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ARMY FM 8-284
NAVY NAVMED P-5042
AIR FORCE AFMAN (I) 44-156
MARINE CORPS MCRP 4-11.1C
FIELD MANUAL
TREATMENT OF
BIOLOGICAL WARFARE
AGENT CASUALTIES
HEADQUARTERS, DEPARTMENTS OF THE ARMY, THE NAVY, AND
THE AIR FORCE, AND COMMANDANT, MARINE CORPS
DISTRIBUTION RESTRICTION: Approved for public release; distribution is unlimited.
17 July 2000
FM 8-284
NAVMED P-5042
AFMAN (I) 44-156
MCRP 4-11.1C
FIELD MANUAL
HEADQUARTERS
NO. 8-284
DEPARTMENTS OF THE ARMY,
NAVMED P-5042
THE NAVY, AND THE AIR FORCE,
AIR FORCE MANUAL (INTERSERVICE)
AND COMMANDANT, MARINE CORPS
NO. 44-156
Washington, DC 17 July 2000
MARINE CORPS
MCRP 4-11.1C
TREATMENT OF BIOLOGICAL WARFARE AGENT CASUALTIES
TABLE OF CONTENTS
Page
PREFACE
vii
CHAPTER
1.
INTRODUCTION
1-1.
The Threat of Biological Warfare Agents Against United States
Forces and Civilian Populations
1-1
1-2.
Modes of Delivery
1-1
1-3.
Employment of Biological Warfare Agents
1-2
1-4.
Classification of Biological Warfare Agents
1-3
1-5.
Portals of Entry
1-3
1-6.
Environmental Detection
1-4
1-7.
Diagnosis
1-5
1-8.
Specimen Collection
1-6
1-9.
Specimen Labeling
1-9
1-10.
Specimen Handling and Shipment
1-10
1-11.
Chain of Custody Responsibilities
1-10
1-12.
Identification Methods for Biological Warfare Agents
1-11
1-13.
Therapy
1-12
1-14.
Case Reporting and Epidemiological Assessment
1-12
1-15.
Prevention
1-12
1-16.
Protective Equipment
1-13
1-17.
First Aid
1-14
1-18.
Protective Measures and Handling of Casualties
1-14
1-19.
Patient Decontamination
1-15
1-20.
Infection Control
1-16
1-21.
Medical Evacuation
1-16
1-22.
Aeromedical Isolation Team
1-18
CHAPTER
2.
BACTERIAL AGENTS
Section
I.
Introduction
2-1
2-1.
General
2-1
i
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
Page
Section
II.
Anthrax
2-1
2-2.
General
2-1
2-3.
Biological Warfare Agent Delivery
2-2
2-4.
Environmental Detection
2-2
2-5.
Prevention
2-2
2-6.
Biological Warfare Clinical Presentation
2-3
2-7.
Diagnosis
2-3
2-8.
Treatment
2-4
2-9.
Control of Patients, Contacts, and Treatment Areas
2-4
2-10.
Medical Evacuation
2-4
Section
III.
Brucellosis
2-5
2-11.
General
2-5
2-12.
Biological Warfare Agent Delivery
2-6
2-13.
Environmental Detection
2-6
2-14.
Prevention
2-6
2-15.
Biological Warfare Clinical Presentation
2-7
2-16.
Diagnosis
2-7
2-17.
Treatment
2-7
2-18.
Control of Patients, Contacts, and Treatment Areas
2-8
2-19.
Medical Evacuation
2-8
Section
IV.
Melioidosis
2-8
2-20.
General
2-8
2-21.
Biological Warfare Agent Delivery
2-9
2-22.
Environmental Detection
2-9
2-23.
Prevention
2-9
2-24.
Biological Warfare Clinical Presentation
2-9
2-25.
Diagnosis
2-9
2-26.
Treatment
2-10
2-27.
Control of Patients, Contacts, and Treatment Areas
2-11
2-28.
Medical Evacuation
2-11
Section
V.
Glanders
2-11
2-29.
General
2-11
2-30.
Biological Warfare Agent Delivery
2-11
2-31.
Environmental Detection
2-11
2-32.
Prevention
2-11
2-33.
Biological Warfare Clinical Presentation
2-12
2-34.
Diagnosis
2-12
2-35.
Treatment
2-12
2-36.
Control of Patients, Contacts, and Treatment Areas
2-13
2-37.
Medical Evacuation
2-13
Section
VI.
Plague
2-13
2-38.
General
2-13
2-39.
Biological Warfare Agent Delivery
2-14
ii
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
Page
2-40.
Environmental Detection
2-14
2-41.
Prevention
2-14
2-42.
Biological Warfare Clinical Presentation
2-14
2-43.
Diagnosis
2-15
2-44.
Treatment
2-15
2-45.
Control of Patients, Contacts, and Treatment Areas
2-16
2-46.
Medical Evacuation
2-16
Section
VII.
Q Fever
2-16
2-47.
General
2-16
2-48.
Biological Warfare Agent Delivery
2-17
2-49.
Environmental Detection
2-18
2-50.
Prevention
2-18
2-51.
Biological Warfare Clinical Presentation
2-18
2-52.
Diagnosis
2-19
2-53.
Decontamination
2-19
2-54.
Treatment
2-19
2-55.
Control of Patients, Contacts, and Treatment Areas
2-20
2-56.
Medical Evacuation
2-20
Section
VIII.
Tularemia
2-20
2-57.
General
2-20
2-58.
Biological Warfare Agent Delivery
2-21
2-59.
Environmental Detection
2-21
2-60.
Prevention
2-21
2-61.
Biological Warfare Clinical Presentation
2-22
2-62.
Diagnosis
2-22
2-63.
Treatment
2-22
2-64.
Control of Patients, Contacts, and Treatment Areas
2-23
2-65.
Medical Evacuation
2-23
CHAPTER
3.
VIRAL AGENTS
Section
I.
Introduction
3-1
3-1.
General
3-1
Section
II.
Smallpox
3-1
3-2.
General
3-1
3-3.
Biological Warfare Agent Delivery
3-1
3-4.
Environmental Detection
3-1
3-5.
Prevention
3-2
3-6.
Biological Warfare Clinical Presentation
3-3
3-7.
Diagnosis
3-4
3-8.
Treatment
3-4
3-9.
Control of Patients, Contacts, and Treatment Areas
3-4
3-10.
Medical Evacuation
3-5
iii
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
Page
Section
III.
Venezuelan Equine Encephalitis
3-5
3-11.
General
3-5
3-12.
Biological Warfare Agent Delivery
3-6
3-13.
Environmental Detection
3-6
3-14.
Prevention
3-6
3-15.
Biological Warfare Clinical Presentation
3-6
3-16.
Diagnosis
3-6
3-17.
Treatment
3-7
3-18.
Control of Patients, Contacts, and Treatment Areas
3-7
3-19.
Medical Evacuation
3-7
Section
IV.
Viral Hemorrhagic Fevers
3-7
3-20.
General
3-7
3-21.
Biological Warfare Agent Delivery
3-9
3-22.
Environmental Detection
3-9
3-23.
Prevention
3-9
3-24.
Biological Warfare Clinical Presentation
3-9
3-25.
Diagnosis
3-9
3-26.
Treatment
3-10
3-27.
Control of Patients, Contacts, and Treatment Areas
3-10
3-28.
Medical Evacuation
3-12
CHAPTER
4.
TOXINS
Section
I.
Introduction
4-1
4-1.
General
4-1
Section
II.
Clostridium Botulinum Toxin
4-1
4-2.
General
4-1
4-3.
Biological Warfare Agent Delivery
4-2
4-4.
Environmental Detection
4-2
4-5.
Biological Warfare Clinical Presentation
4-2
4-6.
Prevention
4-3
4-7.
Diagnosis
4-3
4-8.
Treatment
4-3
4-9.
Control of Patients, Contacts, and Treatment Areas
4-5
4-10.
Medical Evacuation
4-5
Section
III.
Clostridium Perfringens Toxins
4-5
4-11.
General
4-5
4-12.
Biological Warfare Agent Delivery
4-5
4-13.
Environmental Detection
4-6
4-14.
Prevention
4-6
4-15.
Biological Warfare Clinical Presentation
4-6
4-16.
Diagnosis
4-6
4-17.
Treatment
4-6
iv
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
Page
4-18.
Control of Patients, Contacts, and Treatment Areas
4-6
4-19.
Medical Evacuation
4-7
Section
IV.
Ricin
4-7
4-20.
General
4-7
4-21.
Biological Warfare Agent Delivery
4-7
4-22.
Environmental Detection
4-8
4-23.
Prevention
4-8
4-24.
Biological Warfare Clinical Presentation
4-8
4-25.
Diagnosis
4-8
4-26.
Treatment
4-8
4-27.
Control of Patients, Contacts, and Treatment Areas
4-9
4-28.
Medical Evacuation
4-9
Section
V.
Saxitoxin
4-9
4-29.
General
4-9
4-30.
Biological Warfare Agent Delivery
4-10
4-31.
Environmental Detection
4-10
4-32.
Prevention
4-10
4-33.
Biological Warfare Clinical Presentation
4-10
4-34.
Diagnosis
4-10
4-35.
Treatment
4-11
4-36.
Control of Patients, Contacts, and Treatment Areas
4-11
4-37.
Medical Evacuation
4-11
Section
VI.
Staphylococcal Enterotoxin B
4-11
4-38.
General
4-11
4-39.
Biological Warfare Agent Delivery
4-12
4-40.
Environmental Detection
4-12
4-41.
Prevention
4-12
4-42.
Biological Warfare Clinical Presentation
4-12
4-43.
Diagnosis
4-13
4-44.
Treatment
4-13
4-45.
Control of Patients, Contacts, and Treatment Areas
4-13
4-46.
Medical Evacuation
4-13
Section
VII.
Trichothecene Mycotoxins
4-14
4-47.
General
4-14
4-48.
Biological Warfare Agent Delivery
4-14
4-49.
Environmental Detection
4-14
4-50.
Prevention
4-14
4-51.
Biological Warfare Clinical Presentation
4-15
4-52.
Diagnosis
4-15
4-53.
Treatment
4-15
4-54.
Control of Patients, Contacts, and Treatment Areas
4-15
4-55.
Medical Evacuation
4-15
v
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
Page
APPENDIX
A.
RECOGNITION OF A BIOLOGICAL WARFARE
AGENT CASUALTY
A-1.
General
A-1
A-2.
Types of Casualties
A-1
A-3.
Recognize Biological Casualties
A-2
APPENDIX
B.
MEDICAL MANAGEMENT AND TREATMENT IN
BIOLOGICAL WARFARE OPERATIONS
Section
I.
US Army Medical Treatment Facilities
B-1
B-1.
General
B-1
B-2.
Objectives of Health Service Support in Biological Warfare Operations
B-1
B-3.
Planning for the Management and Treatment of Biologically
Contaminated Casualties
B-2
B-4.
Emergency Medical Treatment of Biologically Contaminated
Casualties
B-2
B-5.
Patient Decontamination Methods
B-3
B-6.
Logistics
B-5
B-7.
Training
B-5
B-8.
Casualty Evacuation
B-5
Section
II.
US Air Force Medical Treatment Facilities
B-6
B-9.
General
B-6
B-10.
Detection of Biological Agents
B-7
B-11.
Identification
B-8
B-12.
Decontamination
B-8
Section
III.
US Navy Medical Treatment Facilities
B-9
B-13.
General
B-9
GLOSSARY
.................................................................................... Glossary-1
Section
I.
Abbreviations and Acronyms
Glossary-1
Section
II.
Definitions
Glossary-6
REFERENCES
.................................................................................. References-1
INDEX
........................................................................................ Index-1
PREFACE
Purpose
This publication serves as a guide and a reference for trained members of the Armed Forces Medical
Services and other medically qualified personnel on the recognition and treatment of biological warfare
vi
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
(BW) agent casualties. Information contained in this publication may also be relevant for the diagnosis and
treatment of patients with naturally acquired diseases or illnesses due to pathogens with BW potential.
Scope
a. This publication
(1) Classifies and describes potential BW agents.
(2) Provides procedures for collecting, handling and labeling, shipping, and identifying
potential BW agents.
(3) Describes procedures for medical diagnosing, treating, and management of BW casualties.
(4) Describes medical management and treatment in BW operations.
b. The material in this publication is applicable to both the conventional battlefield and the
integrated environment of the battlefield. (For the purpose of this publication, the integrated environment
is intended to mean warfare and/or contingency operations where nuclear, biological, and chemical [NBC]
weapons/agents are being employed or have a high probability of being employed in addition to conventional
weapons.)
c.
The treatment modalities contained in this manual differ from standard textbooks in that they
apply to BW agent exposures. The method of exposure for most BW agents is by inhalation; whereas, the
endemic disease exposure (if applicable) is by other means. Some are by ingestion, some by arthropod
bites, and others by dermal contact with the agent. This does not preclude service members becoming BW
casualties by these means.
d. The use of the term level of care in this publication is synonymous with echelon of care and
role of care. The term echelon of care is the old North Atlantic Treaty Organization (NATO) term.
The term role of care is the new NATO and American, British, Canadian, and Australian (ABCA) term.
Standardization Agreements
This manual is in consonance with the following NATO Standardization Agreements (STANAGs) and
ABCA Quadripartite Standardization Agreements (QSTAGs):
NATO
TITLE
STANAG
QSTAG
Warning Signs for the Marking of Contaminated or Dangerous Land
Areas, Complete Equipments Supplied and Stores
2002
Reporting Nuclear Detonations, Biological and Chemical Attacks,
and Predicting and Warning of Associated Hazards and Hazard Areas
2103
187
First Aid and Hygiene Training in NBC Operations
2358
vii
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
User Comments
Users of this publication are encouraged to submit recommendations to improve the publication. Comments
should be keyed to the page, paragraph, and line(s) of the text where the change is recommended. The
proponent for this publication is the United States (US) Army Medical Department Center and School
(AMEDDC&S). Comments should be forwarded to: Commander, AMEDDC&S, ATTN: MCCS-FCD,
1400 East Grayson Street, Fort Sam Houston, Texas 78234-6175.
Gender Statement
Unless this publication states otherwise, masculine nouns and pronouns do not refer exclusively to men.
Use of Trade Names/Trademarks
Use of trade names/trademarks in this publication is for illustrative purposes only. Their use does not
constitute endorsement by the Department of Defense (DOD).
References
References listed should be consulted for details beyond the scope of this publication.
viii
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FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
CHAPTER 2
BACTERIAL AGENTS
Section I. INTRODUCTION
2-1.
General
Bacterial organisms comprise the greatest number of pathogens in the list of potential BW agents. They
include the etiologic agents of anthrax, brucellosis, cholera, glanders, melioidosis, plague, Q fever, and
tularemia. Of these, anthrax is the most likely BW threat that troops will encounter in an AO. See
Appendix B for guidance on medical management of BW agent casualties.
Section II. ANTHRAX
2-2.
General
a. Etiologic Agent. The spores of Bacillus anthracis, an encapsulated gram-positive bacillus.
Sporulation occurs under adverse environmental conditions and when vegetative bacteria are exposed to air;
the spores are extremely hardy and can survive extremes of temperature, dryness, and flooding. When
conditions improve, the spores germinate to produce vegetative bacteria.
b. Reservoir. The soil, with worldwide distribution.
c.
Transmission. The stage in the bacterial life cycle, which poses a health hazard, is the spore.
Grazing animals contract spores from the vegetation. Humans contract spores via contact with infected
animals, their hides, wool, or other products; from ingesting contaminated meat; or from inhaling spores
during the processing of wool for textiles. Biting flies in sub-Saharan Africa may also transmit anthrax to
humans. Humans usually do not contract anthrax directly from the soil, unless they work with fertilizers
(bonemeal) prepared from infected animals. Also, humans can contract spores from inhalation of aerosolized
spores released during a BW attack.
d. Endemic Disease. Endemic infectious disease is contracted by inhalation, cutaneous exposure,
oropharyngeal exposure, and ingestion.
(1) Cutaneous anthrax accounts for more than 90 percent of all anthrax cases worldwide.
Disease results when Bacillus anthracis spores are introduced into the skin via inoculation of small cuts/
abrasions or inapparent skin lesions. It may possibly be introduced by biting flies. Cutaneous anthrax
features a painless necrotic ulcer with a black eschar and local edema. The case fatality rate for untreated
cutaneous anthrax is up to 20 percent, but with early, effective therapy is reduced to less than 5 percent.
(2) Oropharyngeal and GI diseases occur following the ingestion of anthrax spores, usually
from consuming meat from infected animals. The clinical features of oropharyngeal and GI anthrax are
discussed in paragraph 2-6.
2-1
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
(3) Inhalation anthrax occurs when individuals working with animal hides, wool, or bonemeal
inhale the spores. Also, inhalation anthrax may occur from inhalation of aerosolized spores released during
a BW attack. The clinical features of inhalation anthrax are discussed in paragraph 2-6.
2-3.
Biological Warfare Agent Delivery
Aerosolized spores may be delivered by missiles, bomblets, artillery fires, point release, or airborne line
release. Contamination of food and water may also be used.
2-4.
Environmental Detection
Nuclear, biological, and chemical teams or other bioenvironmental engineering (BEE) personnel operating
similar detection equipment accomplish detection. Preventive medicine/PHS/BEE personnel perform
detection in water supplies. Detection in food supplies may be performed by veterinary, PVNTMED, or
PHS personnel. Detection in animals may be performed by veterinary personnel.
2-5.
Prevention
a. Pre-exposure Prophylaxis. Prevention may be accomplished by immunization plus
chemoprophylaxis.
(1) Immunization. Anthrax vaccine is given in six doses at 0, 2, and 4 weeks and 6, 12, and
18 months, with annual boosting. A minimum of three doses administered within 6 months prior to the
exposure may confer protective immunity.
(2) Chemoprophylaxis. Ciprofloxacin hydrochloride tablets (500 milligrams [mg]) are given
orally every 12 hours beginning prior to imminent anthrax attack. When Ciprofloxacin hydrochloride
tablets are not available, doxycycline hyclate tablets (100 mg) are given orally every 12 hours beginning
prior to imminent anthrax attack. The chemoprophylaxis should be discontinued after attack if the use of
anthrax has been excluded.
b. Post-exposure Prophylaxis. Use immunization with chemoprophylaxis to prevent the clinical
manifestation of the disease.
(1) Anthrax vaccine. For personnel that have completed the six-dose series and are up to
date on boosters, or who have received at least three initial doses within 6 months prior to exposure, no
additional doses are indicated, except to complete the series as previously scheduled. For personnel who
have not received any immunizations, begin series and give a minimum of three doses; complete the six-
dose series, if possible.
(2) Chemoprophylaxis. Chemoprophylaxis is recommended as an adjunct to immunization
for post-exposure prophylaxis. Ciprofloxacin hydrochloride tablets (500 mg) should be taken orally every
2-2
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
12 hours for at least 4 weeks. When Ciprofloxacin hydrochloride tablets are not available, doxycycline hyclate
tablets (100 mg) should be taken orally every 12 hours for at least 4 weeks. The duration of chemoprophylaxis
administration for individuals without receipt of any vaccine should be extended until they receive at least
three doses of vaccine. Chemoprophylaxis should be withdrawn under careful observation and with access
to an MTF with intensive care and consultative assets. If fever develops following the withdrawal of
chemoprophylaxis, empiric therapy for anthrax is indicated pending etiologic diagnosis.
2-6.
Biological Warfare Clinical Presentation
a. Incubation Period. The incubation for anthrax is hours to 7 days. Most cases present within
48 hours post-exposure.
b. Signs and Symptoms.
(1) Inhalation anthrax. Inhalation anthrax will begin with nonspecific symptoms of fever,
malaise, and fatigue. A nonproductive cough and vague chest discomfort may be present. These initial
symptoms may be followed by a short period of symptomatic improvement, hours to 3 days in duration.
This will be followed by an acute phase, including the abrupt onset of severe respiratory distress with
dyspnea, stridor, diaphoresis, and cyanosis. Bacteremia and toxemia, septic shock, metastatic infection
(meningitis in approximately 50 percent of the cases), and death usually occurs within 24 to 36 hours from
the onset of the acute phase.
(2) Oropharyngeal or gastrointestinal anthrax. Oropharyngeal or GI anthrax can occur
following ingestion of food contaminated with anthrax spores.
(a) Oropharyngeal anthrax will present with initial symptoms of fever, sore throat, and
difficulty swallowing. The disease may progress to an acute phase with symptoms including a necrotic
ulcer or eschar involving the hard palate, tonsils, or posterior oropharyngeal wall, edema of cervical tissues
(possibly resulting in upper airway obstruction), and cervical lymphadenopathy. Most acute cases progress
to septic shock and death.
(b) Gastrointestinal anthrax begins with vague initial symptoms featuring fever,
anorexia, nausea, and vomiting. Abdominal pain, bloody vomiting, bloody diarrhea, and possibly massive
abdominal swelling (ascites) may follow these symptoms. Also, septic shock and death may follow these
symptoms.
2-7.
Diagnosis
During the incubation period, nasal swabs and specimens of respiratory secretions sent for PCR are the
most important diagnostic specimens. During the early disease, blood and respiratory secretions may be
sent for rapid identification by genetic typing (PCR). A rapid diagnostic test is available that detects toxin
antigens in the blood during the acute phase. Chest x-ray may be normal or show hilar adenopathy early in
the illness and may show a widened mediastinum and pleural effusions during the acute phase.
2-3
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
2-8.
Treatment
a. Triage Categories. Patients presenting with initial signs of inhalation anthrax should be placed
in the Immediate category, as early aggressive treatment is lifesaving. Depending on the numbers of cases
and available resources, patients presenting in the acute phase of inhalation anthrax should be placed in the
Immediate or Expectant categories.
b. Medical Management.
(1) Supportive care includes maintaining the airway, providing resuscitative fluids, and
providing vasopressors as indicated for shock.
(2) Specific therapy includes the administration of ciprofloxacin (400 mg intravenous [IV]
every 12 hours) or doxycycline
(200 mg IV loading dose, followed by 100 mg IV every 12 hours).
Specific therapy may also include administration of penicillin (4 million units IV) every 4 hours, if isolate is
sensitive to penicillin.
(3) A tracheostomy is indicated for upper airway obstruction due to oropharyngeal anthrax.
Surgical debridement of cutaneous lesions is contraindicated. Surgical drainage of the mediastinum for
inhalation anthrax is not recommended.
c.
Prognosis. The number of cases of inhalation anthrax occurring during the antibiotic era is
too small to establish case fatality rates and efficacy of treatment. Almost all inhalation anthrax cases in
which treatment was begun after onset of significantly severe symptoms have been fatal, regardless of
treatment. Despite medical therapy, most patients with inhalation anthrax die within 24 hours of the onset
of the acute phase of the illness. However, in nonhuman primate trials, animals have responded to aggressive
therapy. The prognosis for oropharyngeal and GI anthrax is poor, with case fatality rates 50 to 100 percent,
even with aggressive therapy.
2-9.
Control of Patients, Contacts, and Treatment Areas
Report all cases to line and medical chains of command.
Employ Standard Precautions for handling, treating, and moving all active cases.
Use sporicidal agents, such as disinfectant strength iodophors, in MTFs for general area
disinfection. Antiseptic strength iodophors are not sporicidal. Hypochlorite solutions may be attenuated by
organic matter, but will provide a disinfectant capability when used in a 5-percent solution. The hypochlorite
solution should be replaced frequently. Autoclaving, steam sterilizing, or burning is required for complete
eradication of spores.
2-10. Medical Evacuation
Patients with anthrax may be evacuated with other categories of patients. Anthrax is not transmissible
person to person. Standard Precautions should be observed during evacuation.
2-4
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
Section III. BRUCELLOSIS
2-11. General
a. Etiologic Agent. The genus Brucella is encapsulated nonmotile bacteria consisting of short,
gram-negative coccoid bacillus. There are four members of the genus Brucella that are human pathogens.
These are Brucella melitensis, Brucella abortus, Brucella suis, and Brucella canis.
b. Reservoir. The following are reservoirs in nature for the disease:
Brucella melitensis. Primarily sheep, goats, and camels. It may also be found in bison,
elk, caribou, and some species of deer.
Brucella abortus. Cattle.
Brucella suis. Swine.
Brucella canis. Dogs and coyotes.
The organisms may be produced in a laboratory for BW purposes, using a single cell or a small amount of
the organism from a natural source.
c.
Transmission. The disease is transmitted to humans by
Inhalation of aerosols or dusts that contain organisms.
Ingestion of unpasteurized dairy products and contaminated meat.
Inoculation of abraded skin or mucosal surfaces.
d. Endemic Disease.
(1) Pathogenesis. Following introduction into the body, Brucella organisms are phagocytized
by polymorphonuclear or mononuclear cells and are transported to regional lymph nodes. However,
Brucella organisms can survive intracellularly. This results in the release of bacteria from lysed cells,
resulting in hematogenous metastasis to other organs, particularly organs high in reticuloendothelial content
(notably the liver, spleen, bone marrow, and possibly, the lungs).
(2) Acute disease. Onset may be sudden or insidious (in approximately one half of all cases)
with nonspecific symptoms of fever, malaise, fatigue, anorexia, weight loss, and depression. Illness
persists as a systemic illness, with or without localizing signs and symptoms. Fever can be intermittent.
Physical examinations may be unrevealing or may disclose fever, mild lymphadenopathy, and
hepatosplenomegaly. Disease localization can occur, usually in tissues high in reticuloendothelial content.
2-5
FM 8-284/NAVMED P-5042/AFMAN (I) 44-156/MCRP 4-11.1C
(3) Osteoarticular. Bone and joint disease is the most common localizing complications,
occurring in up to 40 percent of cases. These include bursitis, sacroiliitis, spondylitis, peripheral joint
arthritis, and osteomyelitis. Vertebral osteomyelitis can result in epidural abscess resulting in spinal cord
compression, and psoas abscess. In addition to developing pyogenic septic osteoarticular infection, patients
may also develop reactive arthropathies. Diagnostic studies can include magnetic resonance imaging (MRI),
computed tomography (CT), and technetium bone scans; plain radiographs may be insensitive early in disease.
(4) Pulmonary infection. Although the respiratory tract is a portal of entry for brucellosis,
pulmonary disease is rare, under 15 percent. Complications may include hilar and paratracheal adenopathy,
interstitial pneumonia, pulmonary nodules, pleural effusions, and empyema.
(5) Genitourinary tract infection. Acute orchitis or epididymo-orchitis are the most common
genitourinary (GU) complications, usually in the absence of systemic symptoms or signs. Intrapartum
infection is rare, but can result in abortion although there is no convincing evidence that the risk is higher
than that of other bacteremic infections. Early diagnosis and therapy will prevent an adverse outcome.
Chronic pyelonephritis has been reported as a rare complication.
(6) Cardiovascular. Endocarditis occurs in less than 2 percent of the cases, but accounts for
most deaths from brucellosis. Other cardiovascular complications may include pericarditis, myocarditis,
and mycotic aneurysms.
(7) Neurologic. Acute or chronic meningitis occurs in less than 2 percent of the cases.
Depression, fatigue, and headache occurring in most cases represent nonspecific features of systemic disease.
2-12. Biological Warfare Agent Delivery
The primary threat is by aerosol release. A foodborne brucellosis attack is unlikely, but could be executed.
2-13. Environmental Detection
Currently, detection is primarily by laboratory analysis of specimens from patients presenting with the
illness or by laboratory testing of foods for the organism. Veterinary/PVNTMED/ PHS/BEE personnel
should collect samples from dairy products and other food items suspected of being contaminated with the
organism. Field NBC reconnaissance teams may collect the agent from an aerosol cloud, but must rely on
the supporting medical laboratory for identification.
2-14. Prevention
a. Pre-exposure Prophylaxis. Vaccines are not currently available for human use; attenuated vaccines
for veterinary use have caused brucellosis following accidental percutaneous or mucous membrane exposures.
Chemoprophylaxis has not been proven to be effective and may delay or mask the onset of the disease.
2-6
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