Plague as a biological weapon: medical and public health management. Working Group on Civilian Biodefense

OBJECTIVE

The Working Group on Civilian Biodefense has developed consensus-based recommendations for measures to be taken by medical and public health professionals following the use of plague as a biological weapon against a civilian population.

PARTICIPANTS

The working group included 25 representatives from major academic medical centers and research, government, military, public health, and emergency management institutions and agencies.

EVIDENCE

MEDLINE databases were searched from January 1966 to June 1998 for the Medical Subject Headings plague, Yersinia pestis, biological weapon, biological terrorism, biological warfare, and biowarfare. Review of the bibliographies of the references identified by this search led to subsequent identification of relevant references published prior to 1966. In addition, participants identified other unpublished references and sources. Additional MEDLINE searches were conducted through January 2000.

CONSENSUS PROCESS

The first draft of the consensus statement was a synthesis of information obtained in the formal evidence-gathering process. The working group was convened to review drafts of the document in October 1998 and May 1999. The final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members.

CONCLUSIONS

An aerosolized plague weapon could cause fever, cough, chest pain, and hemoptysis with signs consistent with severe pneumonia 1 to 6 days after exposure. Rapid evolution of disease would occur in the 2 to 4 days after symptom onset and would lead to septic shock with high mortality without early treatment. Early treatment and prophylaxis with streptomycin or gentamicin or the tetracycline or fluoroquinolone classes of antimicrobials would be advised.

[The properties of the cellular surface of Yersinia pestis strain EV and its achromogenic variants]

The comparative study of the properties of the surface of vaccine strain Y. pestis EV and its achromogenic variants (AV) differing from the initial strain by decreased immunogenicity and by the morphology of colonies, has been made. The achromogenicity of Y. pestis colonies has been shown to correlate with the loss of the outer membrane protein with a molecular weight 22 kD. The synthesis of this protein is determined by chromosomal genes. AV have been found to have different sensitivity to bacteriophages. The analysis of the electrokinetic potential of Y. pestis EV and its AV has revealed that in the latter have surface charge is considerably greater (1.4- to 1.5-fold). As shown in this study, the hemagglutinating activity of AV with respect to red blood cells of humans with blood group I (O) and guinea pigs is decreased by 1-2 orders and these strains do not agglutinate with sheep red blood cells. The low activity of the initial stage of the phagocytosis of AV by mouse macrophages has been shown. The possible role of the 22 kD proteins as an adhesion factor is discussed.

[The effect of a modification to the lipopolysaccharide of Yersinia pestis on its neutrophilokine-inducing activity]

The ability of the isolated and modified Yersinia pestis LPS to induce the synthesis of the neutrophilokines that regulate the macrophage functional activity was studied. It is established that the Y. pestis LPS detoxication, especially by the method of deacylation, does not lead to the decrease in biological, in particular neutrophilokine-inducing activity of these preparations, but actually even increases it. These results are in agreement with many reports showing the possibility of decreasing the LPS toxicity without reducing immunostimulatory activity of this important component of the outer membrane of gram-negative bacteria.

Failure of intragastrically administered Yersinia pestis capsular antigen to protect mice against challenge with virulent plague: suppression of fraction 1-specific antibody response

We evaluated the Yersinia pestis capsular (fraction 1 [F1]) antigen as a potential oral immunogen in mice. We found that single doses of as much as 0.4 mg of F1, administered by intragastric (ig) intubation, were unprotective and did not stimulate production of detectable levels of specific antibody. Three weekly ig doses resulted in low serum antibody levels that also did not provide protection against challenge with virulent Y. pestis. Assays of type-specific antibody following intubation and subsequent challenge with a subcutaneous inoculation of F1 revealed that the quantity of antigen intubated and the secondary IgG2a antibody levels were inversely related, suggesting the induction of tolerance to intragastrically administered F1 antigen. Transfer of spleen cells from intubated mice to F1 immune recipients failed to demonstrate suppression of specific antibody, indicating that the immune tolerance observed in intubated mice was not due to a T suppressor cell-mediated effect. The results of this study indicate that Y. pestis F1 antigen is not likely to be an efficacious immunogen for oral vaccination of mice against plague.

Potency of killed plague vaccines prepared from avirulent Yersinia pestis

Killed plague vaccines prepared from avirulent strains A1122 and EV76S of Yersinia pestis were more effective in mouse potency tests than samples of Plague Vaccine, USP, prepared from killed Y. pestis of the virulent strain 195/P. Manufacture of vaccine from avirulent Y. pestis would obviate requirements for the large containment facilities that are currently needed for producing Plague Vaccine, USP.

[Electron microscopic study of dry live plague vaccine EB by the scanning method]

Dry live plague vaccine EB was examined under microscope; it appeared that in the mentioned preparation the bacterial cells were enclosed in the artificial sucrose-gelatin capsule of the stabilizer which apparently maintained the vital activity of the microorganisms in the state of anabiosis by forming a stable bond with the bacterial body.

[The effects of enzymes and secretions of the gastrointestinal tract on the EB vaccine strain]

Experiments were conducted in vitro. A study was made of the action of the enzymes and of the secretions of the gastrointestinal tract on the viability of the EB vaccine strain. Sensitivity of bacterial cells to the action of saliva, gastric juice, intestinal contents, trypsin, and bile proved to differ. Gastric juice inactivated the vaccine strain which expressed a satisfactory resistance towards the rest of the factors under study practically immediately. There were revealed no significant morphological changes in the cells subjected to the two-hour action of saliva, bile, trypsin and the intestinal content, by means of the electron microscopic examination. These studies permitted to substantiate the rational form of the preparation for oral administration.

Pathogenicity and immunogenic efficacy of a live attentuated plaque vaccine in vervet monkeys

A live attenuated Yersinia pestis (Pasteurella pestis) vaccine strain designated EV51f, which had been passaged through guinea pigs previously treated with ferrous sulfate, was shown to be pathogenic for African green vervet monkeys (Cercopithecus aethips pygerythrus), but not for guinea pigs. The bacilli multiplied in the monkeys, as shown by positive blood cultures, caused an elevation of white cell counts and rectal temperatures, and resulted in death of 26% (13/50) of animals. Postmortem findings of these animals were typical of bubonic-septicemic plague. This vaccine did not cause deaths in 50 guinea pigs even in doses up to 100 million viable bacilli inoculated subcutaneously. It is suggested that the virulence of an attenuated Y. pestis strain which does not produce pigment on a defined medium containing hemin, but possesses all other known virulence determinants, is dependent on the availability of iron in vivo. The serological response of the monkeys as determined by the hemagglutinating and mouse protective antibodies was high one month after vaccination and also in guinea pigs, as shown by virulent challenge. This antibody level declined in monkeys over a period of nearly 6 months, and a decline in immunity was confirmed by virulent challenge which resulted in the death of 30% of vaccinated monkeys. The level of immunity in monkeys did not appear to be related to the dose of vaccine.