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  • William W. Forgey, MD

Bioterrorism and Infectious Disease update part 1 of 3

Updated: Sep 18

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


So, what is the approach to infectious disease?


Identify the potential geographic risk of the diseases; where are they lurking? Let’s look at the vector that spreads the disease; how do we block it from attacking us? If someone gets ill, how do we identify the most likely cause and what is the best treatment available to us? That is what this chapter is about, and you can see why it is important in your planning, particularly if you are leaving the grid.


Tables summarize the diseases of North America (table 9-2) and high-risk illnesses and diseases encountered in world travel (table 9-3) where you find yourself when leaving your normal habitat. The individual sections of this chapter discuss these diseases in greater detail, including treatments when using the items suggested for the Off-Grid Medical Kit. Management of issues such as pain, fever, vector control, water purification, and other preventative measures are covered elsewhere in this book and also must be considered important to preventing and managing these diseases.


Bioterrorism is when one of these diseases is brought to you. Some of these illnesses are rarely seen in North America; others are here but seldom encountered. Some diseases are returning in force due to low immunization rates. The US government classifies potential bioterrorism agents/diseases into three categories:


Category A

  1. Can be easily disseminated or transmitted from person to person

  2. Result in high mortality rates

  3. Might cause public panic and social disruption

  4. Require special action for public health preparation

Category B

  1. Are moderately easy to disseminate

  2. Result in moderate morbidity and mortality

  3. Require special enhancements of CDC’s diagnostic capacity and enhanced surveillance

Category C

  1. Availability

  2. Ease of production and dissemination

  3. Potential for high morbidity and mortality rates and major health impact

Diseases found naturally in North America that are considered category A are plague (page 232) and tularemia (page 241), and in category B are typhus fever (page 242) and various food and waterborne diseases (pages 218–242). Other category A diseases such as anthrax (the last case in the US was in 1976), botulism (caused by poor food preservation), and smallpox (now extinct from the world except in certain US and Russian laboratories), are not something you will encounter unless there is a mass bioterrorism release. The viral hemorrhagic fevers are also in this category (Ebola, Marburg, Lassa, Machupo viruses). Category B agents encountered naturally are brucellosis, glanders, melioidosis, psittacosis, and Q fever—again, diseases that are so rare as to be insignificant in the normal experience of a prepper.


This takes us back to the issue of a mass terrorism release of the rare diseases. Your greatest risk comes not from the weaponized dispersal of a disease, but from nature effectively accomplishing identical results. Included in this group are the diseases listed in tables 9-1 and 9-2, below, and the childhood diseases that are reappearing because decreased immunization rates have resulted in the loss of “herd immunity,” the percent of a population that, when immune from an illness, will interrupt the spread of that illness through the remaining, even nonimmune, population. If a certain percentage of a group loses its herd immunity, a single case can spread like wildfire through the entire group, infecting even those who have some immunity due to the overwhelming number of germs that a massive flare in the infection causes. Depending upon how virulent the germ is and how easily it spreads, various levels of immunity must be present to prevent this “wildfire” spread.




It is interesting that some of the most dangerous diseases have a relatively low herd immunity required for the group protection from disease acceleration. Ebola has a high case-fatality rate of 60 to 90% in the case of the Zaire strain and 40 to 60% in the Sudan variety. But for potential number of deaths on the planet, it is hard to beat the danger of influenza. An aggressive strain of influenza could reach a mortality rate of 2.5%, but as the disease spreads easily among nonimmune persons, where virtually everyone catches it (unlike Ebola, which no one should catch with simple body fluid precautions), the death toll can be astounding.


Sometimes herd immunity does not protect you from a disease like tetanus, as you catch this from spores when they enter your body via the skin from the environment and not from another person.


A bioterrorism release of a germ will not collapse the grid, but a grid collapse frequently causes a massive infectious breakout of the various waterborne diseases, including typhoid fever and cholera. If the grid is intact during a bioterrorist release, it would require and can rely on the expertise of the CDC and US Department of Homeland Security to respond with appropriate guidance and treatment, including specialized vaccine. In my opinion, the prepper needs to prevent and manage the diseases listed in this book. Prevention is simple, basic, and critical. It consists of proper hygiene (washing hands), proper water sourcing, proper food preparation and storage, proper insect protection, and proper immunizations. Beyond the commonly recommended infant, childhood, and adult immunizations, the prepper should consider typhoid, as it commonly explodes during natural disasters. The grid will withstand a bioterrorism attack but is vulnerable to many natural and human-made events, including nuclear warfare (chapter 4), and it is those issues that the prepper must calculate into the survival equation.




MANAGING INFECTIOUS DISEASES IN NORTH AMERICA AND POTENTIAL OFF-GRID TRAVEL DESTINATIONS


Anaplasmosis

Caused by the bacterium Anaplasma phagocytophilum and previously known as human granulocytic ehrlichiosis (HGE), this has more recently been called human granulocytic anaplasmosis (HGA). It is transmitted primarily from the black-legged tick (Ixodes scapularis) and the western black-legged tick (Ixodes pacificus). Symptoms including fever, headache, chills, and muscle aches occur within 1 to 2 weeks of a tick bite. Lab tests can eventually confirm the diagnosis, but symptoms are similar to the other tick-borne diseases. The firstline treatment for adults and children of all ages is doxycycline.


Babesiosis

First discovered in Yugoslavia in 1957 and detected in the United States in 1968, this malaria-like illness is caused by a protozoan parasite that invades red blood cells. Two species have been identified, Babesia microti in the northeastern United States, and B. equi in California. An unidentified species caused this disease in a patient in Washington State. Of the approximately 2,000 cases reported in the United States, 95% were reported in Connecticut, Massachusetts, Minnesota, New Jersey, New York, Rhode Island, and Wisconsin. Tick-borne transmission of Babesia parasites is well established in these states.


Symptoms begin gradually 1 week after a tick bite with fatigue and loss of appetite, giving way in several days to fever, drenching sweats, muscle aches, and headache. The illness ranges from mild to severe, with death occurring in about 10% of patients. Treatment is available with oral quinine plus clindamycin (not included in the recommended medical kit). Protection from tick bites is best accomplished by treating clothing with permethrin (see page 202).


Blastomycosis

This infectious disease is caused by the fungus Blastomyces dermatitidis. Outbreaks usually cluster, with multiple members of a party becoming ill. It is found in the Mississippi River Valley and the southeastern United States. It is also found in various parts of Africa. Wisconsin may have the highest incidence of blastomycosis of any state, with yearly rates ranging from 10 to 40 cases per 100,000 persons in some northern counties. In the United States it has been associated with beaver lodges and digging in contaminated soil. It can also result from dog bites.


Onset of illness is slowly progressive, usually starting with a cough and developing into pneumonia with fevers, shortness of breath, chest pain, and drenching sweats. The symptoms generally present 3 weeks to 3 months after breathing in the fungal spores.


Infected blood carries the fungus to the skin and other tissues. Skin lesions enlarge with a collapsed center, purplish-red border, and frequent ulcerations.


Treatment is with specific antifungal medications.


Chikungunya Fever

This viral infection is spread by the Aedes mosquito (see Mosquitoes, page 204). Although not related to dengue fever, it is very similar clinically, with particularly miserable, virtually crippling joint aches, particularly of the ankles, wrists, and hands. Since it mimics dengue and Zika virus, it is best to avoid treating with nonsteroidal antiinflammatory medications such as ibuprofen or aspirin, as there can be bleeding complications with these diseases. Use Tylenol or Ultram for pain management. The painful effects of this disease can last for months.


Cholera

This intestinal infection, caused by the bacterium Vibrio cholerae, produces profuse, cramping diarrhea. Death can come from dehydration; indeed, the death toll can reach the tens of thousands during an epidemic. Ingestion of water contaminated with the bacteria spreads the disease. Humans are the only documented hosts for this disease.


The most important treatment is to use oral rehydration as indicated on page 88. Antibiotics can reduce the shedding of cholera in the stool and can reduce diarrhea volume and duration by 50% but are not required for treatment, only adequate rehydration. A single dose of 3 doxycycline 100 mg tablets from the Rx Oral/Topical Medication Module is adequate to treat shedding.


Coccidioidomycosis

Also called San Joaquin fever or valley fever, coccidioidomycosis is a fungal infection caused by Coccidiodes immitis. Found in the San Joaquin Valley of California and throughout the southwestern United States, this disease is caught by inhaling the fungal spores in dust.


Symptoms can be delayed in travelers, appearing after leaving the endemic area. The primary symptoms are those of an upper respiratory infection, bronchitis, or pneumonia. Incubation time varies and a progressive form may occur weeks, months, or years after the original infection in people with decreased immunity (e.g., AIDS patients, people on steroids, or those receiving chemotherapy).


Treatment is not required for those with upper respiratory infection symptoms. The diagnosis should be made with special blood tests to avoid missing other treatable pneumonia. Progressive disease must be treated with intravenous antifungal medications.


Colorado Tick Fever

A viral disease spread by ixodid (hard-shelled) ticks, this disease is twenty times more common in Colorado than Rocky Mountain spotted fever. It is also found in the other states of the western Rocky Mountains and in provinces of western Canada. It is most frequent in April and May at low altitudes, and in June through July at high altitudes. Onset is abrupt, with chills, fever of 100.4 to 104°F (38 to 40°C), muscle aches, headache, eye pain, and eye sensitivity to light (photophobia). The patient feels weak and nauseated, but vomiting is unusual. During the first 2 days, up to 12% of the victims develop a rash. In half the cases the fever disappears after 2 to 3 days, and the patient feels well for 2 days. Then a second bout of illness starts, lasting intensely for 2 to 4 days. This second phase subsides, with the patient feeling weak for 1 to 2 additional weeks.


This disease requires no treatment other than bed rest, fluids to prevent dehydration, and medications to treat fever and aches. However, as the same ticks can also spread potentially dangerous Rocky Mountain spotted fever, treatment with doxycycline (100 mg twice daily), as described on page 235, should be started immediately and continued for 14 days. Do not wait for the characteristic rash of Rocky Mountain spotted fever or the fever pattern of Colorado tick fever to develop, or for a firm diagnosis of either to be established by a physician.


Dengue

Dengue—also called breakbone fever or dandy fever—is a viral infection caused by group B arbovirus or flavivirus and is spread by bites from the Aedes aegypti mosquito. Dengue is endemic throughout the tropics and subtropics and can be expected to work its way into the southern United States due to the spread of the mosquito vector.


After an incubation period of 3 to 15 (usually 5 to 8) days, there is a sudden onset of fever (104°F or 40°C), chills, headache, low back ache, pain behind the eyes with movement of the eyes, and extreme aching in the legs and joints. The eyes are red and a transient flushing or pale pink rash occurs, mostly on the face. There is a relatively slow pulse rate for the temperature (see page 29). The fever lasts 48 to 96 hours, followed by 24 hours of no fever and a sense of well-being. A second rapid temperature increase occurs, but generally not as high as the first. A bright rash spreads from the arms and legs to the trunk, but generally not to the face. Palms and soles may be bright red and swollen. There is a severe headache and other body aches as well. The fever, rash, and headache constitute the “dengue triad.” The illness lasts for weeks, but mortality is nil. Treatment is rest and the use of pain and fever medication.


A condition called dengue hemorrhagic fever shock syndrome is lethal, however, and usually occurs in patients younger than 10, generally infants under 1 year of age. Dengue may be confused with Colorado tick fever, typhus, yellow fever, or other hemorrhagic fevers such as the Ebola virus or Rift Valley fever in Africa.This is a reaction to having had a dengue infection in the past and developing a partial immunity. A second infection of the disease (there are 4 serotypes that are closely related) can result in an autoimmune reaction that attacks the kidneys and causes other evidence of bleeding.


Echinococcus

Also called hydatid disease, the echinococcus infection is caused by the larval stage of a tapeworm found in dogs (with sheep as an intermediate host) or in wolves in wilderness areas (with moose as the intermediate host). This disease is found worldwide but is most commonly a problem in Europe, Russia, Japan, Alaska, Canada, and the continental United States, particularly Isle Royale in Lake Superior. When ingested by sheep, moose, or humans, the eggs form embryos that pass through the intestinal circulation into the liver and sometimes beyond into the lungs, brain, kidneys, and other tissue. There a fluid-filled cyst forms, which contains scolices, brood capsules, and second-generation (daughter) cysts containing infectious scolices. The hydatid cysts maintain their presence, sometimes bursting and spreading in a malignant fashion, causing destruction of liver, lung, and other critical tissues. After remaining without symptoms for decades, abdominal pain, jaundice, or chest pain and coughing may commence.


If the intermediate host is eaten by a carnivore (dog, wolf, or man), the infectious scolices are released into the gastrointestinal tract, where they develop into adult worms, and the life cycle continues.


Most hydatid disease is from the tapeworm (Echinococcus granulosis), but a rapidly progressive form develops when infection is caused by the E. multilocularis tapeworm. This tapeworm is carried primarily by foxes and domestic dogs and cats. Numerous small cysts form that multiply rapidly.The result is often fatal.There is no adequate medical treatment; attempts at surgical removal of multiple cysts are the only reliable hope for cure.


Ehrlichiosis

Since its discovery in 1987, the incidence of ehrlichiosis has increased to approximately 1,000 cases per year. In North America the time of greatest risk is May through July. This is a rickettsial infection caused by Ehrlichia chaffeensis that is spread by several species of ticks.


The incubation time ranges from 1 to 21 days (mean 7 days). It presents with high fever and headache, with other common symptoms being tiredness, nausea, vomiting, muscle aches, and loss of appetite. Twenty percent of victims develop a rash, but this rash is seldom on the feet or hands. This disease can range from mild, flulike symptoms to its extreme, which can be fatal.


The drug of choice is doxycycline, 100 mg twice daily for at least 3 days, beyond fever detection and until evidence of clinical improvement, typically 5 to 7 days total duration.


Encephalitis

Encephalitis from group A arbovirus (western equine encephalitis, eastern equine encephalitis, Venezuelan equine encephalitis) in the United States and Canada, and from group B arbovirus (St. Louis encephalitis) in the United States can be prevented by liberal use of repellent and covering exposed areas with netting or clothing to prevent bites from infected mosquitoes. Symptoms of these illnesses include high fever (104°F, or 40°C) and generally headache, stiff neck, vomiting, and, at times, diarrhea. These cases can be fatal and require evacuation to medical help.


Cool the patient with external means (cool water, fanning), and the use of aspirin or Mobigesic. The disease occurs in epidemics; be very careful with mosquito exposure when the disease becomes prevalent.



Giardiasis

Intestinal infection by Giardia lamblia, a single-cell parasite that causes giardiasis or beaver fever, is becoming a significant problem in wilderness travel in the United States and is a very common cause of traveler’s diarrhea. The stools of infected individuals contain the infective cyst form of the parasite. These cysts can live in water for longer than 3 months. Other mammalian vectors, such as the beaver, are responsible for much of the spread of this disease.


In the active disease, the trophozoite form attaches itself to the small bowel by means of a central sucker. Multiplication is by binary fission, or division. Approximately 2 weeks after ingestion of the cysts, there is either a gradual or abrupt onset of persistent watery diarrhea, which usually resolves in 1 to 2 weeks, but may persist less severely for several months. Abdominal pain, bloating, nausea, and weight loss from malabsorption may occur. Giardiasis is often without symptoms at all, and a chronic carrier state exists. In the United States about 4% of stools submitted for parasitology examination contain G. lamblia cysts.


Diagnosis is by finding cysts in stools, or trophozoites from gastric suction, or the “string test” from the duodenum. This latter test is performed by having the patient swallow a string, allowing the far end to pass into the first part of the bowel, or duodenum. When the string is pulled out, a microscopic examination may demonstrate the presence of trophozoites. In active disease the cysts are routinely secreted, but in the chronic carrier state, repeated stool examinations (at least three) are required to provide a 95% accuracy of test results. Treatment is with one of several drugs available in the United States, the most commonly used being Flagyl (metronidazole), 250 mg 3 times daily for 5 days. A better drug is tinidazole, 2 grams taken as a single dose. Prevention is by proper filtration of water, adequate chemical treatment, or heating water to 150°F (66°C). See page 89 for a full discussion of water treatment.


Hantavirus

Hantavirus was the cause of death among members of the Navaho Indian Nation in New Mexico in 1993. The virus has been identified in serum samples from 690 people in twelve states, with the greatest concentration in the western United States. It is caught by inhaling dust contaminated with feces from an infected deer mouse (Peromyscus maniculatus).


The onset of illness is a period of fever, muscle aches, and cough, followed by an abrupt onset of acute respiratory distress. The mortality rate has been 60%! There is no specific treatment available. Avoiding breathing dust that may contain the contaminated mouse feces is the preventative measure. When cleaning out cabins, use a wet mop and avoid sweeping dry debris.



Keep an eye out for part 2 of this post in which I'll address the various strains of Hepatitis, Leptospirosis, Lyme Disease, and Malaria to name a few.


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