Emerging and Re-Emerging InfectionsIntroduction to Infectious Outbreak Reporting and ContainmentLarissa May, M.D.Department of Emergency MedicineThe George Washington University School of Medicine

Clinical Case

28 year old previously healthy female biologist presents with fever and spreading rashTwo days ago she developed a fever, sore throat, and vomitingShe has had several very dark bowel movementsToday her boyfriend noted she was drowsy and disoriented She returned from Uganda 3 days ago, where she was collecting samples from wild monkeys for DNA analysis

Clinical CaseVitals: 84/52 HR 132 T 104.4 94% RA diaphoreticTachypneic with bilateral bibasilar rales Centripetal maculopapular rash with hemorrhagic erythema on the palms and solesSubconjunctival hemorrhages, palatal petechiaeDiffuse abdominal tenderness with guarding; black stool

You are the only physician working in the Emergency DepartmentThe nurse notifies you that you have two urgent incoming calls EMS is transporting a 44 year-old diplomat with massive GI and gingival bleeding, febrile to 102, blood pressure of 60/palpOn the other line a concerned internist is sending two returned travelers with fever and rash

ObjectivesHow do we recognize potential sentinel cases for an outbreak?How do we report a suspected outbreak?What measures can we take toward outbreak containment in the emergency department? What resources are available in the event of an outbreak?

WorkshopED physicianLocal health department National health office (CDC)Hospital administration (Incident command)Infection control officerLaboratory

ObjectivesHow do we recognize potential sentinel cases for an outbreak?How do we report a suspected outbreak?What measures can we take toward outbreak containment in the emergency department? What resources are available in the event of an outbreak?

Why teach outbreak recognition and containment?Factors favoring the emergence of infections: (1992 IOM report)Change in physical environmentHuman behavorial activitiesSocial/political/economic factorsBioterrorismIncreased use of antimicrobials and pesticides1. Centers for Disease Control and Prevention. Preventing Emerging Infectious Diseases. A Strategy for the 21st century.Global Emerging Crisis in Infectious Diseases. Challenges for the 21st century. The Pfizer Journal. V(2), 2004.

Bioterrorism1997: biodefense budget $137 million

2000: $1.5 billion for military biodefense and $1 billion for domestic preparedness

Operation Bioshield: $6 billion over 10 years for vaccines and treatments against potential bioterrorism agentsDavid R. Franz and Russ Zajtchuk. Bioterrorism: Understanding the threat, preparation and medical response. Disease-A-Month 48(8), August 2002.

Outbreak recognition Most outbreaks present as flu-like illness

Size of an outbreak related toVirulencemodes of transmissionextent/mode of disseminationJames W. Buehler et. Al. Syndromic Surveillance and Bioterrorism-related epidemics. Emerging Infectious Diseases, October 2003

Outbreak recognition James W. Buehler et. Al. Syndromic Surveillance and Bioterrorism-related epidemics. Emerging Infectious Diseases, October 2003Severe Gastroenteritis

Fatal pneumonia in healthy patient Widened mediastinum with fever

Rash with synchronous vesicular/pustular lesions

Acute neurologic illness with fever

Advancing cranial nerve palsy with weakness

Outbreak Detection: Epidemiologic CriteriaSevere disease in a healthy patientIncreased number of patients with fever, rash, respiratory or GI symptoms, or sepsisLarge number of rapidly fatal respiratory casesRega. Bioterrorism: A statistical manual to identify and treat diseases of bioterrorism.Mascap Inc, Ohio, 2000.

Outbreak Detection: Epidemiologic CriteriaIncreasing number of ill or dead animalsRapid rise and fall in the epidemic curveMultiple patients presenting from a similar locationEndemic disease at an unusual time of the yearRega. Bioterrorism: A statistical manual to identify and treat diseases of bioterrorism.Mascap Inc, Ohio, 2000.

Syndromic Surveillance: Clinicians RoleHealthy People 2010 initiative calls for improved surveillance systemsSyndromic Surveillance: Collection and analysis of statistical data on health trendsClinicians essential for active syndromic surveillance and reporting to public health officialsDetermination of credible riskInformation technologyMichael Stoto et. Al. The RAND Center for Domestic and International Health Security. Syndromic Surveillance: Is it worth the effort? Chance 17(1), 2004, 19-24. 2. Peter Katona. Bioterrorism Preparedness: A generic blueprint for health departments,Hospitals and physicians. Infectious Diseases in Clinical Practice 11(3), 2004, March/April 2002.

Model for Outbreak EpidemiologySusceptibleExposedInfectiveRemoved VaccinatedKE Nelson. Infectious Disease Epidemiology: Theory and Practice. Aspen Publishers, 2001, p. 119-69.

Who do I report an Outbreak to?Call your local health department first for adviceDepartment of health 24 hour hotlineCheck websiteLocal DOH will contact the Centers for Disease Control and Prevention if necessary International reporting mechanisms exist to detect emerging infections as they occur in their areas of originGlobal Emerging Crisis in Infectious Diseases. Challenges for the 21st century. The Pfizer Journal. V(2), 2004.

Outbreak Containment in the Emergency DepartmentDetection of sentinel caseActivation of the Hospital Emergency Management Plan leads to notification of Administration, Nursing, Clinical Departments, Radiology, Supplies, and other departmentsNotification of Infectious Disease and Infection Control1.Peter Katona. Bioterrorism Preparedness: A generic blueprint for health departments, Hospitals and physicians. Infectious Diseases in Clinical Practice 11(3), 2004, March/April 2002.2. Lynn K. Flowers et. Al. Bioterrorism Preparedness II: The Community and EMS Systems. Emergency Medicine Clinics of North America 20(2), May 2002.

Outbreak Containment in the Emergency DepartmentInform local Department of HealthEpidemiologic surveillance and investigationInform Director of LaboratoryRapid agent detection and confirmationLab specimen handling, testing and referralNeed for outside assistanceEstablishment of a communication system:

1.Peter Katona. Bioterrorism Preparedness: A generic blueprint for health departments, Hospitals and physicians. Infectious Diseases in Clinical Practice 11(3), 2004, March/April 2002.2. Lynn K. Flowers et. Al. Bioterrorism Preparedness II: The Community and EMS Systems. Emergency Medicine Clinics of North America 20(2), May 2002.

Outbreak Containment in the Emergency DepartmentIsolation and environmental controlsGeographical cohortingPatient and healthcare worker cohortingAdmission and expedient discharge of non-infectious patients

1.Peter Katona. Bioterrorism Preparedness: A generic blueprint for health departments, Hospitals and physicians. Infectious Diseases in Clinical Practice 11(3), 2004, March/April 2002.2. Lynn K. Flowers et. Al. Bioterrorism Preparedness II: The Community and EMS Systems. Emergency Medicine Clinics of North America 20(2), May 2002.

Outbreak Containment in the Emergency DepartmentPatient and staff prophylaxis: responsibility of Infection Control and DOHMass patient care: requires pre-identification of surge capacity sites Staffing needs: back up/functional unitsCommunity and mental health needs: involve social work and psychiatry

1.Peter Katona. Bioterrorism Preparedness: A generic blueprint for health departments, Hospitals and physicians. Infectious Diseases in Clinical Practice 11(3), 2004, March/April 2002. 2. Lynn K. Flowers et. Al. Bioterrorism Preparedness II: The Community and EMS Systems. Emergency Medicine Clinics of North America 20(2), May 2002.

Hospital Emergency Incident Command System (HEICS)Incorporate bioterrorism/contagious outbreak plan into existing internal operations in an all hazards approachIncident Command Structure: Incident Commander Sub-chiefs: logistics, operations, finance, planningCommon organizational structure to coordinate response to mass casualty eventPeter T. Pons and Stephen V. Catrill. Mass Casualty Management: A Coordinated Response. Critical Decisions in Emergency Medicine, November 2003.

Hospital Response Plans

CDC Bioterrorism Readiness Plan: A Template for Healthcare FacilitiesSyndrome-based criteriaInfection ControlIsolation precautionsPatient placementPatient TransportCleaning, disinfection, sterilizationDischarge ManagementPost-mortem carePost-exposure managementTriage of large scale exposures and suspected exposuresPsychological aspects and counseling

Centers for Disease Control and Prevention. APIC Bioterrorism Task Force. CDC Hospital Infections program bioterrorism working Group.

Hospital Response PlansActivation/Notification:Administration, media relations, infection controlFacility Protection: security, external triage Decontamination: self-decontamination Supplies/logistics: pharmaceuticals, PPE, ventilatorsAlternative care sites:Expedient discharge of patientsCancellation of elective casesCarl Shulz et. Al. Bioterrorism Preparedness I: The Emergency Department and Hospital. Emergency Medicine Clinics of North America 20(2), May 2002.

Hospital Response Plans

Staff education/training:Mass casualty protocols and drills

Coordination and communication:EMS and Fire DepartmentPoliceGovernmentMedia

Carl Shulz et. Al. Bioterrorism Preparedness I: The Emergency Department and Hospital. Emergency Medicine Clinics of North America 20(2), May 2002.

Outbreak Containment: State and Federal ResponseLocal and State response DHHS identifies and applies containment for epidemicsFEMA coordinates federal assistance NDMS (National Medical Disaster system) DMAT (Disaster Medical Assistance Teams)CDC: epidemiologic and laboratory expertise, control measures and prophylaxisStrategic National StockpileJerry L. Mothershead et. Al. Bioterrorism Preparedness III: State and Federal and Response. Emergency Medicine Clinics of North America 20(2), May 2002.

Resources During an OutbreakCDC Bioterrorism Website www.bt.cdc.govJohns Hopkins Center for Civilian Biodefense Studies www.hopkins-defense.orgUS Army Medical Research Institute for Infectious Diseases www.usamriid.army.mil

HICPAC Infection Control GuidelinesEstablished by CDC in 1991

Standard precautions: exposure to blood and body fluids. Personal protective equipment (PPE): gown, gloves, mask with eye protection

Contact isolation: PPE for all healthcare worker interactions, private room, dedicated patient equipment, limit transporthttp://www.cdc.gov/ncidod/hip/HICPAC/publications.htm

HICPAC Infection Control Guidelines

Droplet: for microbes less than 5 micrometers in diameter, transmissible at less than 3 feet distance. PPE including mask at all times

Airborne: small infectious particles. PPE including N95/PAPR, negative pressure isolation room with 6-12 air changes per hourhttp://www.cdc.gov/ncidod/hip/HICPAC/publications.htm

EBOLAWhat could have been done?1995 Ebola outbreak in Congo: 240 deaths in 4 monthsDelayed outbreak reportingHospital-promoted transmissionProvision of disinfectant and PPE led to containment1997 Ebola outbreak in the Congo: 19 days to outbreak awareness49 days to international assistance

Centers for Disease Control and Prevention. Preventing Emerging Infectious Diseases. A Strategy for the 21st century.

Lessons from SARSOutbreak cost estimated at $80 billion Efficient response by GOARN, GPHIN and Promed mailOntario provincial emergency: creation of SARS unitsSingapore: 10 day quarantine for all SARS contacts, screening of all airport and seaport arrivals for feverJoshua Lederberg et. Al. Emerging Infections: Microbial threats to health in the United Sates. Institute of Medicine, 1992.

Lessons from SARS: ContainmentInfected patients:DetectionIsolationContainment

Conversion of patient roomsinto isolation rooms hotwardsDesignated ambulance serviceBack up teams/functional unitsUninfected patientsMonitoringprotectionLessons Learned from SARS: Management of an Emerging Infectious Disease from a Military Perspective. ww.mindef.gov.sg

Emerging Infections: A Deadly ProspectWhen Veronica brought him back to the same clinic, he was running a fever of 103 degrees F, His systolic blood pressure was low.Although Veronica was panicked, she tried to bear in mind what Azikiwe had told her. American doctors werent like they were in Nigeria..they knew what they were doingNow, after three visits to the HMO, she wasnt so sureStill, no one asked him about travel.

From Level 4: Virus Hunters of the CDC. By Joseph B. McCormick and Susan Fisher-Hoch with Leslie Anne Horvitz. Barnes and Noble Books: New York, New York, 1996.

Clinical Case (continued)A tentative diagnosis of viral hemorrhagic fever is madePatients placed in airborne isolation, cohorted with staffYou call Infectious Disease on Call and Hospital Administration for activation of the Contagious Disease Outbreak PlanYou notify the DC DOH emergency hotline and the CDC for recommendations and assistance in containment of the outbreak and contact tracingIdentification and confirmation of Ebola serotype made by USAMRIID BSL 4 laboratory

Viral Hemorrhagic Fever: FilovirusesMarburg and Ebola cause severe illnessFamily endemic to Central AfricaMarburg first identified in Germany in 1967 in lab-workers exposed to infected monkeysEbola-Reston virus discovered in 1989 in imported monkeysMultiple outbreaks since 1977Ebola Zaire 88% mortalityLong period of infectivityBody fluids of deceased infectious

Omar Lupi and Stephen K.. Tyring. Tropical Dermatology: viral tropical Diseases. Journal of the American Academy of Dermatology 49 (6), December 2003.

Viral Hemorrhagic Fever: FilovirusesIncubation period 4-5 daysSudden onset high fever, sore throat, fatigue, headacheNonpruritic maculopapular centripetal rash desquamates after one weekGI, skin and mucous membrane hemorrhagesOmar Lupi and Stephen K.Tyring. Tropical Dermatology: viral tropical Diseases. Journal of the American Academy of Dermatology 49 (6), December 2003.

Viral Hemorrhagic Fever: FilovirusesLeukopenia, thrombocytopenia, transaminitisMortality from hemorrhage and hypovolemic shockDifferential Diagnosis: Yellow fever, dengue, meningococcemia, leptospirosis, ITPOmar Lupi and Stephen K.Tyring. Tropical Dermatology: viral tropical Diseases. Journal of the American Academy of Dermatology 49 (6), December 2003.

Viral Hemorrhagic Fever: FilovirusesDiagnosisImmunofluorescence or ELISAPCR

TherapySupportive No vaccine yet availableOmar Lupi and Stephen K.Tyring. Tropical Dermatology: viral tropical Diseases. Journal of the American Academy of Dermatology 49 (6), December 2003.

Viral Hemorrhagic Fever: Current GuidelinesContact isolationCannot rule out airborne transmissionPAPR provides better filtration than N95 but more expensive and increases needlestick risk Supportive treatmentExperimental IND for ribavirin in arenavirusesLuciana Borio et. Al. Hemorrhagic Fever Viruses as Biological Weapons: Medical and Public Health Management. JAMA 287(18), May 8, 2002.

Outbreak Preparedness: Goals for CliniciansBe familiar with epidemiologic criteria for sentinel casesKnow your hospital emergency preparedness plans and how to report a suspected sentinel caseFollow basic principles of isolation, infection control, and cohorting in an outbreak

References1. David R. Franz and Russ Zajtchuk. Bioterrorism: Understanding the threat,Preparation and medical response. Disease-A-Month 48(8), August 2002.2. Rega. Bioterrorism: A statistical manual to identify and treat diseases of bioterrorism. Mascap Inc, Ohio, 2000.3. Michael Stoto et. Al. The RAND Center for Domestic and International Health Securtiy. Syndromic Surveillance: Is it worth the effort? Chance 17(1), 2004, 19-24.4. Ben Y. Reise and Kenneth D. Mandl. Syndromic Surveillance: the effects of syndrome grouping on model accuracy and outbreak detection. Annals of Emergency Medicine 44(3(), September 2004.5. James W. Buehler et. Al. Syndromic Surveillance and Bioterrorism-related epidemics. Emerging Infectious Diseases, October 20036. Edward N. Barthell et. al. Syndromic Surveillance: The Frontiers of Medicine project: a roposal for the standardization communication of ED data for public health uses including syndromic Surveillance. Annals of Emergency Medicine 39(4), April 2002.7. Peter Katona. Bioterrorism Preparedness: A generic blueprint for health departments, Hospitals and physicians. Infectious Diseases in Clinical Practice 11(3), 2004,March/April 2002.8.Seth Foldy et. Al. Syndromic Surveillance Using Regional Emergency Medicine Internet. Annals of Emergency Medicine 44(3), September 2004.9.The George Washington University Contagious Disease Outbreak Plan. January 2005.

References10. Fred M. Burkles, Jr. Mass Casualty Management of a Large Scale Bioterrorism Event: An Epidemiologic Approach that Shapes Triage Decisions. Emergency Clinics of North America 20(2), May 2002.11.KE Nelson. Infectious Disease Epidemiology: Theory and Practice.Aspen Publishers, 2001, p. 119-69.12.Centers for Disease Control and Prevention. Preventing Emerging InfectiousDiseases. A Strategy for the 21st century.13. Global Emerging Crisis in Infectious Diseases. Challenges for the 21st century. The Pfizer Journal. V(2), 200414. Joshua Lederberg et. Al. Emerging Infections: Microbial threats to health in the United Sates. Institute of Medicine, 1992.15. Lessons Learned from SARS: Management of an Emerging Infectious Disease from a Military Perspective. www.mindef.gov.sg16. Lynn K. Flowers et. Al. Bioterrorism Preparedness II: The Community and EMSSystems. Emergency Medicine Clinics of North America 20(2), May 2002.17. Fred M. Henretig. Medical Management of the Suspected Victim of Bioterrorism:An algorithmic approach to the undifferentiated patient. Emergency Medicine Clinics of North America 20(2), May 2002.18. CDC Bioterrorism Website www.bt.cdc.gov19. John Hick et. Al. Health Care Facility and Community Strategies for Patient Surge Capacity.Annals of Emergency Medicine Volume 44 Number 3 September 200420. Jerry L. Mothershead et. Al. Bioterrorism Preparedness III: State and Federal and Response. Emergency Medicine Clinics of North America 20(2), May 2002.21. Centers for Disease Control and Prevention. APIC Bioterrorism Task Force.CDC Hospital Infections program bioterrorism working Group.

References22. Peter T. Pons and Stephen V. Catrill. Mass Casualty Management: A CoordinatedResponse. Critical Decisions in Emergency Medicine, November 2003.23. Carl Shulz et. Al. Bioterrorism Preparedness I: The Emergency Department and Hospital. Emergency Medicine Clinics of North America 20(2), May 2002.24. www.cdc.gov/ncidod/hip/HICPAC/publications.htm25. Luciana Borio et. Al. Hemorrhagic Fever Viruses as Biological Weapons: Medical and Public Health Management. JAMA 287(18), May 8, 2002.Omar Lupi and Stephen K.Tyring. Tropical Dermatology: viral tropical Diseases. Journal of the American Academy of Dermatology 49 (6), December 2003.28. 21st Century Bioterrorism and Germ WeaponsU.S. Army Field Manual for the Treatment of Biological Warfare Agent Casualties, 2000.29. Robert Darling et. Al. Threats in Bioterrorism I: CDC Category A agents. Emergency Medicine Clinics of North America 20(2), May 2002.30.The 1, 2, 3's of Biosafety Levels Jonathan Y. Richmond, Ph.D. Director, Office of Health and Safety Centers for Disease Control and Prevention Atlanta, GA 30333. Adapted from the CDC/NIH 3rd edition of Biosafety in Microbiological and Biomedical Laboratories