immunization for smallpox ended in the United States in 1972 (CDC, 2017). The incubation period for smallpox lasts from 7 to 19 days. The person is not contagious during this period. This phase is followed by fever, body aching, and sometimes vomiting. The second stage is sometimes contagious and lasts from 2 to 4 days. The next stage starts with the outbreak of rash or spots in the mouth and throat and is highly contagious. This stage lasts about 4 days. The areas then form pustules which break out over the entire body lasting about 5 days, then scabs form. It takes about 6 days for the scabs to fall off. The patient is still contagious during this period. It takes about 4 weeks after the rash appears for all scabs to fall off and for the patient to be considered no longer contagious (CDC, 2017). See Figure 1 for pictures of smallpox rashes and pustules.
(National Institute of Allergy and Infectious Disease, 2021). This disease rejuvenated concern for how health systems can maintain quality care when faced with unrelenting burdens (CDC, 2021c). The National Academy of Medicine recently suggested, in its call to face the threat of modern disasters and pandemics, that we develop tiered, proactive strategies that necessitate a cross-cutting, collaborative approach to addressing increasingly difficult healthcare management decisions (Margus et. al, 2020). Smallpox virus The virulence of even one case of smallpox makes it a public health emergency in a population that has not been immunized. In July 2018, the U.S Food and Drug Administration approved TPOXX (tecovirimat) for the treatment of smallpox. This was in response to the concern of smallpox being used as a bioweapon (USHHS, 2021a). This is a key issue in the United States because
Figure 1. Smallpox
[photographs] (CDC, 2016)
Anthrax Anthrax is not contagious. Infection occurs when people inhale the spores. This can happen when working with wool or animals or in any delivery device containing anthrax. The spores can get into an open wound and, when delivered in a bomb, will complicate recovery with the concomitant contamination of wounds. In the United States, transmission from animals is rare as herds are vaccinated (CDC, 2015a). Symptoms may include flu-like symptoms, such as sore throat, mild fever, fatigue, and muscle aches, which may last a few hours or days, mild chest discomfort, shortness of breath, nausea, coughing up blood, swollen glands, or painful swallowing. The only ways to confirm an Anthrax diagnosis are to measure antibodies or toxins in the blood or test directly for Bacillus anthracis in a blood sample, skin lesion swab, spinal fluid, or respiratory secretions. Samples must be taken before the patient begins taking antibiotics for treatment (CDC, 2015a). Tularemia Tularemia can be in contaminated water or food. The most serious mode of transmission is inhalation from a bomb. When ingested, patients may develop sore throat, tonsillitis, and ulcers in the mouth. These symptoms are usually accompanied by swollen lymph glands and fevers that can reach 104 °F. When the tularemia bacteria are inhaled, the effects on the lungs make it difficult to breathe. The bacteria are quickly carried throughout the body by the circulatory system. Patients may present coughing and have irritation and inflammation of the eyes (CDC, 2015b). To confirm a diagnosis of tularemia, blood cultures are taken. Laboratory technicians should take special precautions. As with other infectious agents, antibiotics such as streptomycin, gentamicin, doxycycline, and ciprofloxacin are given. Treatment of the infection can last from 10 to 21 days, and full recovery can be expected. Since the transmission is not from person to
person, isolation is not necessary. This bacterium may be found in rabbits, rodents, and hares and can be transmitted by tick bites. Some countries vaccinate for tularemia, but the United States does not (CDC, 2018i). Brucellosis There are three types of brucellosis: Abortus, melitensis, and suis. The most common brucellosis transmission is from drinking contaminated milk or eating milk products from sheep, cows, and goats. Terrorists may use this bacterium in a bomb or aerosol to infect populations. The bacteria can enter through wounds, mucous membranes, or inhalation. It is extremely rare to spread this from person to person. The presenting symptoms are sweats, fever, malaise, anorexia, headache, fatigue, and muscle pain. These symptoms may become recurrent, and arthritis may result in the joint areas. Diagnosis is confirmed through blood cultures. Treatment is a combination of doxycycline and rifampin antibiotics for a minimum of 6 to 8 weeks (CDC, 2012; CDC, 2019). Melioidosis Melioidosis is primarily found in the tropics and is also called Whitmore’s disease . It is found in contaminated soil and water and can be spread by inhaling the dust or when contaminated soil comes in contact with an abrasion (CDC, 2021a). A high mortality rate is associated with the bacterium Burkholderia pseudomallei that causes this disease. Pneumonia is the chief presenting feature. Treatment consists of a long course of intravenous antibiotics (Stewart et al., 2017). Melioidosis is used as a bioweapon because it is resistant to many antibiotics, making it difficult to treat. Without prompt treatment, nine out of 10 people will die. Bioterrorists may release this agent in the air, water, or food. It may be hard to diagnose melioidosis quickly, which further contributes to mortality because it presents like many other common diseases such as pneumonia, flu, or tuberculosis (CDC, 2017b).
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