Table 1. Features of Possible Bioterrorism Agents.

Disease	Mortality Rate	Typical Incubation Period	Vaccine Available	Treatment Available	Precautions Needed
Anthrax, Inhalation	High without treatment	Usual 1-7 d Up to 60 d	Effective Restricted availability	Antibiotic Supportive	Supportive Standard (barrier) only
Anthrax, Cutaneous	Low	Usual 1-7 d Up to 60 d	Effective Restricted availability	Antibiotic	Standard Contact for draining lesions
Smallpox	Moderate	Usual 10-12 days Rarely as early as 3 or late as 17 days	Effective before and after exposure Restricted availability	Supportive Immune globulin Experimental antiviral	Highly contagious; Standard Droplet Airborne
Plague (pneumonic)	100% untreated	1-4 days	Licensed, limited availability	Antibiotics	Highly contagious; Standard Droplet
Botulism	High without treatment	12-36 hours Occasionally longer	No	Antitoxin Supportive	Standard
Tularemia (pulmonary)	Moderate without treatment	Usually 3-5 days; varies with strain and innoculum	Limited availability; not post-exposure Antibiotics Standard	Antibiotics	Standard
Viral hemorrhagic fevers	Varies according to virus, ranging from <1% to 50-90%	Varies according to virus, ranging from 1-2 days to a week or more	Limited availability: Yellow Fever vaccine Several other vaccines under development	Supportive Antiviral agents show some promise for some viral infections	Most are highly contagious: Standard Droplet Airborne

Table 2. Clinical Findings, Differential Diagnosis and Tests for BT and Other Agents of Public Health Importance.

Disease	Important Findings	Differential Diagnosis	Important Tests	Precautions	Other
Anthrax, Inhalation	Mild "URI" prodrome, followed by Abrupt onset severe pulmonary symptoms Chest pain Respiratory distress inconsistent with degree of pulmonary infiltration Rapid progression Large pleural effusions Headache Meningeal symptoms	Pulmonary embolism Inhalation exposure to toxic or caustic agent Dissecting aortic aneurysm	Chest X-ray, CT Scan, or MRI: hilar adenopathy with widened mediastinum pleural effusions; patchy infiltrates Blood or CSF culture with large, gram-positive "boxcar" shaped rods; sputum smear may be unremarkable Blood, CSF cultures positive for non-motile, non-hemolytic Bacillus species	Standard barrier precautions; no risk of person-to-person spread of Anthrax	Immediately notify public health authorities; Immediately notify law enforcement agencies if BT suspected Immediately hospitalize in intensive care Start aggressive antimicrobial therapy and supportive treatment immediately
Anthrax, Cutaneous	Painless pruritic papule, progressing to vesicles and then a black eschar Regional adenipathy low grade fever	Brown recluse spider bite Orf (sheep-associated, viral, cutaneous infection more common in New Zealand but also found in U.S.)	Lesion demonstrates typical microorganisms on microscopic and culture exams	Standard precautions Contact precautions for draining lesions	Immediately notify public health authorities; Immediately notify law enforceent agencies if BT suspected Start aggressive antimicrobial therapy
Pneumonic Plague	Severe bilateral pneumonia Hemoptysis Hypoxemia and cyanosis Shock Headache	Severe community acquired pneumonia Hantavirus pulmonary syndrome	Gram-negative coccobacilli or bacilli in sputum or blood (clasically have a "safety-pin" appearance on Wrights or Giemsa stain	Communicable by droplet spread: Standard barrier precautions plus droplet precautions<	Immediately notify public health authorities; Immediately notify law enforcement agencies if BT suspected Immediately hospitalize in intensive care Start aggressive antimicrobial therapy and supportive treatment immediately Encourage family and close friends to remain for epidemiologic interviews; obtain contact information for all known recent close contacts and exposures for public health follow-up
Smallpox	2-4-day non-specific prodrome with fever Fever may subside when rash develops Vesicular, then pustular, rash, which tends to erupt in a single, synchronized crop of lesions (in contrast to chickenpox) Rash begins on the face and distal extremities, sometimes involving palms and soles, and spreads centrally (vs. chickenpox, which most prominent on the trunk and less prominent peripherally) Headache Delirium Vomiting Back pain	Chicken pox Vaccinia side effects Disseminated herpes zoster Monkey pox Cowpox	Virologic testing of vesicle or pustular fluid specimens in highest security laboratory (Level 4)	Standard Airborne Contact	Immediately notify public health authorities; Immediately notify law enforcement agencies if BT suspected Immediately hospitalize in intensive care with appropriate isolation facilities Seek expert advice about experimental antiviral treatments Encourage family and close friends to remain for epidemiologic interviews; obtain contact information for all known recent close contacts and exposures for public health follow-up
Botulism	Acute bilateral descending flaccid paralysis beginning with cranial nerve palsies Patients usually alert and afebrile Important early symptoms include blurred vision, diplopia and dry mouth	Guillain-Barre Syndrome Myasthenia gravis Tick paralysis Eaton-Lambert syndrome Toxic exposure to organophosphates	Normal spinal fluid EMG shows normal nerve conduction velocity and normal sensory findings but shows facilitation of muscle action potential on repetitive nerve stimulation Serum for mouse neutralization bioassay conducted by specialized laboratories	Standard precautions; not transmitted from person to person	Supportive care is critical Antitoxins may be available from public health departments
Viral hemorrhangic fevers	Fever Severe microvascular damage with disseminated hemorrhage Petechiae Shock Severe headache Muscle pain Delirium	Meningococcemia Thrombotic thrombocytopenic purpura (TTP) Hemolytic uremic syndrome	Viral isolation in Biosafety level 3 or 5 facility ELISA or PCR testing available for some viruses	Communicability varies according to virus Contact precautions Droplet Precautions	Collect patientís contact and travel information, if possible, for public health authorities Notify hospital about suspicions and transfer to hospital with appropriate isolation facilities
Tularemia	Fever Chills and rigors Headache Initial sore throat Non-productive cough	All influenza-like illnesses	Small gram-negative coccobacilli in pulmonary secretions Sputum and blood culture Rapid testing with DFA, PCR, or antigen-detection CXR shows peribronchial infiltrates Pleural effusions common	Standard Precautions No person-to-person transmission