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  • William W. Forgey, MD

Bioterrorism and Infectious Disease part 2 of 3



Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.


Hepatitis A

A viral infection of the liver, hepatitis A (infectious hepatitis) has worldwide distribution. It is transmitted by ingestion of infected feces, in water supplies contaminated by human sewage, in food handled by persons with poor hygiene, or in contaminated food such as raw shellfish grown in impure water. Contaminated milk and even infusion of infected blood products (see Hepatitis B, below) can spread this disease.


From the time of exposure to the appearance of symptoms takes 15 to 50 days. The disease can range from minor flu-like symptoms to fatal liver disease. Most cases resolve favorably within 6 to 12 weeks. Symptoms start abruptly with fever, lethargy, and nausea. Occasionally a rash develops. A characteristic loss of taste for cigarettes is frequent. In 3 to 10 days the urine turns dark, followed by jaundice, with yellowing of the whites of the eyes and the skin. The stool may turn light colored. There is frequently itching and joint pain. The jaundice peaks within 1 to 2 weeks and fades during the 2to 4-week recovery phase. The hepatitis A patient stops shedding virus in the stool prior to the jaundice developing and is therefore not contagious by the time the diagnosis is normally made. Personal hygiene helps prevent spreading, but isolation of the patient is not strictly required.


In most cases no specific treatment is required. After a few days to 2 weeks, appetite generally returns and bed confinement is no longer required, even though jaundice remains. The best guideline is the disappearance of the lethargy and feeling of illness that appeared in the first stages of the disease. Restrictions of diet have no value, but a low-fat diet is generally more palatable.


If profound prostration occurs, the trip should be terminated for the patient, and he should be placed under medical care. If possible, unimmunized contacts should be immediately given the hepatitis A shot, but the only practical solution is to immunize everyone against hepatitis A prior to leaving the grid.


Hepatitis B

Another viral infection of the liver, hepatitis B (serum hepatitis) is also worldwide in distribution. Transmission is primarily through infusion of infected blood products, sexual contact, use of contaminated needles or syringes, or even sharing contaminated razor blades. Dental procedures, acupuncture, and ear piercing and tattooing with contaminated equipment will also spread this disease.


Incubation period from time of exposure to the development of symptoms is longer than with hepatitis A, namely 30 to 180 days. The symptoms are similar, but the onset is less abrupt, and the incidence of fever is lower. There is a greater chance of developing chronic hepatitis (5 to 10% of cases). Mortality is higher, especially in elderly patients, where it ranges from 10 to 15%.


Immunization is available and is very effective.


Hepatitis C

A form of hepatitis, with similar manifestations to hepatitis B, has been designated as hepatitis C (formerly “non-A, non-B” since evidence of exposure to those virus particles was not previously found in blood tests). The transmission is probably the same as for hepatitis B. Incubation period is from less than 2 weeks to more than 25 weeks, with an average of 7 weeks for the development of clinical disease. Immunization is available. Specific treatment is available for this disease.


Hepatitis D

Hepatitis D, or the “delta agent,” can only infect a person who has hepatitis B. The presence of this mutated RNA particle causes the infection to be more fulminant. It spreads only by contaminated needle use. No specific treatment exists. It is considered prudent in persons who have this disease to immunize them with the only two vaccines now available, injections of vaccines for Hepatitis A and Hepatitis B.


Hepatitis E

An epidemic form of hepatitis (that is not A or C) has been termed hepatitis E. Spread by ingestion of contaminated food or water, the incubation period from time of contact ranges from 2 to 9 weeks, with a mean of 45 days. The disease mimics hepatitis A. The fatality rate in pregnant women is highest, about 20%. Outbreaks have been confirmed throughout developing areas of the Old World.There is no immunization or specific treatment available.


Hepatitis G

A new virus has been identified as the hepatitis G virus. A member of the family Flaviviridae, it can be spread by blood and sexual contact, just as with hepatitis B. There is no immunization or specific treatment available.


Leptospirosis

This disease is caused by a spirochete, genus Leptospira; a similar organism causes syphilis and Lyme disease. Like those diseases, this organism can attack virtually any organ system, yet 90% of those infected have no symptoms. The organism can live in damp soil, vegetation, and mud, but dies almost instantly upon drying. It spreads into the environment due to contaminated urine from ill animals. This germ is located all over the world, including the northern United States. Cuts and abrasions on the skin increase the risk of illness, while wearing protective footwear or clothing decreases it.


The incubation period is 7 days, with a range of 2 to 29 days. Initially it can present with high fever, headache, chills, muscle aches, red eyes, abdominal pain, diarrhea, rash, and jaundice. It may occur in two phases. Recurrent fevers of up to 102 ̊F (38.9°C). After the first phase, the patient may recover, then relapse 6 to 12 days later with similar symptoms. About 200 cases are identified in the United States (50% in Hawaii), but this is considered the most widely spread disease from an animal in the world. Between 1 and 5% of cases are fatal. The most serious form is called Wiel’s disease, which includes jaundice and severe lung, kidney, and bleeding disorders. It is treated with doxycycline, 100 mg twice daily for 2 weeks, but recent studies are unclear if antibiotics actually help. However, I subscribe to the old adage: You should not die in the tropics unless you die on doxycycline.


Lyme Disease

Lyme disease is caused by the spirochete Borrelia burgdorferi.The disease lives in various mammals but is transmitted to humans by the bite of several species of ticks. The disease is most common in the Northeast, extending through Connecticut and Massachusetts down to Maryland; in Wisconsin and Minnesota; throughout the states of California and Oregon; and in various south Atlantic and southcentral states, with cases reported in 43 of the Lower 48 states. A map showing the reported incidence of Lyme disease per county by state within the United States is located at www.cdc.gov. It has been found in the former Soviet Union, China, Australia, and Japan as well as several European countries.


The disease goes through several phases. In stage one, after an incubation of 3 days to a month, about 95% of victims develop a circular lesion in the area of the bite. It has a clear to pink center, raised border, is painless, and ranges from 1 to 23 inches in diameter. There are usually several such patches. The patient feels lethargic and has headache, muscle and joint pain, and enlarged lymph nodes. In stage two, 10 to 15% of patients can develop meningitis, and less than 10% develop heart problems. Symptoms may last for months but are generally self-limited. Approximately 60% enter stage three, the development of actual arthritis. Frequently a knee is involved. The swelling can be impressive. Stage three can start abruptly several weeks to 2 years after the onset of the initial rash.


Treatment of stage one Lyme disease is a tetracycline, such as doxycycline, 100 mg taken twice daily for 21 days. Alternate drugs are penicillin and erythromycin. Treatment of choice for stage two and three Lyme disease consists of Rocephin, 2 grams given intravenously (IV) daily for 14 to 21 days.


For prevention of Lyme disease after a recognized tick bite, routine use of antimicrobial prophylaxis or serologic testing is not recommended. A single dose of doxycycline may be offered to adult patients (200 mg) if (a) the attached tick can be reliably identified as an adult or nymphal deer tick (Ixodes scapularis) that is estimated to have been attached for more than 36 hours on the basis of the degree of engorgement of the tick with blood or of certainty about the time of exposure to the tick; (b) prophylaxis can be started within 72 hours of the time that the tick was removed; (c) ecologic information indicates that the local rate of infection of these ticks with B. burgdorferi is more than 20%; and (d) doxycycline treatment is not contraindicated.


One manifestation of Lyme disease is the development of a facial paralysis on one side, called Bell’s palsy. The involved side is expressionless since the patient is unable to move the muscles of the forehead, around the eye and so on. While there are other causes of Bell’s palsy, in North America this problem must be considered a result of Lyme disease until ruled out by a physician. Treatment of Bell’s palsy caused by Lyme disease is with oral antibiotic for 21 days.


Malaria

Human malaria is caused by five species of a protozoan: Plasmodium falciparum, P. vivax, P. ovale, P. malariae, and, rarely, P. knowlesi in Southeast Asia. The infection is acquired from the bite of an infected female anopheles mosquito. It may also be spread by blood transfusion. Falciparum malaria is the most serious. While all forms of this disease make people ill and may be lethal, P. falciparum is the one that kills.


Regions of the world where malaria may be acquired are subSaharan Africa, parts of Mexico and Central America, Haiti, parts of South America, the Middle East, the Indian subcontinent, and Southeast Asia. Resistance to chloroquine by the deadly P. falciparum has become widespread. For travelers in resistant areas, there are several prophylactic medications that are currently used: Malarone, Lariam, and doxycycline. To use Lariam (mefloquine), 250 mg, take 1 tablet weekly, starting 1 week prior to departure and continuing for 4 weeks after return. An alternate drug regimen, especially necessary when P. falciparum has become resistant to mefloquine, is the use of doxycycline, 100 mg to be taken once daily for prevention. This must be started the day before exposure, continued daily and for 4 weeks after exposure.


In areas with relapsing malaria (P. vivax and P. ovale), primaquine should be taken 1 tablet daily during the last 2 weeks of chloroquine therapy. This is usually appropriate for anyone faced with long exposure in areas with a high concentration of these strains of malaria. The International Association for Medical Assistance to Travellers (www.iamat.org) provides the percentage of P. falciparum versus P. vivax and P. ovale, as well as current information on resistance to chloroquine for each country.


If you are moving off the grid into an area with malaria, taking a very long-term (multiple years) of an antimalarial drug, while safe, may be impractical. Your best approach is strict mosquito protection with permethrin treatment of clothing, bed netting, residual spraying of building interiors, and skin protection—and the use of a treatment dose of medication if someone comes down with possible malaria. In children malaria frequently presents with diarrhea and abdominal pain, but in all expect severe fever with profuse sweating, headache, nausea, and vomiting. This can lead to convulsions and death. A good treatment is to use Malarone (250 mg atovaquone + 100 mg proguanil) 4 tablets once daily (take with food or milk and the same time each day, repeating the dose if patient vomits within 1 hour of taking it). A pediatric treatment dose is also devised based upon weight.The pediatric tablet is 62.5 mg atovaquone + 25 mg proguanil.





Measles (Rubeola)

A viral disease, measles spreads easily by inhalation and is one of the most contagious viral diseases; 90% of unimmunized persons who are exposed catch it. Occurring 1 to 3 weeks after exposure, usually 2 weeks, onset is with a high fever 105°F (40.6°C) and typically conjunctivitis, runny nose, and cough. Within 3 to 7 days after the fever, a rash appears on the face, then covers the entire body, lasting for 4 to 7 days. It is contagious 4 days before and 4 days after the rash breaks.


One per 1,000 cases can develop deadly brain infections. It can cause diarrhea, middle ear infections, and pneumonia, which can also become fatal. Persons with ear infections, and pneumonia may have a secondary bacterial infection as well due to their weakened condition, and these can be treated with antibiotics, but an antibiotic will not help if the cause is just from the measles. There is no specific treatment. Only use acetaminophen (Tylenol) and not aspirin or NSAIDs like ibuprofen when treating the fever. You can treat cough and runny nose symptoms. Children who contract this disease should receive 200,000 units of vitamin A (50 units under 6 months; 100,000 units for 6 to 11 months) with a repeat dose in 2 to 4 weeks. If this breaks out in a group, any nonimmunized persons will catch it.


Immunization is protective and is provided by the measlesmumps-rubella (MMR) vaccine.


Meningococcal Meningitis

This acute bacterial infection caused by Neisseria meningitidis results in inflammation of the brain and central nervous system. Many cases are without symptoms or consist of a mild upper respiratory illness. Severe cases begin with sudden fever, sore throat, chills, headache, stiff neck, nausea, and vomiting. Within 24 to 48 hours, the victim becomes drowsy and mentally confused, followed by convulsions, coma, and death. Immediate and appropriately large doses of the proper antibiotic are critical to save the patient’s life; the medical kit only has Rocephin, which must be given in large amounts: 1 gram IM twice daily. The disease is spread by contact with the nasal secretions of infected persons (sneezing and coughing).


While the disease is found worldwide, large epidemics are more common in tropical countries, especially sub-Saharan Africa in the dry season, New Delhi (India), and Nepal.

In 80% of healthy young adults, bacterial meningitis is caused by the meningococcus bacteria discussed in this section or by a pneumococci bacterium. Vaccines are available against both organisms.


Mumps

This virus infection spreads by respiratory droplets either by inhalation or touching them on surfaces. The incubation period is 16 to 18 days (range, 12 to 25). The disease starts with fever, headache, loss of appetite, and muscle aches. The hallmark of the disease is swelling of one or both parotid (salivary) glands. People are the most contagious from a few days before illness until 5 days after the onset of parotid gland swelling. The complications can be infections of the testicle, hearing loss, meningitis, encephalitis, and pancreatitis. Treat the fever with acetaminophen (Tylenol) and avoid aspirin.


Immunization is protective and is provided by the MMR vaccine. Unfortunately, the mumps component of this shot is the least effective and provides only about 88% protection, which may gradually decline and, in case of outbreaks, the MMR should be boosted.


Plague

Plague is caused by a bacterium (Yersinia pestis) that infects wild rodents in many parts of the world, including the western United States and parts of South America, Africa, and Asia. Epidemics occur when domestic rats become infected and spread the disease to humans. Bubonic plague is transmitted by infected fleas, while pneumonic plague is spread directly to other people by coughing. Plague is accompanied by fever, enlarged lymph nodes (bubonic plague) and, less commonly, pneumonia (pneumonic plague).


Treatment is with doxycycline, 100 mg twice daily. Treat fever as necessary. Isolate the patient, particularly if coughing. Drainage of abscesses (buboes) may be necessary (see page 147). Exposed persons should be watched for 10 days, but incubation is usually 2 to 6 days.


Rabies

Rabies can be transmitted on the North American continent by several species of mammals, namely skunk, bat, fox, coyote, raccoon, bobcat, and wolf. Obviously, if removing an animal from a trap, jogging past an animal, separating mother from child, or taking food from a critter causes an attack, the most likely cause of the attack is not from a rabid animal, but a scared or angry one. An attack by a wounded animal is cause for concern, as the animal may be wounded due to loss of coordination from rabies. Any unprovoked attack by one of these mammals should be considered an attack by a rabid animal. Dogs and cats in the United States have a low incidence of rabies. Information from local departments of health will indicate if rabies is currently of concern in your area.


Animals whose bites have never caused rabies in humans in the United States are livestock (cattle, sheep, horse), rabbits, gerbils, chipmunks, squirrels, rats, and mice. A significant epidemic of raccoon rabies has now extended from Florida to Connecticut, with isolated reports from New Hampshire and Ohio showing an expansion of this epidemic north and west. Hawaii is the only rabies-free state. Canada’s rabies occurs mostly in foxes and skunks in the province of Ontario.


The rabies vaccine available in the United States is very effective, with low side effects. It is expensive, but much less expensive than having to acquire post-exposure rabies immune globulin in addition to the complete series of shots.


The incubation can be brief or take months. It is caused when the virus is able to reach a peripheral nerve synapse, then penetrates it and moves toward the brain at the rate of 4 inches (10 cm) per day! Once the virus is in the nerve, the patient is doomed. Rabies is vicious, virtually 100% fatal once it develops clinically. It is sometimes called hydrophobia because the person appears to be afraid of water. They will be very thirsty but will choke when trying to swallow. Spasms, high fever, and terrible headache rapidly progress to death. Because of this, there is generous use of rabies vaccine and rabies-specific immune globulin to provide immediate, passive immunity until the vaccine can take effect. Approximately 16,000 to 39,000 people are vaccinated in the United States yearly to prevent this disease. Persons having to work with potentially rabid animal populations can be immunized with the vaccine and given yearly booster shots. It is possible to obtain the disease by merely being contaminated with the saliva or blood of an infected animal if it encounters a break in the skin or mucous membranes, and possibly even by breathing in dust infected with the virus. The first aid treatment will always be to irrigate the wound area, especially with a virucidal material, such as a saturated iodine water solution used for water purification (page 90), soap and water, or the other methods indicated for wound cleansing (page 122).


Relapsing Fever

This bacterial infection is caused by several species of Borrelia spirochete and is spread by body lice in Asia, Africa, and Europe, or by soft-bodied ticks in the Americas (including the western United States), Asia, Africa, and Europe. Symptoms occur 3 to 11 days from contact with the tick or louse vector and start with an abrupt onset of chills, headache, muscular pains, and sometimes vomiting. A rash may appear and small hemorrhages present under the skin surface. The fever remains high from 3 to 5 days, then clears suddenly. After 1 to 2 weeks a somewhat milder relapse begins. Jaundice is more common during relapse. The illness again clears, but between 2 and 10 similar episodes reoccur at intervals of 1 to 2 weeks until immunity fully develops.


Antibiotics are available for effective treatment. Mortality is low, less than 5% in healthy adults. Treatment is with doxycycline, 100 mg twice daily for 5 to 10 days. Personal hygiene is effective in preventing louse-borne disease, while control of ticks with insect repellent and frequent body checks and tick removal minimize the chance of tickborne disease. Unlike many tick-borne diseases that will not spread to humans unless the tick has been attached for longer than 2 days, relapsing fever can be caught soon after attachment.


Rocky Mountain Spotted Fever

This is an acute and serious infection caused by a microorganism called Rickettsia rickettsii and transmitted by ixodid (hard-shelled) ticks. It is most common in North Carolina, Virginia, Maryland, the Rocky Mountain states, and the state of Washington. The peak incidence of cases is from May to September. Onset of infection occurs after a 3to 12-day incubation period (average 7 days from the tick bite). Fever reaches 103 to 104°F (40°C) within 2 days. There is considerable headache, chills, and muscle pain at the onset. In 4 days a rash appears on the wrists, ankles, soles, and palms and then spreads to the trunk. Initially pink, this rash turns to dark blotches and even ulcers in severe cases.


Any suspected case of Rocky Mountain spotted fever should be considered a medical emergency. Do not wait for the rash to develop; rather, start the patient on antibiotics from the Rx Oral/Topical Medication Module. Give doxycycline, 100 mg, 1 tablet every 12 hours, and keep on this dosage schedule for 14 days. This is the drug of choice, and its early use can cut the death rate from 20% to nearly zero. Prevention is by the careful removal of ticks and the use of insect repellent and protective clothing. Obviously, anyone suspected of having this disease needs to be seen immediately by a physician.


Rubella (German Measles, 3-Day Measles)

A viral disease (unrelated to measles), this is highly contagious and is spread by persons between 7 days before and 5 to 7 days after the onset of the characteristic rash, which starts on the face and spreads to the body. Frequently there are aching joints, especially in young women. Incubation from exposure averages 14 days (range is 12 to 23 days). The illness may start with a low-grade fever and lymph node enlargement. Some people will not have symptoms, but they will also be contagious. It is extremely dangerous to a pregnant woman’s baby, even more so than Zika virus.


There is no treatment. Avoid aspirin for fever and use acetaminophen (Tylenol). It is prevented with immunization using the measlesmumps-rubella (MMR) vaccine.


Schistosomiasis

Blood trematodes or flukes are responsible for schistosomiasis (bilharziasis, safari fever). The eggs are deposited in freshwater and hatch into motile miracidia, which infect snails. After developing in the snails, active cercariae emerge, which can penetrate exposed human skin. Swimming, wading, or drinking freshwater must be avoided in infected areas.


Schistosoma mansoni is found in tropical Africa, part of Venezuela, several Caribbean islands, the Guianas, Brazil, and the Middle East. S. japonicum is encountered in China, Japan, the Philippines, and Southeast Asia. S. haematobium is in Africa, the Middle East, and small portions of India and islands in the Indian Ocean, all probably pretty far off the grid. The former two species are excreted in the stools, and the latter in urine. Shedding may occur for years. No isolation is required of patients. Specific treatments for the various species are available. Initial penetration of the skin causes an itchy rash. After entry, the organism enters the bloodstream, migrates through the lungs, and eventually lodges in the blood vessels draining either the gut or the bladder, depending upon the species. While the worms are maturing, the victim will have fever, lethargy, cough, rash, abdominal pain, and often nausea. In acute infections caused by S. mansoni and S. japonicum, victims develop a mucoid, bloody diarrhea and tender liver enlargement. Chronic infection leads to fibrosis of the liver with distension of the abdomen. In S. haematobium infections, the bladder becomes inflamed and eventually fibrotic. Symptoms include painful urination, urgency, blood in urine, and pelvic pain.





Keep an eye out for final segment of this post (part 3) which will covering Tapeworms, Chagas Disease, Typhoid Feaver West Nile Virus, Zika Virus and several others in between.



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