1. Safe Handling, Packaging & Shipping of Infectious Substances Utah Department of Health November 21, 2002 Kim Christensen

3. Objectives • Information on possible organisms • Why these organisms? • Safety • Samples • Packaging • Transport/Shipping

4. Agents of Highest Concern • Bacillus anthracis (Anthrax) • Francisella tularensis (Tularemia) • Yersinia pestis (Plague) • Botulinum toxin (Botulism) • Variola major (Smallpox) • Viral Hemorrhagic Fevers

5. Other Possible Agents • Brucella spp. – Brucellosis • Coxiella burnetti – Q-fever • Arboviruses (West Nile) – encephalitis • Mycotoxins • Ricin Toxin – Castor beans • SEB – Staphylococcus Enterotoxin B

6. Why these organisms? • Can cause disease via aerosol route • Fairly stable in aerosolized form • Susceptible civilian population • High morbidity and mortality rates • Difficult to diagnose and/or treat • Some can be transmitted person-to-person

7. Bacillus anthracisAnthrax • Bacillus anthracis – • Gram-positive, spore-forming bacillus (rod)

8. Bacillus anthracisAnthrax • Cutaneous Exposure- • A skin lesion evolving during a period of 2-6 days from a papule, through a vesicular stage, to a depressed black eschar.

9. Cutaneous Anthrax • Intense itching • Painless skin sore • Incubation 1-5 days (up to 60) • 20% fatality if untreated (may spread to blood) • Direct contact with skin lesion may result in cutaneous infection

10. Inhalation Anthrax • Inhalation Anthrax- • A brief prodrome resembling a viral respiratory illness with radiograph evidence of mediastinal widening

11. Inhalation Anthrax • Flu-like symptoms – • Fever, fatigue, muscle aches, difficulty breathing, headache, chest pain & non-productive cough • 1-2 day improvement followed by respiratory failure, meningitis may develop • No person-to-person spread

12. Francisella tularensisTularemia • Humans become infected by: • Handling infected animal carcasses • “Rabbit Fever” • Bites of ticks, deer flies, or mosquitoes • No person-to-person transmission • Endemic in Utah

13. Pneumonic- Incubation 3-5 days Flu-like symptoms Mortality – 30% untreated <10% treated Ulceroglandular Ulcer w/adenopathy Glandular Adenopathy w/o lesion Oculoglandular Painful, purulent conjunctivitis Typhoidal Possible presentation for BT Septicemia TularemiaClinical Presentations

14. Yersinia pestisPlague • Transmission – • Inhalation • Direct contact • Fleas

15. Bubonic Flu-like with painful buboes (lymph nodes) Septicemic Similar to bubonic No swelling of lymph nodes PlagueClinical Presentations

16. Pneumonic Highest mortality Rapid transmission Fever Hemoptosis Lymphadenopathy Cough PlagueClinical Presentations

17. Plague • Distribution • Highest in 4 corners area – Western states • Prairie dog population

18. Clostridium botulinum Organism – gram positive, spore-forming, anaerobic bacilli Botulinum toxin Neurotoxin A, B, C1, D, E, F, G Botulism

19. Botulism • Foodborne • Diplopia (double vision), blurred vision, flaccid, symmetric paralysis (rapid progression) • Infant • Constipation, poor-feeding, “failure to thrive”, weakness, impaired respiration and death • Wound • Same symptoms as foodborne w/infection through a wound • Other • Non-infant patient with no suspect food or wound

20. Botulism • Foodborne • Most likely presentation for BT event • Mortality • Currently 5-10% • Previously 60% • Wound • Mortality 15% • Emerging problem of drug users • Injecting Black Tar Heroin

21. Orthopox virus DNA virus Brick-shaped structure 200 nm in diameter Incubation 8-16 days Mortality 30% Clinical symptoms Acute Fever Headache Vomiting Backache Variola majorSmallpox

22. Variola majorSmallpox • 4 Types • 1. Ordinary – most frequent • 2. Modified • Mild • Occurring in previously vaccinated persons • 3. Flat • 4. Hemorrhagic • Much shorter incubation • Not likely to be recognized as Smallpox (initially)

23. Variola majorSmallpox • Disease Progression • Incubation Period • Initial Symptoms – Prodrome • Rash Development & Distribution • Variola minor • Less common clinical presentation • Much less severe disease

24. Rash Begins on face, hands, forearms & spreads to lower extremities within 7 days Lesions on palms & soles of feet Variola majorSmallpox

25. Rash Synchronous progression: maculesvesicles pustules scabs Variola majorSmallpox

26. Smallpox • Spread by infected droplets • Most infectious after onset of rash • Contagious until the last scab falls off • Vaccine given within 4 days of exposure can prevent disease or lessen symptoms • 70% recovery rate • Chicken pox vs. Smallpox

27. Ebola Lassa Marburg Hanta Dengue Yellow fever Crimean-Congo Rift Valley fever Other Viral Hemorrhagic Fevers

28. Viral Hemorrhagic Fevers • High Fever with: • Mucous membrane bleeding • Petechiae • Malaise • Muscle-aches • Headaches • May have diarrhea or vomiting • Fatality depends on virus – 90% Ebola

29. Viral Hemorrhagic Fevers • Mosquito or tick vectors • Person-to-person transmission through body fluids/blood • Vaccine available for Yellow Fever • People can be infected but show no signs or symptoms of disease

30. Protection of First Responders & Health Care Workers • Knowledge • Universal Precautions • Communication • Vaccination • Prophylaxis

31. Safety First • First Responders • Personal Protective Equipment • Established protocols • Transporters • Regulations • Lab Personnel • Personal Protective Equipment • Established protocols • Biosafety Containment • Vaccinations • Use Universal Precautions – treat everything as if it were contaminated

32. Safety • First Responders • Know what you “might be” dealing with • Protect yourself • Protect the community • Protect the next in line (transporter) • Recommendations for the Selection and Use of Protective Clothing & Respirators Against Biological Agents: • www.bt.cdc.gov/DocumentsApp/Anthrax/Protective/10242001Protect.asp

33. Safety • Transporter/Shipper • Know what you “might be” dealing with • Protect yourself • Protect the public • Follow rules and regulations • IATA, USPS, DOT, Etc.

34. Safety • Laboratory Personnel • Handle & process according to Biosafety Level Classifications (Level 1, Level 2, Level 3, Level 4) • Biosafety in Microbiological & Biomedical Laboratories CDC/NIH, 4th Edition. • Protect yourself • Protect other laboratorians • Protect the public

35. Samples • Clinical specimens • Non-clinical • Environmental • Evidentiary Materials

36. Clinical Specimen SelectionAll clinical specimens should go directly to a Level A Laboratory for processing

37. Cutaneous Vesicular Stage Fluid from intact vesicles on sterile swab Eschar Stage Without removing eschar, rotate swab beneath edge of eschar & collect lesion material Gastrointestinal Stool 5-10 grams Sterile, leakproof container Rectal swab Blood Institution’s procedure Routine blood cultures Bacillus anthracisAnthrax

38. Bacillus anthracisAnthrax • Inhalational • Sputum • > 1 mL expectorated sputum • Sterile, leakproof container • Blood • Institution’s procedure • Routine blood cultures

39. Pneumonic Bronchial Wash/Transtracheal Aspirate > 1 ml Institution’s procedure Sputum/Throat Routine throat culture (swab) Expectorated sputum – sterile, leakproof container Septicemic Blood Institution’s procedure Routine blood culture Bubonic Biopsied Specimen Liver, spleen, bone marrow, lung Tissue aspirate May yield little material Yersinia pestisPlague

40. Francisella tularensisTularemia • Biopsied tissue • Scraping of an ulcer - preferred • Swab of an ulcer – alternate • Tissue Aspirate • Bronchial/Tracheal Wash • Institution’s procedure • Sputum/Throat • Routine throat culture • Sputum expectorated into sterile, leakproof container • Blood

41. Foodborne Clinical Material Serum Gastric contents Vomitus Stool Enema fluid Autopsy Samples Intestinal & Gastic contents Serum Food Samples Infant Stool Enema fluid Post-mortem samples (intestinal contents) Food samples Environmental Samples Clostridium botulinum & Botulism Toxin

42. Wound Serum Wound tissue, exudate, swab Anaerobic transport Stool Enema fluid Isolate Bioterrorism – Intentional Release Serum Stool Enema fluid Gastric aspirate Nasal swab Food samples Environmental samples Clostridium botulinum & Botulism Toxin

43. Variola majorSmallpox • Report immediately to UDOH • UDOH contacts CDC & FBI

44. Variola majorSmallpox • Biopsy Specimen • 2-4 portions of tissue • Sterile, leakproof, freezable container • Scabs • Scrapings/material • Sterile, leakproof, freezable container • Vesicular fluid • Separate lesions • Include cellular material

45. Viral Hemorrhagic Fever • Specific handling conditions are currently under development at the CDC. • Serum • 10-12cc of serum

46. Urine At least 25 mL Screw-cap plastic containers Freeze ASAP Whole Blood Two – 5 or 7 mL purple-top (EDTA) tubes – vacuum-fill only (unopened) Whole Blood One 5 mL or 7 mL gray-top or green-top tube (unopened) One empty tube Whole Blood Two 10 mL red-top tubes no anticoagulant Do not separate serum from cells Chemical ExposureSpecimens to be collected from each individual

47. Non-Clinical SpecimensTo be delivered directly to the UDOH - Lab • Animal • Carcass, tissue, blood, bone, skin • Vector • Fleas, mosquitoes, ticks, flies • Human • Post-mortem specimens

48. Environmental SamplesTo be delivered directly to the UDOH - Lab • Water • At least 500 mL • Soil/Mud • Plant Material • Food

49. Evidentiary MaterialsTo be delivered directly to the UDOH - Lab • Non-organics • Powder • Paper • Containers • Organics • Hair • Wood • Liquids • Example procedure for collecting environmental samples: • www.bt.cdc.gov/Agent/Anthrax/environmental-sampling-apr2002.asp

50. Chain of Custody • Always observe a Chain of Custody • Evidence • CollectorTransporter Laboratory • Each person to touch the sample must sign for it. • Laboratory – • Signed for each time the sample is manipulated