tick saliva or feces ``` animal products (e.g. skinning, dressing or eating infected animals) water, dust, or hay ```

Question 31

Category A Agents: Tularemia: Clinical Presentations * Average incubation period of _ days * Abrupt onset of _ • Syndromes o _: most common; lesion + lymphadenopathy o _ o _ o _: lymphadenopathy o _ o _: disseminated infection that does not fall into other categories; hardest to diagnose • In antibiotic era, death rate 4%

Answer 31

3-5 fever, chills, headache, malaise, anorexia, and fatigue o Ulceroglandular: most common; lesion + lymphadenopathy o Oculoglandular o Pharyngeal o Glandular: lymphadenopathy o Pneumonic o Typhoidal: disseminated infection that does not fall into other categories; hardest to diagnose

Question 32

Category A Agents: Tularemia: Diagnosis * Alert microbiology lab!!! * _ culture - (large / small), gram-(positiv e/ negative) _ * _ cultures (rarely positive) * Antibodies – _, confirm the diagnosis * _: inflammation, pleural effusion and enlarged hilar lymph nodes Transmission-Isolation * No _-to-_transmission * No _: “standard precautions”

Answer 32

* Sputum culture - small, gram-negative coccobacilli * Blood cultures (rarely positive) * Antibodies – retrospective, confirm the diagnosis * Chest x-ray: inflammation, pleural effusion and enlarged hilar lymph nodes * No person-to-person transmission * No special isolation: “standard precautions”

Question 33

Category A Agents: Tularemia: Treatment Preferred: _ or _ (intramuscular, intravenous) for 10 days Alternatives: _, _, or _ (all oral) for 10 days Prevention * _ no longer available * _ or _ for 14 days as post-exposure prophylaxis

Answer 33

streptomycin or gentamicin doxycycline, ciprofloxacin, or chloramphenicol Vaccine Ciprofloxacin or doxycycline

Question 34

Category A Agents: Plague: Yersinia pestis * Cause of “_” - 14th Century Europe * 3 world _ * 3,000 cases worldwide in 1994 * Naturally occurring disease in the _ USA * Gram-(positive / negative) _ * _ staining, “safety pin”

Answer 34

* Cause of “Black Death” - 14th Century Europe * 3 world pandemics * 3,000 cases worldwide in 1994 * Naturally occurring disease in the southwestern USA * Gram-negative bacillus * Bipolar staining, “safety pin”

Question 35

Category A Agents: Plague: Virulence Factors (some of many): 1. _: acts as a protease, promotes adhesion, and coagulase (flea mid-gut) 2. _: Type III secretion system 3. _ Naturally occurring infection This is a disease of _. Fleas obtain a blood meal from an infected _. _ multiplies and blocks digestive system of flea. Flea takes another blood meal from _ and regurgitates bacteria into _.

Answer 35

1. Plasminogen activator 2. Yersinia outer protein virulon 3. LPS rodents rodent Y. pestis human human

Question 36

Category A Agents: Plague: Symptoms (3)

Answer 36

1. Acute febrile lymphadenitis – “bubonic plague” 2. Pneumonic 3. Septicemic

Question 37

Category A Agents: Plague: Symptoms 1. Acute febrile lymphadenitis – “bubonic plague” a. Most (common / rare) form b. Sudden onset of _ c. Intense pain and swelling in _ 2. Pneumonic a. Infection of the _ b. Incubation: 2-4 days c. _, _, and _ d. Bloody _ e. _: pneumonia f. Mortality – 50% 3. Septicemic a. Generalized infection (_) b. Presumably after escape from the _

Answer 37

a. Most (common / rare) form b. Sudden onset of fevers, chills, weakness, headache c. Intense pain and swelling in lymph nodes a. Infection of the lungs b. Incubation: 2-4 days c. Fever, cough and difficulty breathing d. Bloody sputum e. Chest x-ray: pneumonia f. Mortality – 50% a. Generalized infection (blood stream) b. Presumably after escape from the lymph nodes

Question 38

Category A Agents: Plague: Transmission (pneumonic plague)-Isolation • (Contagious / Not contagious) • _ – gowns and gloves • _ precautions for 72 hours while on appropriate antibiotics Treatment Preferred: _ or _ (intramuscular, intravenous) x 10 days Alternatives: _, _ or _(oral) x 10 days Prevention: Mass casualty setting or post-exposure _ Preferred antibiotics: _ or _ (oral) for 7 days Vaccine: _

Answer 38

Transmission (pneumonic plague)-Isolation • Contagious • Isolation – gowns and gloves • Droplet precautions for 72 hours while on appropriate antibiotics Treatment Preferred: streptomycin or gentamicin (intramuscular, intravenous) x 10 days Alternatives: doxycycline, ciprofloxacin or chloramphenicol (oral) x 10 days Prevention: Mass casualty setting or post-exposure prophylaxis Preferred antibiotics: doxycycline or ciprofloxacin (oral) for 7 days Vaccine: No longer available

Question 39

Category A Agents: Smallpox: Variola major/Variola minor • (DNA / RNA) virus • Only human disease _ o _ as only host Clinical Presentation * _ day incubation period * _ followed 5 days later by _ * Severe subtypes: _ smallpox, _ smallpox

Answer 39

• DNA virus • Only human disease eradicated from the planet (Rinderpest is an animal disease that has been eradicated) o Humans as only host * 10-14 day incubation period * Prodrome followed 5 days later by rash * Severe subtypes: hemorrhagic smallpox, flat smallpox

Question 40

Category A Agents: Smallpox: Evolution of rash * _ -_ and _ * _ – filled with _ * _ – filled with _ * _ * _ * all lesions _

Answer 40

* Maculopapular -flat and raised (macular = flat, papular = raised) * Vesicles – filled with clear fluid * Pustules – filled with pus * crusts * scarring * all lesions of same form

Question 41

Category A Agents: Smallpox: Transmission * most contagious from the onset of the rash through the first _ of rash * _ or _ (small particles that can be spread in the air, e.g. from coughing) * _ * _ – objects which the infection can live on for limited periods of time (e.g. contaminated clothing or bed linens) * infectious until _ Isolation • All individuals with possible smallpox should be isolated immediately 1. _ room 2. _ – masks to filter out infection - used for other infections in the hospital, such as patients with tuberculosis 3. _ and _ • _ and _ should be vaccinated and placed under surveillance

Answer 41

* 7-10 days * droplet nuclei or aerosols * direct contact * fomites * the scabs have healed 1. Negative pressure 2. N95 respirators hospital, such as patients with tuberculosis 3. Gowns and gloves • Household and other close contacts

Question 42

Category A Agents: Smallpox: Variola vs. Varicella (_ vs. _) ``` Variola (_) • Rash most dense on _ and _ (_) • Lesions appear over _ days and evolve _ • Rash occurs on _ • Pruritic (itchy) / Doesn’t itch ``` ``` Varicella (_) • Greater concentration of lesions on _ (_) • Lesions appear in _, _ • Rarely seen on _ or _ • Pruritic (itchy) / Doesn’t itch ```

Answer 42

smallpox vs. chickenpox ``` (smallpox) • face and extremities (centrifugal) • 1-2 days, at the same rate • palms • Doesn’t itch ``` ``` (chickenpox) • the trunk (centripetal) • crops, different stages of maturation in adjacent areas • palms or soles • Pruritic (itchy) ```

Question 43

Category A Agents: Smallpox: Vaccine The smallpox vaccine comes from the observation that milkmaids who had developed _ never got smallpox. Historically this has been a _ vaccine. These vaccines have been 95% effective in preventing disease (historically) and are useful even if given 4 days after exposure. Before 2001 – _ This vaccine is grown on calf skin and contains _, _, _, and _. It is a _ vaccinia virus so there is a risk of dissemination in someone who is immunocompromised. It can also lead to complications in people with _ and it can be spread to close contacts. Current vaccine – _ 2000 This is similar to the previous vaccine but it has been modified to grow in _ cells and it does not contain any _. There are still the same contraindications as the previous vaccine except for _. This is in the Strategic National Stockpile Future vaccines Vaccines that would be safe in _ and _ patients.

Answer 43

cowpox live cowpox (vaccinia virus) Dryvax polymyxin B, streptomycin, tetracycline and neomycin live, replicating vaccinia atopic skin disease ACAM vero antibiotics antibiotic allergies. This is in the Strategic National Stockpile immunosuppressed and atopic

Question 44

Category A Agents: Smallpox: Vaccine Contraindications: – _ (HIV; corticosteroid use or chemotherapy; organ transplant; leukemia or lymphoma) – _ – e.g. eczema – _ ``` Normal, mild adverse reactions • _ and _ • Swollen regional _ • Low grade _ • _, _, _ • _ • 1 out of 3 people may feel badly enough to miss work, school or recreational activities ``` Serious adverse reactions • _ – spreading the vaccinia virus by sexual/skin contact • _ – a widespread vaccinia rash after hematogenous dissemination • _ reaction Life-threatening adverse reactions • Seen in 14-52/million vaccinations • Mortality 1-2/million vaccinations • _ – widespread infection of the skin in people with skin conditions • _ – progressive infection at the vaccination site with tissue destruction • Post-vaccinia _ Treatment: _ (antiviral)-no established efficacy _

Answer 44

Vaccine Contraindications – Immunodeficiency – Chronic skin condition – Pregnancy ``` Normal, mild adverse reactions • Sore and red • Swollen regional lymph nodes • Low grade fever • Fatigue, headache, muscle aches • Itching • 1 out of 3 people may feel badly enough to miss work, school or recreational activities ``` Serious adverse reactions • Inadvertent inoculation – spreading the vaccinia virus by sexual/skin contact • Generalized vaccinia – a widespread vaccinia rash after hematogenous dissemination • Allergic reaction Life-threatening adverse reactions • Seen in 14-52/million vaccinations • Mortality 1-2/million vaccinations • Eczema vaccinatum – widespread infection of the skin in people with skin conditions • Progressive vaccinia – progressive infection at the vaccination site with tissue destruction • Post-vaccinia encephalitis Treatment: Cidofovir (antiviral)-no established efficacy ST-246

Question 45

Category A Agents: Viral Hemorrhagic Fevers Diverse viruses from different families that cause _ manifestations o Filoviridae: Ebola, Marburg o Arenaviridae: Lassa Fever, Machupo * (DNA / RNA) viruses causing _ and generalized _ damage * In animals - may be spread by _, _, _, _, _, and _ • Human infections - contact with _ and _ o exposure to reservoir: _ - _ viruses

Answer 45

high lethality hemorrhagic o Filoviridae o Arenaviridae * RNA viruses causing high fevers and generalized vascular damage * In animals - may be spread by aerosol, urine, feces, fomites (objects), saliva and ocular exposure • Human infections - contact with blood and body fluids o exposure to reservoir: rodents-arenaviruses

Question 46

Category A Agents: Viral Hemorrhagic Fevers: Clinical manifestations * _, _, _, _ * Contagious: _, _, _; some are vector borne (e.g. Crimean Congo Hemorrhagic Fever) * Generally no treatment (supportive) EXCEPT a. _ respond to _ (IV form not FDA approved) • Outbreaks controlled with _ and the use of protective clothing; in the US setting, patients to be placed in negative isolation room with _ precautions.

Answer 46

* Fever, severe illness, petechiae, unexplained bleeding * Ebola, Marburg, Lassa a. Arenaviruses respond to ribavirin • barrier-nursing protocols, airborne

Question 47

Category A Agents: Botulism Botulism is a toxin-mediated disease caused by _, a gram (positive / negative) _ forming _. There are several forms of botulism that occur, but in a bioterrorism situation the presumed route of exposure would be _. Botulism is (contagious / not contagious) and (does / does not) require isolation of patients. Inhalational exposure would most closely mimic _ botulism. Toxin Characteristics The toxin of botulism is an (endotoxin / exotoxin) that is secreted by the bacteria. The toxin targets the nerve synapse preventing the release of _ (neurotransmission)

Answer 47

Clostdium botulinum gram positive spore anaerobic bacillus inhalational not contagious does not gastrointestinal exotoxin acetylcholine

Question 48

Category A Agents: Botulism Clinical Features Botulism causes a _ that is characterized by cranial nerve dysfunction without sensory symptoms. There is no _, _, or _. Diagnosis The diagnosis of botulism is made _, but culture, PCR, antibody testing, and assays in mice can be used for confirmation. Treatment The treatment includes both _, which can include prolonged mechanical ventilation, as well as administration of an _ obtained from the CDC. (FDA approved).

Answer 48

bilateral symmetric descending acute paralysis fever, tachycardia, or mental status changes clinically supportive care heptavalent anti-toxin

Question 49

Anthrax 1) Microbiology 2) Vector 3) Virulence Factors 4) Treatment 5) Vaccine 6) Clinical Features 7) Other

Answer 49

1) Gram positive, spore-forming bacilli 2) Livestock 3) Capsule, Edema toxin, Lethal toxin 4) Penicillin, Ciprofloxacin, Doxycycline, Raxibacumab 5) 5 doses + yearly booster 6) Cutaneous, GI, Inhalational 7) Amerithrax 2001 attacks

Question 50

Tularemia 1) Microbiology 2) Vector 4) Treatment 5) Vaccine 6) Clinical Features 7) Other

Answer 50

1) Gram negative cocco-bacillus 2) Rabbits, Ticks, Flies 4) Streptomycin 5) N/A 6) Ulceroglandular, Pneumonic, Oculoglandular, Typhoidal, Glandular 7) Martha’s Vineyard

Question 51

Plague 1) Microbiology 2) Vector 3) Virulence Factors 4) Treatment 5) Vaccine 6) Clinical Features 7) Other

Answer 51

1) Gram negative bacillus 2) Rodents, Fleas 3) LPS, Type III secretion system, Plasminogen activator 4) Streptomycin 5) N/A 6) Bubonic, Pneumonic, Septicemic 7) SW US

Question 52

Smallpox 1) Microbiology 2) Vector 4) Treatment 5) Vaccine 6) Clinical Features

Answer 52

1) Orthopox virus 2) Eradicated 4) cidofovir? 5) +++ 6) Centrifungal rash, Lesions of same age, Contagious after rash appears

Question 53

Viral Hemorrhagic Fevers 1) Microbiology 2) Vector 4) Treatment 5) Vaccine 6) Clinical Features 7) Other

Answer 53

1) RNA viruses 2) Rodents for arena viruses 4) None 5) None in US 6) Bleeding, shock 7) Africa