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Preparedness for Emerging Infections and Bioterrorism:

Are We There Yet?

Adi Gundlapalli, MD, PhDWasatch Homeless Health Care, Inc.

Infectious DiseasesUniversity of Utah Hospital & Clinics

Salt Lake City, Utah

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One bright sunny day…

A child is brought in for evaluationFever and URI for 2 daysBy the way…She has a skin rash

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This is her hand…

Courtesy: Michael Anderson, The New York Times

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And this is her pet…

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This is a true story

The New York Times, April 18, 2004 • By Gretchen Reynolds (NYT) 5347 words

Late Edition - Final , Section 6 , Page 32 , Column 1

“Why Were Doctors Afraid to Treat Rebecca McLester?”

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Unknown Skin Lesion

The worry: smallpox-like lesionsThe problem: who would see her?To find smallpox vaccinated health care workers

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Unknown Skin Lesion

The child had monkeypox!Transmitted from prairie dogs that came in contact with a sick African rat

In a small town in Illinois

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Are We Prepared?

Why are we concerned?What are some of those diseases?What can we do?

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Is There a Problem?http://www.ahrq.gov/clinic/epcindex.htm#healthcare

Training of Clinicians for Public Health Events Relevant to Bioterrorism Preparedness 2001“Modest” evidence: detect and manage infectious disease outbreaksVery little evidence: bioterrorism preparedness

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Is there a problem?

Provider Perspective“On the Front Lines: Family Physicians’Preparedness for Bioterrorism”

•FM Chen et al, J Fam Pract, 2002:745-750

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Provider Perspective

Oct 2001: 976 Family Physicians63% response!26% felt preparedTraining would be welcomed

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Is there a problem?

“Ready and Willing? Physicians’ Sense of Preparedness for Bioterrorism”

•Alexander and Wynia, Health Affairs (Millwood), 2003;22(5):189-97

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Physician Perspective

526 of 1000 Physicians responded21% felt prepared80% were willing to do what it takes – even at the risk of becoming ill

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Is There a Problem?

National Assoc. of Comm. Health Centers, Inc.Nov 2001: HC Preparedness Survey

137 Health Centers

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Community Health Centers

91%Inadequately prepared for a pubic health emergency involving bioterrorism

84%Identified training as a key component

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Patient Perspective

Are our patients at risk?Why not?

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Our patients

No different from other patientsHigher risk sub-categories

Foreign Born (migrant/refugees)• TB: esp. multi-resistant• “Exotic” imported diseases

Homeless

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Higher Risk?

Delay in seeking care• Care Without Coverage: Too Little Too Late

• IOM Report 2002, National Academy Press

With regard to infectionsMore severe illness before seeking careMay be transmitted to othersOutbreak before you know it!

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Higher Risk?NACHC Issue Brief #75, July 2003PL 107-188: Public Health Security and BioTPreparedness and Response Act of 2002

Awaiting a report by HHS SecretaryFactors that may make underserved areas more vulnerable to biological attacks

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Most Recent Survey

NACHC 2003: PreparednessResults not published yetNot fully prepared?Better prepared than 2001?

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So…

We are not fully preparedOur patients are at risk

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What are we facing?

Emerging infectionsNatural disease outbreaks

Avian InfluenzaMonkey poxSARSWest Nile VirusMulti-drug resistant TBCommunity Associated MRSA

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What are we facing?

Agents of Bio-TerrorismCategory A: easiest to transmit

AnthraxBotulismPlagueSmallpoxTularemiaViral Hemorrhagic fevers

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Recognition of agents

Easier said than doneEmerging infections & Bio-T agents

Similar presentationClusters of illness?

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Recognition

Nothing specificGeneral symptom complex

Most have respiratory componentMany have fever and rash

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Non-outbreak Situation

We will all miss the first few casesBe aware of clusters of illnessAre you seeing more than one patient with similar illnesses?Are others noting the same?

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Non-Outbreak Situation

Anything common among patients?Exposure?

Same householdSame animalSame substanceSick contactSame travel

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Outbreak Situation

Heightened awarenessKnow what is circulating in your communityGlobal Village

Your local health districtYour stateYour countryWorld

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Epidemiologic Clues

Travel HistorySARSTBMeasles (airplane)

Any sick contactsSARSTB

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Epidemiologic Clues

Any contact with animalsTularemiaPlagueMonkeypoxAvian Influenza

Mosquito exposureWest Nile Virus

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Some emerging infections

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West Nile Virus

1937: Uganda1950s: Egypt and Israel1999: First seen in the USHow did it get here?

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West Nile

How do you get it?

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West Nile Virus Transmission CycleMosquito vector

Incidental infections

Bird reservoir hosts

Incidental infections

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West Nile Virus

Fortunately, most are mild illnessesWest Nile Fever

Acute Febrile Illness• Sudden onset• Malaise, headache, anorexia • Myalgia, nausea and vomiting• Rash, lymphadenopathy, eye pain

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West Nile

NeurologicalMost dreaded manifestation, 1 in 150EncephalitisMeningitis less commonOther neurological signs• Flaccid paralysis (looks like polio)

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West Nile

DiagnosisHigh index of suspicion in the summerKnow what is in your backyardAppropriate testing (serum, CSF)

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West Nile

ManagementSupportiveNo specific treatment

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Anthrax

Described in history worldwideForms

SkinGastro-intestinalRespiratory system

Inhalation Anthrax (US): 20th cent.

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Anthrax

Cutaneous (skin)Blister, then painless ulcerSkin necrosis (dying of the skin cells)

Courtesy CDC

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Inhalational anthrax

Patients are sickerMortality is highPresents like the fluThen pneumoniaNO PERSON to PERSON SPREAD

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Diagnosis of anthrax

Microbiology specimensAlert the lab!Seek expert consultation

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Management

Actually it can be treatedCiprofloxacin, doxycycline, pen GTreatmentProphylaxis for exposed personsThere is a vaccine

Used mostly in the military

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Monkeypox

1958 : lab monkeys1970:first reported human caseSporadic cases in AfricaSurge after smallpox vaccination was stopped?

Did the vaccine protect?

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US Monkeypox Outbreak

June 2003In the news: mid-westSick African rats were importedContact with local prairie dogsTransmitted illness to petsThen to humans

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Monkeypox features

A rather long incubation periodUpto 12 days

Fever, muscle aches, headacheJust like the flu!Lymph node swellingRash a few days later

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Diagnosis and Management

Diagnosis by suspicion onlyMay look like smallpoxNeeds special diagnostic testsNo specific treatmentSmallpox vaccine for the exposed

The CDC does recommend this

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Monkeypox cases, July 03State Cases

Under Investigatio

n

Lab-Confirmed

Cases

Illinois 13 9Indiana 16 7Kansas 1 1Missouri 2 2Ohio 1 0Wisconsin 39 18Total 72 37

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Monkeypox

Animal to humanPerson to person possible

Large respiratory dropletsClose contact requiredSecretions from skin lesionContaminated bedding/objects

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SARS

Severe Acute Respiratory SyndromeThis is truly an emerging infectionNot known to exist before 2003Knowledge is still “emerging”Current thinking

Animal reservoirCivet cats in China?

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SARS

Caused by a coronavirusA mutant cousin of the cold virus!

Highly communicablePerson to personLarge droplet: close contact neededFrom inanimate objects?

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SARS

2003: 8098 cases with 774 deathsThe US was largely sparedUnlucky: Southeast Asia & Canada2004: Handful of cases

ChinaLab accidents

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SARS

Presents like the fluNo specific treatmentHighly contagiousWill it become seasonal?

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What does SARS look like?

InfluenzaAvian influenzaOther viral respiratory illnessesSevere pneumonia

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Now that we have discussed some diseases…

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What Constitutes Preparedness?

No right answerSome common denominatorsStart with the Disaster Plan

Everyone has one

Review the communicable disease section

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Please hold on…

Courtesy AVG Family

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Now – Here is THE plan you need…

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Not so fast…

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I can’t write YOUR plan!

We are all the same…Yet differentWe are

Urban Community Health CentersRural Health CentersHomeless HealthMigrant Health

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We are different

Different trainingDifferent expertiseResources are variableOur disasters are different!

Natural disasters: EarthquakesChemicalNear Port-of-Entry

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Basic PrinciplesAwarenessTriage areaWaiting room

Can you isolate ill from the well?

Prompt identification of ill patientsCan you take them into a private room?

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Respiratory Etiquette (CDC)

Basic infection controlSurgical mask for coughing patientsMasks for front office/intake team

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Other Basics

Personal Protective Equipment (PPE)N95 Mask with fit-testingGowns, gloves, face shields

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Other Basics

Room cleaningGood disinfectant- hospital grade

Medical Waste DisposalLaundry Facilities

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Now…

We have equipped our clinic and ourselves

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Increase our awareness

Some suggestionsDisclaimer

These are only suggestionsNot validated yet

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Syndromic Surveillance

Look for groups of symptoms“Syndrome”Not specific for anythingMAY suggest an illness

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Syndromic Surveillance

Best Example – ValidatedInfluenza-like illness (ILI) surveillanceLooking for either

Fever AND Cough ORFever AND Sore throat

During flu seasonPatient with ILI most likely has the flu!

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A Suggestion

Syndromic surveillanceIn the season: Influenza-like illnessOther times:

Fever with Cough and SOBModify for West Nile: fever + HA

Rash with Fever

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Sample Work SheetFever With Cough and SOB

or Influenza-like IllnessRash with Fever Concerned

?

Children Adults Children Adults

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

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Sample work sheet

What will this alert you to?Most of the time

The usual suspects!

Influenza in the winterChildhood illnesses

ChickenpoxMeasles

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When would I use this?

Not all the time!Large outbreak in the world (SARS)Unusual activity in my communityWhen threat level is raised to Orange?

Otherwise we do not do anything differently

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Seen anything unusual?

Notification Local health departmentTechnical assistance from them

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Partnerships

Build bridges before the flood!Do you know how to contact

Your local health departmentYour State health department

Do they know you?

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Partnerships

Do you have consult services?Can you call someone?Where can you refer your patients?

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Communication is the key

Bi-directionalCurrent information

Accurate and timelyWhere will you get it?• Health departments

You will hear a lot from the mediaRumors/Panic

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Communication is the key

Information TO public healthYou are their eyes and ears!They depend on you!

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Challenges

No one size fits all!Basic plan: You all have oneTailor to your specific needs

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Challenges

RESOURCESTrainingQuick access to

InformationSpecialistsPublic health

Build bridges now

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Scenario 1: Rebecca

What happened to Rebecca?Emergency smallpox vaccinationAdmitted to isolation roomSupportive careGood outcome

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Scenario 2

36 year old womanPresents with fever and coughSlowly progressingWalks in to the waiting roomShe is actively coughing

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Scenario 2

No travel historyNo risk factors for TBBy the way…

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Scenario 2

Live-in NannyThe employer is also sickThe employer just returned from a business trip to China

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Scenario 2: Respiratory

What would you do?

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Scenario 2

You are concernedDifferential includes

SARSInfluenza: avian and humanOther viral diseaseOther bacterial diseaseA new disease?

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Scenario 2: Respiratory

Mask for patient and providersIsolate in private roomBasics: Is she stable?What does her employer have?Call local HD and local ERWho are her contacts?

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Acknowledgements

My colleaguesWasatch Homeless Health Care, Inc.University of Utah School of Medicine• Hospital Epidemiology and Inf Diseases

Local Homeless Service ProvidersNorth York General Hospital, Toronto

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Acknowledgements

CHC ColleaguesKeith Horwood, MD, SLCMel Ray, PA-C, Green River, Utah

Colleagues at CHAMPSGina AstorinoDarci Martinez

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This is where we work…

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Questions and Comments

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Resources

Local HD and State HD websiteswww.cdc.govhttp://www.bt.cdc.gov/Other government sitesMajor university sitesNational associations (NACHC)

Adi Gundlapalli, MD, PHD

Dr. Gundlapalli is board certified in internal medicine and infectious diseases and has received training in both basic and clinical research. His research interests include issues in infection control, epidemiology of upper respiratory infections, public health surveillance for emerging infections and agents of bioterrorism, and health care for the homeless. He is actively involved in research and teaching at the University of Utah School Of Medicine and has presented his work at national and international meetings. Dr. Gundlapalli has also been invited by several local and national organizations to lecture on topics relating to infectious diseases and public health.

Adi Gundlapalli received his basic medical training in India and graduate training in immunology at the University of Connecticut Health Center in Farmington, CT. He then completed an internal medicine residency at the University of Connecticut and moved to the University of Utah School Of Medicine where he completed a fellowship in infectious diseases and hospital epidemiology. He is currently the medical director of Wasatch Homeless Health Care, Inc. in Salt Lake City, Utah and adjunct assistant professor of medicine at the University of Utah School Of Medicine .