BIOTERRORISM PREPAREDNESS

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BIOTERRORISM PREPAREDNESS

• California Preparedness Education Network
• A Program of the California Area Health Education
  Centers
• Funded by ASPR Grant T01HP01405

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WHAT DO YOU NEED TO KNOW?

• Understand the risk of bioterrorism
• Recognize a potential bioterrorist event
• Meet immediate care needs of patients
• Notify appropriate authorities
• Participate in coordinated emergency response

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DEFINITION OF BIOTERRORISM

• The intentional use of
  micro-organisms or toxins derived from living
  organisms to produce death or disease in humans,
  animals, or plants

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What is an emerging infectious disease?

• In 1991, Institute of Medicine attempted to
  define
• new, re-emerging, or drug resistant infections
  whose incidence in humans has increased within
  the past 2 decades or whose incidence threatens
  to increase in the near future.

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What is an emerging infectious disease?

• Novel
• Does not have to be new agent
• Infectious (or potential)
• Must have proper host environment
• Usually has animal or environmental reservoir
  (exception smallpox)
• Other factors augment emergence

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Factors underlying infectious disease emergence

• Changes in human demographics and behavior
• New technologies and industries
• Economic development and changes in land use
• International travel and commerce
• Microbial adaptation and change
• Breakdown of public health measures

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Bioterrorism Emerging Infectious diseases

• Principles in an emerging infectious disease
  apply to bioterrorism
• Public health and surveillance approaches are
  similar
• Healthcare response similar
• Criminal responses differ
• Preparedness and response for bioterrorism and
  pandemic influenza are largely identical

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BIOTERRORISM

• Biological agents (variola, anthrax, yersinia)
• Micro-organisms
• May involve person-to-person spread
• Vaccines, antibiotics may be effective
• Biotoxins (botulinum, ricin)
• Toxins derived from micro-organisms
• No person-to-person spread
• Behave more like chemicals

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WHY BIOTERRORISM?

• Agents easy to manufacture
• Possible to attack covertly
• Psychological impact
• Potential economic impact

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Biological weapons
Conventional weapons

• Unannounced, not immediately obvious
• First responders are likely to be health care
  providers (emergency physicians, primary care,
  and hospitals)

• Announced/obvious
• Majority of terrorist events have been overt
  (conventional, chemical, nuclear)
• Resembles traditional mass casualty or HAZMAT
  incident

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CDC PRIORITY CATEGORIES

• June 1999 criteria for categories
• Level of Public health impact
• Dissemination potential
• Potential to cause public fear and disruption
• Need for special public health preparedness

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CDC CATEGORY A AGENTS

• Agents that would have maximum impact on
  population
• Ease of dissemination
• Person-to-person transmission
• High mortality
• Need for public health preparedness!

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CDC CATEGORY A AGENTS

• Bacteria
• Anthrax (Bacillus anthracis)
• Plague (Yersinia pestis)
• Tularemia (Francisella tularensis)
• Viruses
• Smallpox (Variola major)
• Viral Hemorrhagic Fevers (filoviruses,
  arenaviruses bunyaviruses, and flaviviruses)
• Biotoxins
• Botulism (Clostridium botulinum toxin)

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ANTHRAX Index Case OCTOBER 2001

• 63 year-old man presented to clinic with fever,
  confusion, and respiratory symptoms
• Blood CSF gram stain gram-positive bacilli
• Died despite antibiotic therapy
• Last U.S. case of inhalational anthrax 1976
• Exposure ? Weaponized anthrax spores sent in mail

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ANTHRAX ATTACK

• 18 cases 11 inhalational, 7 cutaneous
• 7 cases seen by physician and unrecognized
• Mortality
• 65 in patients presenting critically ill
• No deaths in patients treated early
• More than 30,000 placed on prophylaxis
• (none became ill)

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ANTHRAX

• Bacillus anthracis (spores)
• No person-to-person spread
• Multiple forms
• Drug of choice Ciprofloxacin

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CLINICAL FORMS OF ANTHRAX

• Primary clinical forms
• Inhalational
• Has a rare natural occurrence
• Prodrome to severe respiratory disease
• Cutaneous
• Most common form in naturally occurring cases
• Characteristic lesion, low mortality if treated
• Gastrointestinal
• Very rare natural occurrence
• The CDC recognizes a fourth form
• Oropharyngeal least common form in naturally
  occurring cases
• Secondary forms
• Anthrax Meningitis

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INHALATIONAL ANTHRAX

• 45 case fatality rate in 2001 attack
• Present within 1-2 weeks of exposure
• Nonspecific febrile prodrome (hours to days) then
  severe pulmonary disease
• CXR shows mediastinal widening (may be subtle)
• Anthrax Meningitis manifests in 50 of
  Inhalational Anthrax patients

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NORMAL vs. ANTHRAX CHEST X-RAY
The classic appearance of inhalation anthrax on a
chest x-ray is mediastinal widening with clear
lungs.
Normal CXR
Source American College of Physicians
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INHALATIONAL ANTHRAX FINDINGS 2001

• CXR classically shows mediastinal widening with
  clear lung fields
• In the 2001 case series, other findings included
• Pleural effusions or infiltrates or both
• Hilar adenopathy
• Paratracheal fullness
• Air space opacification
• Non-contrast chest CT was useful in leading to a
  presumptive diagnosis in some patients

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CUTANEOUS ANTHRAX
The case fatality rate of cutaneous anthrax is
20 without antibiotic treatment, and lt1 with
antibiotics.
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PLAGUE

• Yersinia pestis
• Three forms
• Pneumonic plague (person-to-person spread)
• Bubonic plague (rare person-to-person spread)
• Septicemic (rare person-to-person spread)
• Drugs of choice IM / IV (preferred)streptomycin
  and gentamycin
  Orallytetracyclines (i.e. doxycycline) or
  fluoroquinolones (i.e. ciprofloxacin)

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PLAGUE THEN NOW
WWII Unit 731Japanese conducted experiments in
bioterrorism on POWs
December 15, 2004March 15, 2005
Re-opened diamond
mine in the Congo WHO reports 130 suspect cases
of plague (septicemic pneumonic). At least 57
have died. Of approximately 7000 workers, 2/3
have fled. WHO is continuing to follow up with
contacts.
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PNEUMONIC PLAGUE

• Aerosolized bacilli
• Present in 1 day to 1 week
• Person-to-person spreaddroplet isolation
• Short, febrile prodrome
• Rapid progression to severe pneumonia
• Fatality 100 if untreated within 24 hours of
  symptom onset

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BUBONIC PLAGUE

• Incubation period 2-6 days
• Characteristic bubosgrossly enlarged,
  extremely tender lymph nodes
• Bite of infected fleaoccasional sporadic
  outbreaks
• Suppurative lymphadenopathy and fever
• If untreated, can lead to secondary forms of
  plague pneumonic, septicemic, meningococcal
  (rare)

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SEPTICEMIC PLAGUE

• Associated with hunting/ skinning
• Rare, usually seen as secondary presentation to
  pneumonic or bubonic forms of plague
• Progression
• Purpura
• Disseminated intravascular coagulation (DIC)
• Acral cyanosis and necrosis
• Often fatal even when treated
• Black Death

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TULAREMIA

• Francisella tularensis
• No person-to-person spread
• Multiple distinct forms
• Slow-growing organismmay or may not show on
  routine culture
• Drug of choice Streptomycin or Gentamicin

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TULAREMIAMULTIPLE CLINICAL FORMS

• Ulcero-glandular
• Most common form in naturally occurring cases
• Glandular
• Oropharyngeal
• Intestinal
• Pneumonic
• Primary pleuro-pulmonary disease
• Typhoidal
• Febrile illness without early localizing signs
  and symptoms

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TYPHOIDAL PNEUMONIC TULAREMIA

• Abrupt onset of febrile illness in 3-5 days
• Rapid progression to life-threatening pneumonitis
  in 80 of typhoidal cases
• Case fatality rate for typhoidal tularemia is 35
  in untreated patients

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SMALLPOX

• Two forms
• Variola Major and Variola Minor
• Person-to-person spread very rapid
• Use airborne precautions
• Incubation period 7-17 days (patient is
  asymptomatic / virus not contagious)
• Nonspecific febrile prodrome

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SMALLPOX

• Vesicular to pustular rash over 4-5 days
• Starts on palms, soles and face
• Vaccinate contacts within 3 days of exposure
• Utilize ring vaccination
• Cidofovir may fight smallpox

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SMALLPOX RASH
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VIRAL HEMORRHAGIC FEVERS (VHFs)

• Multiple viruses
• (four distinct families filoviruses,
  arenaviruses, bunyaviruses, and flaviviruses)
• Person-to-person spread contact isolation

• Incubation 2 days to 2 weeks
• Present with nonspecific viral prodrome

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VIRAL HEMORRHAGIC FEVERS

• Progresses rapidly to severe hypotension,
  shock, CNS dysfunction, mucosal and GI bleeding,
  edema
• Look for febrile bleeding disorders
• Antiviral drug usage
• - Ribavirin for Lassa Fever and HFRS
• (hemorrhagic fever with renal syndrome)

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VIRAL HEMORRHAGIC FEVERS
Gingival bleeding
Ecchymosis
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BOTULISM

• Botulinum toxin - potent biotoxin
• C. botulinum bacteria in an anaerobic
  environment causes Botulism
• No person-to-person spread
• Multiple forms

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FORMS OF BOTULISM

• Infant
• Wound
• Iatrogenic - Botox
• Gastrointestinal
• Food-born (ingested toxin)
• Pulmonary (inhaled aerosolized toxin)

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BOTULISM

• Descending flaccid motor paralysis
• Usually bulbar palsies first (diplopia,
  dysphagia)
• Does not pass into brain (mental function intact)
  
• Pulmonary exposuresonset within 72 hr
• Supportive care is critical
• Botulinum antitoxin

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BOTULISM
Infant botulism
Pupillary facial paralysis
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CDC CATEGORY B AGENTS

• Potential for use as bioterrorist agents
• Moderate morbidity, low mortality
• Lower priority for public health preparation
  (than Category A Agents)
• What was the bioterrorist attack that used
• a Category B Agent?

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Oregon, September 1984 Rajneeshi cult
Contaminated salad bars with Salmonella group B
To influence outcome of local election. 750
people poisoned
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Examples of Category B Agents

• Q Fever
• Ricin toxin
• Staphylococcal enterotoxin B
• Typhus fever,
• Viral encephalitis (alphaviruses)
• Water safety threats
• Vibrio cholerae
• Cryptosporidium parvum)

• Brucellosis
• Epsilon toxin of Clostridium perfringens
• Food safety threats Salmonella species,
  Escherichia coli O157H7
• Shigella
• Glanders
• Melioidosis
• Psittacosis (Chlamydia psittaci)

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CDC CATEGORY C AGENTS

• Could easily be developed and used for mass
  exposure
• Recognized as potential future threats
• Potential for high morbidity and mortality rates

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Category C agents Also EID list

• Hantaviruses
• SARS
• Multidrug-resistant tuberculosis
• MRSA
• Nipah virus
• Tickborne encephalitis viruses
• Tickborne hemorrhagic fever viruses
• Yellow fever
• Pandemic influenza

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Summary table
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OVERVIEW OF MANAGEMENT ISSUES

• Decontamination
• Personal Protective Equipment (PPE)
• Isolation
• Prophylaxis
• Treatment

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DECONTAMINATION

• In a COVERT bio-agent release
• Patients will present days after
  eventdecontamination will be futile
• In an OVERT bio-agent release
• May require patient decontamination
• Clothing removal provides 80-90 decontamination
• Soap water adequate
• Wastewater release not an issue

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PERSONAL PROTECTIVE EQUIPMENTFOR BIOLOGICAL
AGENTS

• Level D protection adequate for healthcare
  providers
• Mask (N-95)
• Face shield
• Gloves (latex OK)
• Gown
• Bio-agents are generally a low dermal threat

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Respirators
www.cdc.gov/niosh
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ISOLATION

• Isolation most important concept in suspected
  bioterrorist event
• If agent is known, isolation is CRITICAL for
  agents with potential for person-to-person spread
• Smallpox (Variola major)
• Viral Hemorrhagic Fevers
• Pneumonic plague

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ISOLATION FOR UNDETERMINED AGENT

• Treat all suspected events the same
• Use airborne/droplet precautions
• PPE for health care providers
• Mask on patient
• Isolate in private room if possible
• Negative pressure if available

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Respiratory Isolation

• Need single room
• Airflow out from room to exhaust
• HEPA filter attached
• At least 6-12 AC per hour
• Preferable to have ante room
• If not available, put patient in private room
  with door closed

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Decontamination of clinic

• Clean all surfaces with chlorhexadine
• High alcohol or bleach based 2nd alternative
• Dispose of soiled linens, supplies in biohazard
  immediately

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What can you do for patients in the waiting room?

• Educate on outbreak status
• cough area
• Hand washing and hygiene
• Respiratory etiquette
• Have alcohol based hand rub
• Lots of tissues and masks!!!!!!!

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Respiratory Etiquette

• Cough etiquette
• Cover nose and mouth
• Use tissues and throw away
• Hand hygiene
• Mask and separate symptomatic patients
• Droplet precautions
• Visual alerts in all languages

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Hand Hygiene

• Single most important measure
• Gloves should augment hand-washing
• Use antibacterial soap or chlorhexadine based
  soap
• Proper technique important
• Addition of alcohol based washless gels

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PROPHYLAXIS
NO CREDIBLE EXPOSURE ? NO PROPHYLAXIS!

• Person-to-biological-agent exposure give
  prophylaxis for
• Smallpox (ring vaccination within 3 days of
  exposure), anthrax, plague, tularemia
• Person-to-person exposure only need prophylaxis
  if
• Agent is transmitted person-to-person
• AND
• There is a treatment (smallpox, plague)

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EARLY TREATMENT

• SUPPORTIVE care is most important!
• Is SPECIFIC therapy available?
• Viruses
• Viral Hemorrhagic Fevers ribavirin for some
• Bacteria
• Anthrax, tularemia, plague antibiotic therapy
• Biotoxins
• Botulinum antitoxin for some types

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Summary table
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RECOGNITION AND NOTIFICATION
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BIOTERRORISM EMERGING INFECTIOUS DISEASE

• Increase the chance of not missing the first case
  based on clinical suspicion
• Epidemiologic clues may or may not be available
  to clinicians, especially for the first case or
  two

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TOOLS FOR RECOGNITION

• Environmental surveillance
• Not feasible in most cases
• Epidemiologic surveillance
• Relies on confirmed diagnoses
• Mandatory reporting
• Provider role in recognizing suspect cases
• Relies on monitoring by community providers
• Syndromes difficult to recognize early on

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EPIDEMIOLOGIC CLUES

• Unusual disease / symptoms (exotic disease)
• Epidemic numbers with similar syndromes
• Tight geographic cluster
• Unusual timing for endemic disease
• Rapidly increasing disease incidence in a healthy
  population
• Multiple diseases in one patient

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EPIDEMIOLOGIC CLUES

• Dead animals (especially multiple species)
• History of visible cloud
• Claims by aggressors
• Fulminant disease presentations
• Travel history

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ALERTING THE AUTHORITIES

• Clinicians communicate with COUNTY health
  departments (not CDC, FBI, etc.)
• REPORT
• All suspected illnesses caused by potential
  bioterrorism agents
• Unexplained critical illness or death
• Rare diseases of public health importance

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Report within one day
Report Immediately all CDC Category A Agents are
listed here in bold
Report within 7 calendar days
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REPORTABLE ILLNESSES
COMMUNITY
Clinician Suspects BT Agent
Confidential Morbidity Mortality Report
Immediate phone call
Local Public Health Department Business
Number or After Hours Number
LOCAL
Local Public Health Laboratory
Facilitate Specimen Submission to Lab
Facilitate Reporting of Clinical Scenario,
Surveillance / Confidential Morbidity Mortality
Report
California Department of Health Services,
Division of Communicable Disease Control
STATE
State Laboratories
FEDERAL
Centers for Disease Control
CDC Laboratories
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FEDERAL RESPONSE
STATE handles coordination with Federal agencies

• Federal Emergency Management Agency (FEMA)
• Disaster Medical Assistance Teams (DMAT)
• Strategic National Stockpile (SNS)

12-hour Push Packages in SNS
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PARTICIPATING
ROLES THAT CLINICIANS MAY FILL

• Mass prophylaxis
• Immunizations
• Antibiotics
• Triage
• Assessment and referral of patients
• Patient education

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WHY BIOTERRORISM IS DIFFERENT THAN OTHER TYPES OF
TERRORISM

• Incubation periods
• Victims widely dispersed
• Victims likely to present for days to weeks
• Even hoaxes can cause significant impact
• Potential for many casualties
• First responders may be HEALTHCARE PROVIDERS

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