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PLAGUE AND ITS CURE

Saddam Hussein has been producing plague germ stockpiles
in Iraq as well as in a plant in Sudan he built for the
Sudanese Fanatical Muslim Government.  
This IS one disease we must prepare for.


PLAGUE--  (bubonic plague, pneumonic plague)

What is plague?

Plague is a serious illness caused by bacteria called Yersinia pestis. The disease is carried by rodents (i.e., rats and mice) and their fleas, which can then transmit the disease to humans as well as to other animals. Plague is very rare in the United States, but cases are still reported in the southwestern states of New Mexico, Arizona, Colorado, Nevada, and California. The most common form of plague is bubonic plague which affects the body's lymph nodes. When the infection involves the lungs, the disease is called pneumonic plague.

How do you get it?

You can get plague from the bite of infected fleas or by a scratch or bite while handling infected animals. You can also get it by breathing in airborne droplets from people who have the plague infection in their lungs or from infected household pets.

Editor:  Balaam's Ass Speaks--  The problem in germ warfare is that the plague is distributed on the wind and inhaled.  This gets it into the blood and lungs, and the progress of the disease is more rapid. Thus, the drug cures must be ON HAND, and they must be started at once as symptoms appear.

What are the symptoms of plague?

The first symptoms of bubonic plague include the sudden onset of fever with painful swelling of the lymph nodes, called bubos in the areas closest to the flea bite (typically, in the groin, armpit, or neck). Chills, muscle-aches, weakness, fatigue, nausea, and headache may also occur. If the infection spreads to the lungs, it produces pneumonia that is highly contagious and often, fata. Pneumonic plague is characterized by fever, swelling of the lymph nodes, cough, chest pain, and frequently, blood in the saliva.

When do symptoms start?

The symptoms of plague begin 1 to 7 days following the bite of an infected flea.

What is the treatment for plague?

Antibiotics can be prescribed by a doctor to treat plague. It is extremely important to detect and treat the disease early in its course. If left untreated, about half of those with bubonic plague will die. Prompt treatment can reduce the case fatality to less than 5%. Persons who are infected with pneumonic plague should be quarantined for 3 full days of medical therapy.

How do you keep from getting it?

Avoid rat-infested areas if possible. If you go to areas where plague is endemic (an ongoing problem), take precautions to protect yourself against rodents and their fleas.

Avoid contact with sick or dead animals found on the roadside or in the woods. The risk of being bitten by infected fleas is high when plague infection kills large numbers of rodents. The infected and starving fleas aggressively look for new hosts.

Carefully supervise the activities of all children and household pets (i.e., dogs and cats) when outdoors in forest/picnic areas where rodents make their nests.

International travelers to a plague-endemic area (areas reported to have an ongoing plague problem) are generally at low risk for infection for Y. pestis. If you are travelling to a plague endemic area call your doctor or the Health Department for advice.

Report all suspected plague cases promptly to your doctor or to the Department of Health.

"Return to Navigating the Communicable Diseases - Table of Contents"


I OFFER A SECOND AND RATHER INTERSETING PRESENTATION:

Authored by Demetres Velendzas, MD, Emergency Medicine, Department of Traumatology & Emergency Medicine, University of Connecticut Health Center and Susan Dufel, MD, FACEP, Residency Director, Associate Professor of Emergency Medicine, Department of Traumatology & Emergency Medicine, University of Connecticut Medical Center

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Background:

The plague has caused more fear and terror than perhaps any other infectious disease in the history of mankind. It has laid claim to nearly 200 million lives and has brought about monumental changes such as the end of the Dark Ages and the advancement of clinical research in medicine. Although it is still debated by historians, the plague has been responsible for three great pandemics in history. The first spread from the Middle East to the Mediteranean basin during the 5th and 6th century AD, killing approximately 50% of the population in these areas.

The second pandemic afflicted Europe between the 8th and 14th century wiping out nearly 40% of the population of Europe. The 3rd pandemic started around 1855 in China and spread to every major continent. It was during this pandemic in 1894 that Alexandre Yersin isolated the plague bacillus, developed an antiserum to combat the disease, and postulated its connnection with fleas and rats.

The plague bacillus was named Yersinia Pestis in his commemoration. These pandemics have suceeded in entrenching the plague in every major continent, with the possible exception of Australia. Unlike smallpox, the plague will never be eradicated. It lives in millions of animals and on billions of fleas that reside on them. It is a disease of the desert, the steppes, the mountain, and the forest. The epidemic in India in October of 1994, which affected nearly 600,000 residents, is a reminder of the ease with which the plague can escape medical control.

Pathophysiology:

The exact pathophysiology of the plague is unknown. The etiologic agent is Yersinia Pestis, an aerobic, facultatively anaerobic, intracellular gram negative bacillus.  The organism can be transmitted from a host to a human via the bite of a vector. There are more than 200 different rodents and species that can serve as hosts. These include domestic cats, dogs, squirrels, chipmunks, marmots, deer mice, rabbits, hares, rock squirrels, camels, and sheep.

The vector is usually the rat flea, Xenopsylla Cheopis. Thirty different species have been identified as able to carry the plague bacillus, however, including ticks and human louses. Rodents that are resistant to the infection form an enzootic stage that assures the long term survival of the bacillus. Occasionally, the infected animals are not resistant to the disease and die. This is known as an epizootic stage and it ensures the spread of the organism to new territory. A sylvatic stage occurs when humans are infected from wild animals. Transmission is not only vector mediated, but may occur via inhalation of aerosilized bacilli or close contact with infected tissue or fluid.

The bacillus proliferates in the fleas esophagus preventing food entry into the stomach. To overcome starvation, the flea begins a blood sucking rampage. Between its attempts to swallow, the distended bacillus - packed esophagus recoils, depositing the bacillus into the victims skin. The bacillus invades nearby lymphoid tissue producing the famous bubo - an inflamed, necrotic, and hemorrhagic lymph node.

Spread occurs along the lymphatic channels towards the thoracic duct with the eventual seeding of the vasculature. Bacteremia and septicemia ensue. The bacillus potentially seeds every organ including the lungs, liver, spleen, kidney, and rarely the meninges. Direct inhalation of the bacillus results in pneumonic plague and subsequent bacteremia and septicemia. The bacillus causes a multilobar hemorrhagic and necrotizing bronchopneumonia.

The third type of plague is primary septicemic plague. It is hypothesized that this occurs when the bacillus is deposited early in the vasculature bypassing the lymphatics. There is early dissemination with sepsis without the formation of a bubo. This is usually seen in bites to the oral, tonsillar, and pharyngeal area and is believed to occur because of the short lymphatic distance to the thoracic duct.

Frequency:

In the U.S.: An average of 18 cases per year have been reported during the last few decades. The prairie dog repopulation of the southwestern plains that had been depleted by an epizootic stage is nearly complete. There is some evidence to suggest that a new epizootic stage is begining with higher sylvatic infections being reported since 1992. West of the 100th parallel, in states like New Mexico, Arizona, Colorado, Utah, and California there exists one of the largest animal foci of the plague worldwide. It is of note that only one case of imported plague has been reported since 1926.

Internationally: Between 1967 and 1993 there have been annually an average of 1,666 cases of the plague reported by the World Health Organization. The number of actual cases is probably much higher given the failure of many countries to diagnose and report the plague. In decreasing order the following countries reported the most cases of the plague since 1979: Tanzania, Vietnam, Zaire, Peru, Madagascar, Burma, Brazil, Uganda, China, and the United States.

Mortality/Morbidity:

Bubonic Plague has 1-15% mortality in treated cases and a 40 - 60% mortality in untreated cases.  Septicemic plague (either primary or secondary) has 40% mortality in treated cases and a 100% mortality in untreated cases.   Pneumonic plague (either primary or secondary) has a 100% mortality if not treated within the first 24 hours of infection.

Sex:

Greater than 50% of cases occur in males.

Age:

Approximately 50% of cases occur in persons less than 20 years of age.

History:

Recent travel in the southwestern and pacific coast regions of the United States, particularly in New Mexico, Arizona, California, and Utah should raise suspicion of a flea bite. Although imported plague is rare, similar suspicion should exist for any recent travel in endemic areas outside the US.

Close contact with any potentially infected host or rural environment should raise suspicion for the plague. Although historically the rat has been thought to be the main plague host, currently in the United States, the ground and rock squirrel are the most common hosts. It is also noteworthy that in recent years the domestic cat has emerged as a prominent host that transmits the plague to veterinarians.

Fever, chills, body aches, sore throat, headache, and weakness.

Enlarged, painful, swollen "node"

Abdominal pain, nausea, vomiting (bloody at times), constipation or diarrhea, black or tarry stools. It is noteworthy that gastrointestinal complaints may precede the development of a bubo.

Cough which may be productive of bloody sputum.

Shortness of breath

Stiff neck (if meningitic infiltration by the plague bacillus has occurred)

Physical:

Temperature of 37 - 40.9 C, tachycardia, tachypnea, hypotension if in late septic shock.

Inguinal bubo (60%), axillary bubo (30%), cervical (10%), or epitrochlear (10%). Bubo's are usually no greater than 5 cm, extremely tender and erythematous, and surrounded by a boggy hemorrhagic area.

At the site of the flea bite there may be a maculo - papular lesion. Other dermatologic findings include vesicles, pustules, skin cyanosis of extremites (digits, penis, nares), ecchymosis, and petechiae (from DIC). It is thought the name "black death" originated because of the (black) cyanotic color of the necrotic limbs of infected individuals.

Diffuse crackles, diffuse areas of dullness to percussion (secondary to the patchy consolidation of pneumonic plague), hemoptysis

Diffuse abdominal tenderness, with or without guarding, splenomegaly, hematochezia or heme positive stools

Nuchal rigidity, diffuse muscle and joint tenderness

Various degrees of mental status changes, ranging from mild confusion or agitation to delirium and coma  

Seizures

Bleeding from any body site or cavity, ie. hematemesis, hematochezia, hemoptysis.

Gangrene and necrosis of areas like the digits, penis, nares. (This is a phenomenon ascribed to peripheral thrombosis secondary to DIC and cyanosis)

 

TREATMENT:

Prehospital Care:

Supportive Care

Crystalloid infusion to maintain normal vital signs and clinical hydration state.

Oxygen administration via nasal cannula, non - rebreather mask, or intubation, as determined by the respiratory

distress of the patient. Pulse oximetry can be used to monitor the degree of respiratory compromise.

Isolation Precautions

Health care personel should assume universal precautions when dealing with any patient with an infectious diseasepresentation. This should include goggles, gloves, and gown. If respiratory symptoms are present masks should be worn.

Emergency Department Care:

Supportive care

Depending on the stage of presentation supportive care will vary. Early presentation may only require crystalloid administration with monitoring of vital signs, clinical state, and urine output. Septic shock would require invasive hemodynamic monitoring with crystalloid and vasopressor agents. Airway managment may require intubation and mechanical ventilation with PEEP.

Empiric Antibiotic Coverage (see next section)

Strict Isolation Precautions

If respiratory symptoms are present universal precautions must be instituted with strict respiratory isolation for the first 72 hours of therapy. If no respiratory symptoms are present only 48 hours of isolation are needed or until there is no purulent drainage by the bubo. All contaminated material should be incinerated or autoclaved.

Consultations:

Infectious Disease Specialist

Early notification of the Centers For Disease Control will allow samples to be sent to the headquarters in Colorado for diagnosis by fluorscent antibody testing. In addition, the CDC in conjunction with the Department of Health will attempt to identify the source of the plague and implement early epidemiologic control measures to control a potential epidemic.

Medical Intensivist

In most cases of the plague some degree of septic shock will be present. Invasive hemodynamic monitoring and close observation of fluid and cardiac status will require admission to a Medical Intensive Care Unit.

MEDICATION:

Medical management of the Plague can involve a myraid of supportive medications, including crystalloids, colloids, medications used for intubation, vasopressor agents, antiulcer, and antipyretic agents. This section will only cover the antibiotic management of the plague. It is essential that antibiotics be given early, after samples for diagnostic purposes have been obtained.

Drug Category: Antibiotics - Drugs that cover Y. Pestis should be empirically given to any patient with predisposing risk factors, signs and symptoms of the plague.

Drug Name:  Streptomycin - Streptomycin is the drug of choice in combination with tetracycline or chloramphenicol. Because of the drugs toxicity it is usually discontinued after the first five days of treatment and tetracycline (or chloramphenicol) is continued alone for the remaining course. Streptomycin is a class D antibiotic for pregnancy. Given the high mortality of the plague, however, streptomycin and chlorapmhenical are the antibiotics of choice for the treatment of the plague in a pregnant patient.

Adult Dose:  30mg/kg/day IM divided either bid,tid,or qid Maximum daily dose 2g

Pediatric: 20-30mg/kg/day IM divided either bid, tid, or qid

Note - newborn infants with transplacental infection by the plague should receive gentamycin instead.

Contraindications: Contraindicated in a documented aminoglyside hypersensitivity reaction

Interactions: Synergistic toxicity with other ototoxic,nephrotoxic and peripheral neuromuscula

Pregnancy: D - Unsafe in pregnancy

Precautions:  Impaired renal funtion ( may need dose adjustment)

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Tetracycline (Sumycin, Tetracyn IV):  Drug of choice for use with streptomycin for the first five days of treatment (or until the patient is afebrile) and alone for the remaining course.(Marcus 1989)

Adult Dose:   15mg/kg (maximum 1g) po loading dose; 40-50mg/kg po q4 hours day 1; 30mg/kg po q 6hours for a total of 10 - 14 days of therapy; if oral therapy not tolerated may give IV 5mg/kg iv loading dose; 15mg/kg iv q4hours day 1; 5mg/kg iv q6hours for the remainding treatment; May switch to po at any time if patient can tolerate it.

Pedistric Dose: If the suspicion of the plague is high some authors recommend similar dosages and regimens for all pediatric cases, even children less than 8 years old.

Contraindications:  Pregnancy, Children less than 8 years of age

Interactions: Other nephrotoxic and hepatoxic drugs.

Pregnancy: D - Unsafe in pregnancy

Precautions: Renal insufficiency, liver disease, use with dairy products and Fe salts

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Drug Name:  Chloramphenicol (chloromycetin) - Drug of choice to be used instead of tetracycline, in plague meningitis (better CNS penetrations), profound hypotension, pleural or pericardial involvement, and in the pregnant patient.

Adult Dose: 50 - 100 mg/kg/qd iv divided q6hours; 30 mg/kg/qd po divided q6 hours may be substituted instead of iv for the last 5 days of therapy

Pediatric:  Infant 0-7 days 25 mg/kg po or iv qd; Infant >7 days 50 mg/kg/qd po or iv divided q12 hours

Contraindications:  No absolute contraindications. Careful in pregnancy, with breast- feeding, hepa

Interactions:  May increase effects of warfarin, phenytoin, chlorpropamide, and tolbutamide

Pregnancy:   C - Safety for use during pregnancy has not been established  

Precautions:  May cause anemia, aplastic anemia, childhood leukemia, and grey - baby syndrome

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Drug Category: Prophylactic antibiotics - This is how to take the drug if Plague is in the area or you know a terrorist release of the toxin has taken l\place where you were present.

[  Editor:  Balaam's Ass Speaks--  If the plague is active in your area in epidemic proportions, I suggest you take one 500 mg of Tetracycline a day, on an empty stomach, as a prophylactic. ]

All contacts with the bubonic or septicemic plague should be placed under surveillance. At first sign of illness (fever, adenopathy, etc.) regular antibiotic treatment should be started. Household contacts of patients with the bubonic or septicemic plague may have been exposed to the same fleas so antibiotic prophylaxis is recommended. Prophylaxis is also indicated for all contacts with patients with the pneumonic plague, ie. emergency department and EMS personnel.

Drug Name: Tetracycline - DOC in adults and children greater than 8 years of age.

Adult Dose:  25 - 50 mg/kg/day po divided qid

Pediatric:  250 mg po qid for 5-10 days

Contraindications: pregnancy, children less than 8 years of age,

Interactions:  Dairy products and Fe salts may reduce GI absorption.

Pregnancy:  D - Unsafe in pregnancy

Precautions:  May increase azotemia in patients with prior renal insufficiency.

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Editor:  Balaam's Ass Speaks--  The doctor has to tell you that the drugs are a problem for pregnant women.  If you know a lady you live has become infected with the plague, you will want to do one of the following:

1.  Contact a doctor and see if you can get medical help for the lady.

IF THAT CANNOT BE DONE DUE TO CHAOS:

2.  Start the course and take the risk.  The lady will certainly die if she was infected by breathing in the toxin, and if you do nothing. You should be aware that the baby could be born with problems though.


Cure of choice if you have no opportunity to follow the details above-  Tetracycline-- Double the first two day's doses and then follow normal dosing.  600 mg a day on empty stomach circa two hours after a meal.  Exception is Doxyciline and Minocycline which can be taken with food.  40 pills of 500 to 600 mg each should be taken over a maximum of a 10 day period.  The Dr. in Mexico suggested 500 mg every 6 to 8 hours.

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LINKS:

HERE IS A SOURCE OF CIPRO WHICH IS SAID TO BE GOOD FOR BIO-ATTACKS:
http://www.deskofgold.com/lindex.htm

* * * * *

THE REST OF THE ARTICLES IN THIS SERIES:

SURVIVAL DURING ATTACKS AND PANIC

MORE COMPLETE DISCUSSION OF PANIC AND BIO ATTACKS RESPONSE

A DISCUSSION OF BIOLOGICAL WARFARE AND THE USE OF TOXINS

BOTULISM AS BIOLOGICAL WARFARE AND ITS CURE

PLAGUE AS BIOLOGICAL WARFARE AND ITS CURE

ANTHRAX TERRORIST ATTACK AND HOW TO PREVENT AND CURE IT

SMALLPOX-- NO CURE-- Prelude to Armageddon




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