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Plague

Plague is a disease well-known to humankind. Throughout history, in a series of epidemics, plague has claimed the lives of millions the world over. Human plague in the United States occurs as mostly scattered cases in rural areas effecting 10 to 20 persons each year. Globally, the World Health Organization (WHO) reports 1,000 to 3,000 cases every year.

Conditions that once facilitated the rampant spread of plague have been remedied in much of the world, making epidemics unlikely. However, a bioterrorist release of plague could result in a rapid spread of the pneumonic form of the disease, which could have devastating consequences.

There are currently no specific OSHA standards or directives for plague.

OSHA Standards

The following compliance information includes standards, preambles to final rules (background to final rules), and directives (instructions for compliance officers) applicable to emergency response activities as a result of a bioterrorist attack. For additional information, see the Emergency Preparedness and Response Safety an Health Topics Page.

Note: Twenty-five states, Puerto Rico and the Virgin Islands have OSHA-approved State Plans and have adopted their own standards and enforcement policies. For the most part, these States adopt standards that are identical to Federal OSHA. However, some States have adopted different standards applicable to this topic or may have different enforcement policies.

General Industry (29 CFR 1910)

Preambles to Final Rules

Directives

Plague Disease

Plague is a disease caused by Yersinia pestis, a naturally-occurring bacterium found in many areas around the world, including the United States. There are several forms of plague, including pneumonic, bubonic, and septicemic plague.

  • Pneumonic plague occurs when Y. pestis infects the lungs, and is the most deadly form of the disease. This type of plague can spread from person to person through the air. Transmission can take place if someone breathes in aerosolized bacteria, which could happen in a bioterrorist attack. Pneumonic plague is also spread by breathing in Y. pestis suspended in respiratory droplets from a person (or animal) with pneumonic plague. Direct and close contact with the ill person or animal is necessary for respiratory transmission. Pneumonic plague may also occur if a person with bubonic or septicemic plague is untreated and the bacteria spread to the lungs.

  • Bubonic plague is the most common form of plague. This occurs when an infected flea bites a person or when materials contaminated with Y. pestis enter through a break in a person's skin. Patients develop swollen, tender lymph glands (called buboes) and fever, headache, chills, and weakness. Bubonic plague does not spread from person to person.

  • Septicemic plague occurs when plague bacteria multiply in the blood. It can be a complication of pneumonic or bubonic plague or it can occur by itself. When it occurs alone, it is caused in the same ways as bubonic plague; however, buboes do not develop. Patients have fever, chills, prostration, abdominal pain, shock, and bleeding into skin and other organs. Septicemic plague does not spread from person to person.

The last plague epidemic in the United States occurred in Los Angeles in 1924. Since then, all human plague cases in the U.S. have been sporadic cases acquired from wild rodents or their fleas or from direct contact with plague-infected animals. The following references aid in recognizing disease characteristics and hazards associated with plague.

  • Division of Vector-Borne Diseases (DVBD). Centers for Disease Control and Prevention (CDC). Provides basic disease information on plague, including a fact sheet, questions and answers, images, natural history, diagnosis, epidemiology, prevention and control, scientific literature, and more.

  • Public Health Image Library (PHIL). Centers for Disease Control and Prevention (CDC). Offers several images related to plague that include descriptions.

  • Plague. Centers for Disease Control and Prevention (CDC) and the World Health Organization Collaborating Center (WHOCC). Offers an introduction to plague and its global distribution and provides information on WHOCC and their role in the prevention of plague.

  • Plague. World Health Organization (WHO) Health Topics. Provides information on plague, including a fact sheet, disease outbreak information, publications, and related links.

  • WHO Report on Global Surveillance of Epidemic-prone Infectious Diseases - Chapter 3: Plague [206 KB PDF, 15 pages]. World Health Organization (WHO), Department of Communicable Disease Surveillance and Response. Includes the background and history of plague, as well as information about disease transmission and trends.

  • Current Description of Plague. The University of California Los Angeles (UCLA), Department of Epidemiology, School of Public Health. Provides basic information on plague, including identification, infectious agent, global occurrence, reservoir, mode of transmission, incubation period, communicability, susceptibility and resistance, methods of control, and more. Adapted from the Control of Communicable Diseases Manual 2000, American Public Health Association (APHA).

  • Plague Manual: Epidemiology, Distribution, Surveillance and Control. World Health Organization (WHO). Provides links to PDF documents that contain the comprehensive WHO manual on plague disease.

Plague as a Bioweapon

Yersinia pestis used in an aerosol attack could cause cases of pneumonic plague. One to six days after becoming infected with the bacteria, people would develop pneumonic plague. Once people have the disease, the bacteria can spread to others who have close contact with them. Because of the delay between being exposed to the bacteria and becoming sick, people could travel over a large area before becoming ill and possibly infecting others. Controlling the disease would then be more difficult. A bioweapon carrying Y. pestis is possible because the bacterium is available and could be isolated and grown in quantity in a laboratory. Even so, manufacturing an effective weapon using Y. pestis would require advanced knowledge and technology.

Plague has been identified by the Centers for Disease Control and Prevention (CDC) as a "Category A" agent, meaning it has been given high priority due to its potential threat to national security. The following references provide information on the use of plague as a bioweapon and associated issues to be considered during a plague outbreak.

  • Plague Information. Centers for Disease Control and Prevention (CDC). Contains extensive information regarding plague as a bioweapon, including fact sheets, overviews, FAQs, diagnosis and evaluation, infection control, laboratory testing, surveillance and investigation, selected publications, and education and training materials.

  • Medical Aspects of Biological Warfare. Office of the Surgeon General, Department of the Army. Addresses the weaponization of biological agents, categorizing potential agents as food, waterborne, or agricultural agents or toxins, and discusses their respective epidemiology.
    • Chapter 5: Plague. Worsham PL, McGovern TW, et al. Provides a thorough review of plague, including its history and epidemiology, as well as biological warfare and clinical issues.
  • Medical Management of Biological Casualties Handbook , Seventh Edition [2 MB PDF, 254 pages]. US Army Medical Research Institute of Infectious Diseases (USAMRIID), (2011, September). Contains specific information on a number of potential bioterrorist agents.

  • Hoffman RE, Norton JE. Lessons Learned from a Full-Scale Bioterrorism Exercise. Emerging Infectious Diseases. 2000 Nov-Dec;6(6). Describes a simulated bioterrorist attack during the Topoff exercise in 2000. Participants were told that a Yersinia pestis aerosol had been covertly released, leading to more than 2,000 cases of pneumonic plague, many deaths, and hundreds of secondary cases resulting in pneumonic plague.

  • Inglesby TV, Dennis DT, et al. Plague as a Biological Weapon: Medical and Public Health Management. Journal of the American Medical Association (JAMA). 2000 May 3;283(17):2281-90. Considers the prospect of an aerosol release of Y. pestis bacteria, and provides information on epidemiology, infection signs and symptoms, diagnosis and monitoring, vaccination, medical treatment, infection control, environmental decontamination, and more.

Controls

There are a variety of controls that should be implemented in order to protect workers from exposure to plague. Workers that may be affected, either during regular work activities or during an emergency response, include, but are not limited to, emergency responders, healthcare workers, laboratory personnel, and others. The Plague Disease and Plague as a Bioweapon sections of this Safety and Health Topic provide extensive information on the hazards associated with plague and applicable controls. Additional guidance specific to various types of workers, and associated issues on recognizing and controlling exposure to plague is provided in the following sections:

Emergency Responders

What personal protective equipment should emergency responders use when responding to a potential bio-attack involving plague? How should workers decontaminate themselves if they think they have been exposed to plague?

In a covert attack involving aerosolized plague, there would be no emergency response activity involving emergency responders. The first evidence that a potential attack had occurred would be diagnosis of the disease among exposed individuals, which would happen several days after the actual release. However, it is possible that emergency responders would be required to respond to a bio-attack incident, such as notification regarding an aerosol dissemination device or other suspicious release. The following references provide additional information regarding PPE, decontamination, and other precautions for emergency responders to consider during such an incident.

Healthcare Workers, Mortuary Workers, and Others

What PPE, infection control, and related precautions should healthcare workers use when treating patients with plague?

National infection control guidelines prescribe specific precautions to be taken when treating patients with known or suspected plague. These precautions include "Standard", "Droplet" and "Airborne" Precautions, under certain circumstances. Patient isolation and similar precautions may also be necessary. The following references provide detailed information regarding infection control procedures for plague.

  • OSHA Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances. OSHA, (2005, January). Provides hospitals with practical information to assist them in developing and implementing emergency management plans that address the protection of hospital-based emergency department personnel during the receipt of contaminated victims from mass casualty incidents occurring at locations other than the hospital. Among other topics, it covers victim decontamination, personal protective equipment, and employee training, and also includes several informational appendices.

  • Inglesby TV, Dennis DT, et al. Plague as a Biological Weapon: Medical and Public Health Management. Journal of the American Medical Association (JAMA). 2000 May 3;283(17):2281-90. Considers the prospect of an aerosol release of Y. pestis bacteria, and provides information on epidemiology, infection signs and symptoms, diagnosis and monitoring, vaccination, medical treatment, infection control, environmental decontamination, and more.

  • Bioterrorism Readiness Plan: A Template for Healthcare Facilities [94 KB PDF, 34 pages]. The Association for Professionals in Infection Control and Epidemiology (APIC) and the Centers for Disease Control and Prevention (CDC), (1999, April 13). Provides information on infection control, patient treatment, post-exposure management, decontamination, prophylaxis, and laboratory procedures. Specific information on plague is contained in Section II, pp. 19-22.

  • Medical Management of Biological Casualties Handbook, Seventh Edition [2 MB PDF, 254 pages]. US Army Medical Research Institute of Infectious Diseases (USAMRIID), (2011, September). Contains specific information on a number of potential bioterrorist agents.

What precautions are necessary when handling the bodies of patients who have died from plague?

Similar infection control precautions, as listed previously for live individuals, should be implemented for the post-mortem care of plague patients. These precautions apply to all workers performing post-mortem procedures on plague patients, including healthcare workers, morticians, forensic personnel, or others.

  • Inglesby TV, Dennis DT, et al. Plague as a Biological Weapon: Medical and Public Health Management. Journal of the American Medical Association (JAMA). 2000 May 3;283(17):2281-90. Considers the prospect of an aerosol release of Y. pestis bacteria, and provides information on epidemiology, infection signs and symptoms, diagnosis and monitoring, vaccination, medical treatment, infection control, environmental decontamination, and more.

  • Bioterrorism Readiness Plan: A Template for Healthcare Facilities [94 KB PDF, 34 pages]. The Association for Professionals in Infection Control and Epidemiology (APIC) and the Centers for Disease Control and Prevention (CDC), (1999, April 13). Provides information on infection control, patient treatment, post-exposure management, decontamination, prophylaxis, and laboratory procedures. Specific information on plague is contained in Section II, pp. 19-22.

How should workers decontaminate themselves if they think they have been exposed to plague bacteria?

The risk of re-aerosolization of plague bacteria from contaminated persons is considered low. In situations where there may have been gross exposure to plague, personal decontamination can be performed by removing contaminated clothing and washing exposed skin with soap and water. Additional decontamination procedures can be found in the following document:

  • Bioterrorism Readiness Plan: A Template for Healthcare Facilities [94 KB PDF, 34 pages]. The Association for Professionals in Infection Control and Epidemiology (APIC) and the Centers for Disease Control and Prevention (CDC), (1999, April 13). Provides information on infection control, patient treatment, post-exposure management, decontamination, prophylaxis, and laboratory procedures. Specific information on plague is contained in Section II, pp. 19-22.

What cleaning and disinfection procedures should be utilized in facilities that treat plague patients or handle the bodies of patients who have died from plague?

The principles of Standard Precautions are generally applied for the cleaning, disinfection, and sterilization of equipment and environmental control in facilities. For more information, refer to the following:

  • Bioterrorism Readiness Plan: A Template for Healthcare Facilities [94 KB PDF, 34 pages]. The Association for Professionals in Infection Control and Epidemiology (APIC) and the Centers for Disease Control and Prevention (CDC), (1999, April 13). Provides information on infection control, patient treatment, post-exposure management, decontamination, prophylaxis, and laboratory procedures. Specific information on plague is contained in Section II, pp. 19-22.

Laboratory Workers

What biosafety procedures should laboratory personnel utilize when handling materials potentially contaminated with plague?

Specific biosafety procedures, including PPE, engineering controls, and additional work practices have been established for handling plague bacteria in laboratories. Refer to the following references for more information.

  • Biosafety. Centers for Disease Control and Prevention (CDC), Office of Safety, Health, and Environment. Provides links to material on biosafety regulations, references, and related material.

  • Biosafety in Microbiological and Biomedical Laboratories (BMBL), 5th Edition. Centers for Disease Control and Prevention (CDC), (2009, December). This comprehensive reference on laboratory biosafety practices, including specific information on plague, is available in PDF sections.

  • Hawley RJ, Eitzen EM Jr. Biological Weapons - A Primer for Microbiologists. Annual Review of Microbiology. 2001 Oct;55:235-253. Provides biosafety information for laboratory and field personnel, including discussions on engineering controls, PPE, and decontamination methods.

Environmental Persistence, Identification, and Decontamination

How long would aerosolized plague from a bioweapon persist in the environment?

According to an analysis by the World Health Organization (WHO), in a worst case scenario, a plague aerosol would be effective and infectious for as long as one hour. Y. pestis is very sensitive to sunlight and heating and does not survive long outside its host.

Can plague be detected in the environment following a bioterrorist attack?

There are various methods that can be utilized for detecting bioterrorist agents, including plague. These include surface and air sample gathering techniques, followed by identification methods such as culture growth or polymerase chain reaction (PCR). However, plague bacteria is very fragile, would not persist for long in the environment, and therefore sampling and analysis would not be considered necessary. In the event of a bioterrorist attack involving plague, local, state, and federal responders would determine the need for sampling based on the specific circumstances associated with the release.

What environmental decontamination would be required following a release of aerosolized plague?

There is no evidence to suggest that environmental decontamination following an aerosol release is warranted. A plague aerosol would only remain viable for approximately 1 hour after release, long before the first cases of pneumonic plague would alert health personnel to a clandestine attack. The following references provide additional information on environmental detection, persistence, and decontamination of plague bacteria:

  • Inglesby TV, Dennis DT, et al. Plague as a Biological Weapon: Medical and Public Health Management. Journal of the American Medical Association (JAMA). 2000 May 3;283(17):2281-90. Considers the prospect of an aerosol release of Y. pestis bacteria, and provides information on epidemiology, infection signs and symptoms, diagnosis and monitoring, vaccination, medical treatment, infection control, environmental decontamination, and more.

Public Health Response

What actions would be taken by public health authorities in the event of a bioterrorist attack involving plague?

Various actions may be taken by public health authorities to treat and prevent further infections due to a release of plague bacteria. These measures may include mass distribution of medications, surveillance, quarantine, and communication procedures. The following references provide additional information.

Additional Information

Related Safety and Health Topics Pages


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