BIOTERRORISM June 15, 2006 Christina M. Cabott D.O.

BIOTERRORISM

June 15, 2006

Christina M. Cabott D.O.

Introduction

• Bioterrorist event– Release of biological agent into civilian

population– Purpose

• Creating fear• Illness• Death• Disruption of social and economic infrastructure

Introduction

• Biological agents

– Infectious agents• Contagious• Noncontagious

– Biologically produced toxins• Act as chemical agents within human body

Agents of Concern

Agent selection

1. Potential for public health impact

2. Delivery potential– Estimation of ease for development and dissemination– Potential for person-to-person transmission of infection

3. Public perception (fear) of the agent

4. Special requirements for public health preparedness

Agents of Concern

• Ranking category– Class A agents: most severe potential for

widespread illness and death• Variola major (small pox)• Bacillus anthracis (anthrax)• Yersinia pestis (plague)

– Class B agents: less potential – Class C agents: future threats

Class A Agents

• Variola major (small pox)

– Incubation: 12-14 days– S&S:

• Initially: fever, severe myalgias, prostration• Within 2 days: papular rash on face spreading to

extremities → rash on palms and soles → trunk• Lesions progress at same rate

– Vesicular → pustular → scabs

Class A Agents

• Bacillus anthracis (Cutaneous anthrax)

– Incubation: usually < 1 day, up to 2 weeks– S&S:

• Macule or papule enlarging into eschar • Surrounding vesicles and edema• Sepsis possible

Class A Agents

• Bacillus anthracis (GI anthrax)

– Incubation: usually 1-7 days– S&S:

• Abdominal pain• Vomiting• GI bleeding leading to sepsis• Mesenteric adenopathy on CT

Class A Agents

• Bacillus anthracis (Oropharyngeal anthrax)

– Incubation: usually 1-7 days– S&S:

• Sore throat• Ulcers on base of tongue• Marked unilateral neck swelling

Class A Agents

• Bacillus anthracis (Inhalational anthrax)

– Incubation: usually < 1 week– S&S:

• 1st stage: fever, dyspnea, cough, headache, vomiting, abdominal pain, chest pain

• 2nd stage: dyspnea, diaphoresis, shock• Hemorrhagic mediastinitis with widened

mediastinum on CXR

Class A Agents

• Yersinia pestis (Bubonic plague)

– Incubation: 2-8 days – S&S:

• Fever, chills, painful swollen lymph nodes• Nodes progress to bubo (possibly suppurative)

Class A Agents

• Yersinia pestis (Pneumonic plague)


• Fever, chills, cough, dyspnea, nausea, vomiting, abdominal pain

• Clinical condition consistent with gram-negative sepsis

Class A Agents

• Yersinia pestis (Primary septicemic plague)


• After bubo formation, clinical condition consistent with gram-negative sepsis, DIC

Class A Agents

• Clostridium botulinum (Food-born botulism)


• GI symptoms• Followed by symmetric cranial neuropathies,

blurred vision• Progresses to descending paralysis

Class A Agents

• Clostridium botulinum (Inhalational botulism)

– Incubation: 12-72 hours– S&S:

• Symmetric cranial nerve palsies • Progresses to descending paralysis

Class A Agents

• Francisella tularensis (Tularemia)


• Abrupt nonspecific febrile illness• Progressing to pleuropneumonitis• May have mucocutaneous lesions

Class A Agents

• Filoviruses and arenaviruses (Ebola virus)– Viral hemorrhagic fevers– Incubation: 2 days – 3 weeks, depending on

the virus– S&S:

• Initial: nonspecific febrile illness, sometimes with rash

• Progresses to hematemesis, diarrhea, shock

Class B Agents

• Coxiella burnetii (Q fever)

– Incubation: 2-3 weeks – S&S:

• Fever, myalgias, headache• 30% develop pneumonia

Class B Agents

• Brucella spp (Brucellosis)

– Incubation: 2-4 weeks – S&S:

• Fever, myalgias, back pain• Possible CNS infections, endocarditis

Class B Agents

• Burkholderia mallei (Glanders)


• Suppurative ulcers• Pneumonia• Pulmonic abscesses• Sepsis

Class B Agents

• Alpha viruses (VEE, EEE, WEE)– Encephalitis– Incubation: variable– S&S:

• Fever• Headache• Aseptic meningitis• Encephalitis• Focal paralysis• Seizures

Class B Agents

• Rickettsia prowazekii (Typhus fever)


• Fever• Headache• Rash

Class B Agents

• Chlamydia psittaci (Psitticosis)


• Fever• Headache• Dry cough• Pneumonia• Endocarditis

Class B Agents

• Toxins– Ricin, Staphlococcus, Enterotoxin B

• Food safety threats– Salmonella, Eschericia coli O157:H7

• Water safety threats– Vibrio cholera, Cryptosporidium parvum

Class C Agents

• Emerging threats– Nipah virus– Hanta virus

Recognition of Bioterrorist Event

1. Patient presents with signs, symptoms, or immediately available diagnostic results that obviously indicate a suspect disease process.


2. Patient presents with protean symptoms, but an astute clinician establishes enough criteria (suspicious historical information, signs, symptoms, short turn-around lab results, public health corroborative information, etc.) to designate the patient as a presumptive case until diagnostic confirmation can be accomplished.


3. Patient presents, is evaluated and admitted or released, but not suspected as being a victim of bioterrorism. Diagnostic test results (blood cultures, immunoassays, etc.) subsequently establish a diagnosis, potentially even post mortem.


4. Multiple patients present over a defined period with similar symptoms or historical characteristics, raising the suspicions of a practitioner and causing that individual to report the concern. Further investigation with diagnostic testing and/or public health epidemiological investigation of the cohort establishes the cause.


5. Public health surveillance systems establish unusual patterns of signs, symptoms, or disease in the community and correlate with further investigation to establish the etiology.


• Emergency physician should know– Basic pathological principles for each agent– Modes of dissemination and transmission– Disease signs and symptoms– Recommended diagnostic testing– Recommended therapy

• Immunizations, medicines, or prophylaxis

– Infectious control practices


• Pictorial resources

• Confirmatory tests

• Respond to notification of potential disease by another health or medical professional

• Querying the source for methodology of testing that produced the concern


• Exposure to an unidentified substance

• Source substance and where obtained

• Coordination with outside agencies, such as law enforcement and public health

• Patient exposure risk stratification

Design and Implementation of Community Surveillance Systems

1. Clinical duties are minimally affected- Does not consume valuable clinician or

support staff time and attention

2. Financial investment is not carried by the hospital or professional staff

Design and Implementation of Community Surveillance Systems

3. Patient privacy and hospital proprietary issues are addressed appropriately

4. Participation in the system provides direct benefit to the acute care medical community

- All pertinent epidemiologic information is disseminated in real time to the practitioners

Initial Response to a Potential Bioterrorist Threat

• Within hospital environment– Infection control procedures– Notification of hospital departments

• Administration• Infectious disease• Infection control• Laboratory services • Security • Environmental services


• Within hospital environment– Activation of Emergency Operations Plan

(EOP)• Preplanned surge capacity configuration• Security dept – aid in protection of facility and staff• Media relations

• Outside of hospital environment– Notification of jurisdictional public health

department


• Information that needs to be conveyed to public health department

– 1. Diagnosed or suspected agent of concern– 2. Whether it is a presumed or definitive diagnosis

and how many diagnosis were made– 3. Patient demographics (including occupation)– 4. Recent history of travel or participation in special

events (i.e. mass gatherings, high-profile events, or at- risk gatherings)


• Information that needs to be conveyed to public health department

– 5. Patient condition– 6. Initial testing performed and further diagnostic

testing being conducted– 7. Treatment being provided– 8. Public health assistance required (including testing)– 9. Preferred method of contacting hospital or treating

physicians for follow-up


Local Health Department

Regional or State Public HealthDepartments

CDC

World Health Organization

(WHO)

Local Law Enforcement

FBI


• Protective equipment– Gowns, gloves, respiratory masks

• Patient isolation

• Patient decontamination– Removal of clothing– Soap and warm water– NO bleach

Integration with Local Department of Health

• Development of community wide patient evaluation and treatment protocol– Screening– Testing– Treatment methodologies– Patient and public education

Integration with Local Department of Health

• Clear and concise definition for the suspicious agent

• Reporting requirements (surveillance) for suspected or diagnosed cases– Type of information– Method of reporting (e.g. phone, fax, Internet)– Contact methods (e.g. 24 hr access for

technical advice)

Treatment, Prophylaxis, and Immunizations

• Agent: Variola major

• Vaccination: Vaccinia vaccination– Not recommended for general public use– Contraindicated in immunocompromised pts

and pts with eczema– Useful in preventing disease if given within 4

days of exposure


• Agent: Variola major

• Prophylaxis: Vaccinia immunoglobin– Within 2-3 days of exposure– Limited supplies available– Consider giving it to those with

contraindications to the vaccine

• Treatment:– Mainly supportive


• Agent: Bacillus anthracis

• Vaccination: Anthrax vaccination– 6 part series at 0,2, and 4 week, then 6,12,

and 18 months– Annual boosters required– Not available to the public– Animal models: efficatious in inhalational

anthrax


• Agent: Bacillus anthracis• Prophylaxis:

– Cipro or doxy for 60 days– Amoxicilin if strain not resistant to treatment

• Treatment:– Cipro or doxy (amoxicillin if strain not resistant) in

combo with 2 others, including clindamycin, rifampin, imipenem, aminoglycoside, chloramphenicol, vancomycin, streptomycin, and some macrolides


• Agent: Yersinia pestis

• Vaccination: none

• Prophylaxis: – Cipro or doxy for 7 days– Alt: chloramphenicol

• Treatment: – Streptomycin or gentamycin– Alt: doxy, cipro, chloramphenicol


• Agent: Clostridium botulinum

• Vaccination: – Not available to public– Pentavalent toxoid of C botulinum toxin types

A-E– 3-part series, with yearly booster

• Prophylaxis: none


• Agent: Clostridium botulinum

• Treatment: – Antitoxin: from local public health agency– Antitoxin may preserve remaining neurologic

function, BUT does not reverse paralysis– May require prolonged, assisted mechanical

ventilation and supportive care


• Agent: Francisella tularensis

• Vaccination: – Live, attenuated vaccine under FDA

investigation

• Prophylaxis: – Cipro or doxy for 14 days


• Agent: Francisella tularensis

• Treatment: – Streptomycin or gentamycin– Alt: doxy, cipro, chloramphenicol


• Agent: Filoviruses and arenaviruses (e.g. Ebola virus)

• Vaccination: none

• Prophylaxis: none

• Treatment: – Supportive therapy– Ribavirin may have applicability in

arenaviruses

Treatment for Bioterrorism

• General Emergency Operation Plans– Need to have enough staff to handle large

surge in general patient volume

• Specialty requirements– Patient with unusual medical conditions– Patients who may be contagious– Contamination risks to staff and other patients


• Disease containment– Isolation– Designation of staff to care for infected vs.

noninfected patients– Proper personal protective equipment


• Management of personnel– Need more personnel to care for more

patients– Staff reluctance to care for potentially

infectious patients


• Logistics– Limited supply of drugs and medical supplies– Sharing of critical supplies, staff, and

equipment among local hospitals– National Pharmaceutical Stockpile


• Patient Management– Addressing requirements of each patient

encounter– Preprinted instructions

• Category of risk stratification• Why patient placed in that category• How disease transmitted• Measures to prevent spread• Early signs and symptoms of disease• Appropriate steps if symptoms occur


• Patient Management– Appropriate follow-up– Proper record keeping– Organization of charts


• Vaccinations– Not to be given in a pre-event setting to

general public

• Recommended therapies– Usually not for pregnant or lactating women– Usually not approved for children– Should be given if risk of infection and its

consequences exceeds risks of the medications or vaccines


• Fatality Management– Bodies are considered evidence– Processed through coroner or medical

examiner

Sources of Expert Information

• http://jama.ama-assn.org

• http://www.bt.cdc.gov• http://chemdef.apgea.army.mil/textbook/contents.asp

• http://www.apic.org

• Local poison control center

• CDC’s emergency response center 1-770-488-7100

http://jama.ama-assn.org/

http://www.bt.cdc.gov/

http://chemdef.apgea.army.mil/textbook/contents.asp

http://www.apic.org/

BIOTERRORISM June 15, 2006 Christina M. Cabott D.O.

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