Suspected Plague Exposure
Purpose
The purpose of these policy guidelines is to
recommend procedures for potential biological
suspected plague exposure.
Description of Agent/Syndrome
Plague is an infectious disease of animals and humans
caused by the bacterium Yersinia pestis. Y.
pestis, is found in rodents and their fleas in many areas around the
world. Pneumonic plague occurs when Y.
pestis infects the lungs. The first signs of illness in pneumonic
plague are fever, headache, weakness, and cough productive of bloody or watery
sputum. The pneumonia progresses over 2 to 4 days, may cause septic shock and,
without early treatment, death.
A pneumonic plague outbreak would result with
symptoms initially resembling those of other severe respiratory illnesses. The
size of the outbreak would depend on factors including the quantity of
biological agent used, characteristics of the strain, environmental conditions,
and methods of aerosolization.
Symptoms would begin to occur 1 to 8 days following exposure, and people would die quickly following onset of symptoms. Indications that plague had been artificially disseminated would be the occurrence of cases in locations not to have known enxootic infections, in persons without known risk factors and in the absence of rodent deaths.
Types:
1. Bubonic
Plague - characteristic buboes appear in the groin or axillary or
cervical lymph nodes
2. Systemic
Plague - occurs as primary or secondary bubonic plague with
purpura, DIC and necrosis(without an evident bubo)
3. Pneumonic
Plague -primarily from inhalation of aerosols
4. Plague Meningitis- found mainly in children
5. Pharyngeal
Plague - asymptomatic carriers occur in contacts of plague patients
6. Cutaneous
Plague - ulcer or pustule at inoculation site from flea bite with
buboes
Transmission
Person-to-person transmission of pneumonic plague
occurs through respiratory droplets, which can only infect those who have
face-to-face contact with the ill patient. Indoor contacts of infected
individuals are at higher risk transmission than outdoor contacts. Cold
temperatures, increased humidity and crowding also increase the likelihood of
transmission. Bubonic plague is generally not transmitted directly from person
to person unless there is direct contact with pus from suppurating buboes.
Incubation period
From 1 to 8 days
Signs and Symptoms
The disease is characterized by fever, chills, headache,
malaise, prostration, and leukocytosis that manifests in one or more of the
following principal clinical forms:
• Regional lymphadenitis (bubonic plague)
• Septicemia without an evident bubo
(septicemic plague)
• Plague pneumonia, resulting from hematogenous
spread in bubonic or septicemic cases (secondary pneumonic plague) or
inhalation of infectious droplets (primary pneumonic plague)
• Pharyngitis and cervical lymphadenitis
resulting from exposure to larger infectious droplets or ingestion of infected
tissues (pharyngeal plague)
Diagnosis
LABORATORY CRITERIA FOR DIAGNOSIS:
|
Diagnosis of Pneumonic
Plague Infection Following Use of a Biological Weapon |
|
Epidemiology
and Symptoms |
|
·
Sudden appearance of many persons with fever, cough,
shortness of breath, hemoptysis, and chest pain ·
Gastrointestinal symptoms common (e.g., nausea,
vomiting, abdominal pain, and diarrhea) ·
Patients have fulminant course and high mortality |
|
Clinical
Signs |
|
·
Tachypnea, dyspnea, and cyanosis ·
Pneumonic consolidation on chest examination ·
Sepsis, shock, and organ failure ·
Infrequent presence of cervical bubo ·
(Purpuric skin lesions and necrotic digits only in
advanced disease) |
Laboratory Studies |
|
·
Sputum, blood, or lymph node aspirate ·
Gram-negative bacilli with bipolar (safety pin)
staining on Wright, Giemsa, or Wayson stain ·
Rapid diagnostic tests available only at some
health departments, the Centers for Disease Control and
Prevention, and military laboratories ·
Pulmonary infiltrates or consolidation on chest
radiograph |
|
Pathology |
|
·
Lobular exudation, bacillary aggregation, and areas
of necrosis in pulmonary parenchyma |
Presumptive
·
Elevated serum antibody titer(s) to Yersinia pestis fraction
1 (F1) antigen (without documented fourfold or greater change) in a patient
with no history of plague vaccination
or
Confirmatory
or
Treatment
|
TREATMENT
- One antimicrobial agent should be selected. Therapy
should be continued for 10 days. |
|
|
Patient Category
Recommended Therapy Contained Casualty Setting |
|
|
Adults –
preferred choices Streptomycin, 1 g IM twice daily Gentamicin, 5 mg/kg IM or IV once daily or 2 mg/kg
loading dose followed by 1.7 mg/kg lM or IV 3 times daily† |
Alternative
choices Doxycycline, 100 mg IV
twice daily or 200 mg IV once daily Ciprofloxacin, 400 mg IV twice daily‡ Chloramphenicol, 25 mg/kg IV 4 times daily§ |
|
Children
– preferred choices Streptomycin, 15 mg/kg IM twice daily (maximum
daily dose, 2 g) Gentamicin, 2.5 mg/kg IM or IV 3 times daily† |
Alternative
choices Ciprofloxacin, 15 mg/kg IV twice daily‡ Chloramphenicol, 25 mg/kg IV 4 times daily§ |
Pregnant Women – preferred choices▲Gentamicin, 5 mg/kg IM or IV once daily or 2 mg/kg
loading dose followed by 1.7 mg/kg IM or IV 3 times daily† |
Alternative
choices |
Patient Category Recommended Therapy Mass Casualty Setting |
|
|
Adults –
preferred choices Doxycycline, 100mg orally twice daily†† Ciprofloxacin, 500 mg orally twice daily‡ |
Alternative choices loramphenicol, 25 mg/kg orally 4 times daily§** |
Children
– preferred choices
Doxycycline, †† If >45 kg, give adult dosage. If <45 kg, then give 2.2mg/kg orally twice daily Ciprofloxacin, 20 mg/kg orally twice daily |
Alternative
choices Chloramphenicol, 25 mg/kg orally 4 times daily§** |
|
Pregnant Women – preferred choices▲ Doxycycline, 100 mg orally twice daily†† Ciprofloxacin, 500 mg orally twice daily |
Alternative
choices Chloramphenicol, 25 mg/kg orally 4 times daily§** |
|
*These are consensus recommendations of the Working
Group on Civilian Biodefense and are not necessarily approved by the Food and
Drug Administration. See “Therapy” section for explanations. One
antimicrobial agent should be selected. Therapy should be continued for 10
days. Oral therapy should be substituted when patient’s condition improves.
IM indicates intramuscularly; IV, intravenously. |
|
|
† Aminoglycosides must be adjusted according to
renal function. Evidence suggests that gentamicin, 5 mg/kg lM or IV once
daily, would be efficacious in children, although this is not yet widely
accepted in clinical practice. Neonates up to 1 week of age and premature
infants should receive gentamicin, 2.5 mg/kg IV twice daily. |
|
|
‡ Other fluoroquinolones can be substituted at doses
appropriate for age. Ciprofloxacin dosage should not exceed lg/d in children. |
|
|
§Concentration should be maintained between 5 and
20 pg/mL. Concentrations greater than 25 pg/mL can cause reversible bone
marrow suppression.35,62 |
|
|
\ Refer to “Management of Special Groups” for
details. In children, ciprofloxacin dose should not exceed 1 g/d,
chloramphenicol, should not exceed 4 g/d. Children younger than 2 years
should not receive chloramphenicol. |
|
|
▲Refer to “Management of Special Groups” for
details and for discussion of breastfeeding women. In neonates, gentamicin
loading dose of 4 mg/kg should be given initially.63 |
|
|
# Duration of treatment of plague in mass casualty
setting is 10 days. Duration of postexposure prophylaxis to prevent plague infection
is 7 days. |
|
|
** Children younger than 2 years should not receive
chloramphenicol. Oral formulation available only outside the United States. |
|
|
†† Tetracycline could be substituted for
doxycycline. |
|
Control Measures and Decontamination
Remove clothing from patients if visible flea
infestation is noted. Bag clothing appropriately.
1. In hospital precautions:
a) Pneumonic
Plague: Droplet precautions (patients should wear regular surgical mask
when transported out of room) until 48 hours after the start of effective
therapy and there is a favorable clinical response.
b) Bubonic
Plague: Droplet precautions (patients should wear regular surgical mask
when transported out of room) until pneumonia had been excluded and
appropriate therapy
initiated. Then Standard Precautions.
2. Environmental
decontamination:
No special precautions are
necessary
Notification
Internal: At hospital notify ________.
External: All suspected cases of suspected plague
exposure are Class Al Reportable and should be reported immediately to the
Local Health Department who will then contact the State Health Department
and/or CDC.
Lab
Due to potential risks associated with handling infectious
materials, laboratory testing should be the minimum necessary for diagnostic
evaluation and patient care. Laboratory specimens should be placed in plastic
bags that are sealed, and then transported in clearly labeled, durable,
leak-proof containers directly to the specimen handling area of the laboratory.
Care should be taken not to contaminate the external surfaces of the container.
Lab personnel should be notified of what they are handling. Bio Safety Level 2
should be used for handling specimens.
SPECIMENS
|
PLAGUE
(Yersinia pestis) |
Blood
Cultures: two separate sets from different sites (one set is 2 bottles – 10
ml each bottle) |
2 red-top
or gold-top tubes (for
serology) |
Sputum |
CSF (if
meningeal signs present) |
Bubo
Aspirate |
Skin scraping
of lesions |
ID
Consult |
Note on
requisition |
|
Possible Y. pestis exposure in an asymptomatic
patient |
No |
No |
No |
No |
No |
No |
No |
Not
applicable |
|
Plague – pneumonic or bubonic |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
R/O
Plague |
References
JAMA, May 3, 2000—Vol. 283, No. 17
JAMA, May 3, 2000—Vol. 283, No. 17, 2281-2290
CDC Website
http://www.cdc.gov/ncidod/dvbid/plague/index.htm
Note: These are guidelines that have been developed with data
available as of 1-21-02.
Initially Prepared by
The Akron Regional Hospital
Association
Emergency Preparedness
Subcommittee
August 20, 2002