“Preparing Our Communities”

1® BDLS is a registered trademark of the American Medical Association® BDLS is a registered trademark of the American Medical AssociationV 2.9 04/07V 2.9 04/07

®®

““Preparing Our Communities”Preparing Our Communities”

Welcome!Welcome!

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Faculty DisclosureFaculty Disclosure

• For Continuing Medical Education (CME) purposes as For Continuing Medical Education (CME) purposes as required by the American Medical Association (AMA) required by the American Medical Association (AMA) and other continuing education credit authorizing and other continuing education credit authorizing organizations:organizations:– In order to assure the highest quality of CME programming, In order to assure the highest quality of CME programming,

the AMA requires that faculty disclose any information relating the AMA requires that faculty disclose any information relating to a conflict of interest or potential conflict of interest prior to to a conflict of interest or potential conflict of interest prior to the start of an educational activity. the start of an educational activity.

– The teaching faculty for the BDLS course offered today have The teaching faculty for the BDLS course offered today have no relationships / affiliations relating to a possible conflict of no relationships / affiliations relating to a possible conflict of interest to disclose. Nor will there be any discussion of off interest to disclose. Nor will there be any discussion of off label usage during this course. label usage during this course.

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Biological EventsBiological EventsChapter 5Chapter 5

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ObjectivesObjectives

• Describe the difference between biological events and Describe the difference between biological events and bioterrorism (BT)bioterrorism (BT)

• Discuss public health BT surveillanceDiscuss public health BT surveillance

• Identify the CDC BT Category A agentsIdentify the CDC BT Category A agents

• Identify emerging infectious diseasesIdentify emerging infectious diseases

• Compare and contrast BT and other CBRNE WMD Compare and contrast BT and other CBRNE WMD utilizing the utilizing the DISASTERDISASTER paradigm paradigm

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Biological EventsBiological EventsBiological events: Natural vs. IntentionalBiological events: Natural vs. Intentional

Outbreak of monkey pox in pet Outbreak of monkey pox in pet prairie dogsprairie dogs

Avian Flu pandemicAvian Flu pandemic

Natural occurrence of anthraxNatural occurrence of anthrax

Bubonic plague outbreakBubonic plague outbreak

Release of anthrax in mailRelease of anthrax in mail

Salmonella sprayed on food barSalmonella sprayed on food bar

Smallpox infectionSmallpox infection

Aerosolized botulinum toxinAerosolized botulinum toxin

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Bioterrorism Release Types: Bioterrorism Release Types: Overt or CovertOvert or Covert

Letter sent to the New York Letter sent to the New York Post and NBC News:Post and NBC News:

Containing “white powder”Containing “white powder”

(1763)Captain Simeon Ecuyer had sent smallpox-infected blankets and handkerchiefs to the Indians surrounding the fort (as a supposed peace offering)-- but actually an early example of biological warfare -- which started an epidemic among the Indians.

Covert or Overt ?Covert or Overt ? Covert or Overt ?Covert or Overt ?Covert ReleaseCovert Release

–No notice or threatNo notice or threat

–Difficult to detectDifficult to detect•Persons seek care at usual Persons seek care at usual medical care facilitiesmedical care facilities

•Early symptoms non-specificEarly symptoms non-specific

so detection may be delayedso detection may be delayed

•Focus: Astute clinician make Focus: Astute clinician make diagnosis and notify health diagnosis and notify health department (Detection)department (Detection)

–Notice of release Notice of release providedprovided

–May contain a threatMay contain a threat–Designed to create Designed to create panic or fearpanic or fear

–May be hoax (white May be hoax (white powder) or credible powder) or credible threatthreat

OvertOvert

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Potential Methods of DetectionPotential Methods of Detection

• Increased number of patientsIncreased number of patients• Increased unexplained deaths Increased unexplained deaths • Unusual patient age distribution Unusual patient age distribution • Unusual seasonalityUnusual seasonality• Unusual manifestation of disease Unusual manifestation of disease • Animal die-offAnimal die-off• Notifiable disease reporting by physicians & other providersNotifiable disease reporting by physicians & other providers• Automated reporting of laboratory resultsAutomated reporting of laboratory results• Number and type of 911 callsNumber and type of 911 calls• Number and type of EMS runsNumber and type of EMS runs• Syndromic surveillanceSyndromic surveillance

Public Health SurveillancePublic Health Surveillance

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CDC Categories BT AgentsCDC Categories BT Agents

Divided into Categories A, B,C based on:Divided into Categories A, B,C based on:

• Quantity of agent availableQuantity of agent available

• Ability to disseminate the agentAbility to disseminate the agent

• Person-to-person transmissionPerson-to-person transmission

• Severity of diseaseSeverity of disease

• Public response, panic, etc..Public response, panic, etc..

• Overall risk to national securityOverall risk to national security

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Category A AgentsCategory A Agents

• AnthraxAnthrax

• SmallpoxSmallpox

• PlaguePlague

• Botulinum toxinBotulinum toxin

• TularemiaTularemia

• Viral hemorrhagic feversViral hemorrhagic fevers

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Category B AgentsCategory B Agents(examples)(examples)

• Infectious AgentsInfectious Agents– Brucellosis Brucellosis – GlandersGlanders

• Bio-toxinsBio-toxins– Ricin toxin from Ricinus Ricin toxin from Ricinus

communis (castor beans)communis (castor beans)

– Staphylococcal enterotoxin BStaphylococcal enterotoxin B

Why are these Category B Why are these Category B AgentsAgents•Less quantity available than Less quantity available than Category ACategory A•Harder to disseminateHarder to disseminate•Less person to person Less person to person transmission- if anytransmission- if any•Slightly less severity of Slightly less severity of diseasedisease•Less known to public - Less known to public - therefore less likely to cause therefore less likely to cause panicpanic•Slightly less risk to National Slightly less risk to National SecuritySecurity

• Water safety threatsWater safety threats–Vibrio choleraeVibrio cholerae

• Food safety threatsFood safety threats–Salmonella speciesSalmonella species

–Escherichia coli O157:H7Escherichia coli O157:H7

–ShigellaShigella

• Viral encephalitisViral encephalitis–Venezuelan Equine EncephalitisVenezuelan Equine Encephalitis

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Category CCategory C• Emerging infectious diseases as bioterrorism agentsEmerging infectious diseases as bioterrorism agents

– Nipah virusNipah virus– HantavirusHantavirus

• Emerging infectious disease that posses a significant Emerging infectious disease that posses a significant public health threatpublic health threat– Avian Flu Avian Flu – SARSSARS

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Category A: AnthraxCategory A: Anthrax

Anthrax in CSF—US index caseAnthrax in CSF—US index case

•Endemic in animals worldwide Endemic in animals worldwide with occasional human caseswith occasional human cases

– Handling infected animal Handling infected animal products (especially cattle, products (especially cattle, sheep, horses, mules and sheep, horses, mules and goats)goats)

•Spores used for bioattackSpores used for bioattack

– Aerosolized directly or sent Aerosolized directly or sent in mail/packagesin mail/packages

•Three formsThree forms

–Cutaneous, Inhalation, GICutaneous, Inhalation, GI

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AnthraxAnthrax – Clinical Features – Clinical Features

• InhalationInhalation– Incubation: 2-43 days (may be longer)Incubation: 2-43 days (may be longer)– Prodrome Prodrome

• Fevers, malaise, dry cough, chest pain, dyspnea, Fevers, malaise, dry cough, chest pain, dyspnea, myalgiamyalgia

– AbruptAbrupt onset of fulminant illness onset of fulminant illness• Sudden high fever, respiratory distress, shockSudden high fever, respiratory distress, shock• Meningitis in ~50%Meningitis in ~50%• Actual pneumonia uncommonActual pneumonia uncommon

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Inhalational anthraxUS index case

Widened mediastinum & pleural effusions Widened mediastinum & pleural effusions Normal Chest X-RayNormal Chest X-Ray

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Anthrax – Clinical FeaturesAnthrax – Clinical Features

• CutaneousCutaneous– Incubation: 1 to 7days (up to 12 days)Incubation: 1 to 7days (up to 12 days)

– Erythematous “itchy” papule Erythematous “itchy” papule ulcer ulcer characteristic characteristic black eschar with surrounding erythema and edemablack eschar with surrounding erythema and edema

– Regional adenopathy and systemic symptoms (e.g., Regional adenopathy and systemic symptoms (e.g., fever, malaise)fever, malaise)

– Most lesions completely resolveMost lesions completely resolve

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Anthrax – Clinical FeaturesAnthrax – Clinical Features

• GastrointestinalGastrointestinal– Incubation period 1-7 daysIncubation period 1-7 days– NotNot likely after a bioattack likely after a bioattack– Presents as febrile illness with bloody Presents as febrile illness with bloody

diarrheadiarrhea– Eating undercooked infected meatEating undercooked infected meat

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Anthrax DiagnosisAnthrax Diagnosis• Blood cultures Blood cultures

– Usually positive in < 24hUsually positive in < 24h• Gram stain pleural fluid or CSF Gram stain pleural fluid or CSF

– Sputum gram stain/culture is usually NOT positiveSputum gram stain/culture is usually NOT positive• Inhalational diseaseInhalational disease

– Very suggestive if fever and widened mediastinumVery suggestive if fever and widened mediastinum• Cutaneous diseaseCutaneous disease

– Culture fluid from under escharCulture fluid from under eschar• Nasal swabs are a Nasal swabs are a poorpoor test test

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AnthraxAnthrax –Treatment –Treatment• Ciprofloxacin 400 mg IV q12h Ciprofloxacin 400 mg IV q12h

– 10-15 mg/kg for children10-15 mg/kg for children – Other fluoroquinolones probably also effectiveOther fluoroquinolones probably also effective

OROR

• Doxycycline 100 mg IV q12hDoxycycline 100 mg IV q12h– 2.2 mg/kg for children2.2 mg/kg for children

PLUSPLUS

• 1 or 2 additional antibiotics1 or 2 additional antibiotics – Clindamycin, rifampin, vancomycin, penicillin, Clindamycin, rifampin, vancomycin, penicillin,

chloramphenicol, imipenem, or clarithromycinchloramphenicol, imipenem, or clarithromycin

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Prophylaxis and Infection Prophylaxis and Infection ControlControl

• ProphylaxisProphylaxis

– Ciprofloxacin 500 mg PO BID(Peds:10-15 mg/kg)Ciprofloxacin 500 mg PO BID(Peds:10-15 mg/kg)

oror– Doxycycline 100 mg PO BID (Peds:2.2 mg/kg)Doxycycline 100 mg PO BID (Peds:2.2 mg/kg)– Continue for 60 days (? 100 days)Continue for 60 days (? 100 days)– Vaccine available for DOD forcesVaccine available for DOD forces

• Infection ControlInfection Control

– Standard barrier precautions are neededStandard barrier precautions are needed– Not transmitted person-to-personNot transmitted person-to-person

• Only immunize / prophylaxis exposed at BT attackOnly immunize / prophylaxis exposed at BT attack

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Anthrax Vaccination ScheduleAnthrax Vaccination Schedule

• 6 shots over 18 months, then annual booster6 shots over 18 months, then annual booster

– Dosing schedule is 0.5 mL subcutaneously at each Dosing schedule is 0.5 mL subcutaneously at each visitvisit

– Then yearly boostersThen yearly boosters

1 2 3 4 5 60

2 w

eeks

4 w

eeks

6 m

onth

s

12 m

onth

s

18 m

onth

s

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BotulismBotulism

Clostridium botulinumClostridium botulinum

A Toxin Producing Obligate, Anaerobic, Spore Forming, A Toxin Producing Obligate, Anaerobic, Spore Forming,

Gram Pos. BacillusGram Pos. Bacillus

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Botulism - GeneralBotulism - General• Caused by a toxin produced by Caused by a toxin produced by

Clostridium botulinumClostridium botulinum

• Sporadic cases and outbreaks caused by Sporadic cases and outbreaks caused by tainted foodstainted foods

• For bioattack toxin could be delivered as For bioattack toxin could be delivered as an aerosol or used to contaminate food / an aerosol or used to contaminate food / waterwater

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BotulismBotulism - Clinical Features - Clinical Features• 12 to 36 hour “incubation” 12 to 36 hour “incubation”

– Range 2 h to 8 daysRange 2 h to 8 days

• Clinical recognition is key to diagnosisClinical recognition is key to diagnosis• Bulbar palsies: Bulbar palsies: Must be present!Must be present!

– Ptosis, blurred vision, dry mouth, dysarthria, trouble Ptosis, blurred vision, dry mouth, dysarthria, trouble swallowingswallowing

• Afebrile,“AAO x 3”, difficulty speakingAfebrile,“AAO x 3”, difficulty speaking• Descending skeletal muscle paralysisDescending skeletal muscle paralysis

• Death: Respiratory muscle paralysisDeath: Respiratory muscle paralysis

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17 Year-Old 17 Year-Old with Mild Botulism with Mild Botulism

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Botulism - TreatmentBotulism - Treatment

• Supportive careSupportive care

• Respiratory failureRespiratory failure– Prolonged Ventilator supportProlonged Ventilator support

• Antitoxin Antitoxin – State health department obtainedState health department obtained– Prevents further damagePrevents further damage– Does not alter current damageDoes not alter current damage

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Botulism – Botulism – Infection ControlInfection Control

ProphylaxisProphylaxis• No proven prophylaxis at this timeNo proven prophylaxis at this time• Investigational VaccineInvestigational Vaccine

IsolationIsolation• Standard precautions (not P-to-P)Standard precautions (not P-to-P)

Need to contact public health authority immediately:Need to contact public health authority immediately: Others may be exposed to contaminated food source Others may be exposed to contaminated food source or agentor agent

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PlaguePlague

Yersinia pestisYersinia pestis

Yersinia pestis Yersinia pestis

Source: www.cdc.govSource: www.cdc.gov

Gram Neg., Anaerobic, Rod Shaped Bac.Gram Neg., Anaerobic, Rod Shaped Bac.

““Safety Pin” Bipolar on Wright StainingSafety Pin” Bipolar on Wright Staining

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Plague - GeneralPlague - General• Endemic in animals Endemic in animals

throughout the worldthroughout the world– Prairie dogs in the Prairie dogs in the

Southwestern USSouthwestern US• High potential as a BT agent High potential as a BT agent • Endemic form Endemic form

– Spread to humans via a Spread to humans via a flea vector flea vector

– Results in bubonic form Results in bubonic form of the diseaseof the disease

• Bioattack Bioattack – Most likely aerosolizedMost likely aerosolized– Results in pneumonic Results in pneumonic

plagueplague– Release of infected fleasRelease of infected fleas

BuboesBuboes


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Plague – Clinical FeaturesPlague – Clinical Features

• Following Aerosolized BioattackFollowing Aerosolized Bioattack– 1- 6 day incubation1- 6 day incubation– Abrupt onset Abrupt onset

• High fever, chills, and malaiseHigh fever, chills, and malaise• Cough with bloody sputumCough with bloody sputum• SepsisSepsis

– Severe rapidly progressive pneumoniaSevere rapidly progressive pneumonia– Untreated 100% mortalityUntreated 100% mortality

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Plague - DiagnosisPlague - Diagnosis• CXR with patchy infiltratesCXR with patchy infiltrates

• Culture of blood and sputumCulture of blood and sputum– Need to inform the laboratory if you suspect Need to inform the laboratory if you suspect

plague … special techniquesplague … special techniques

• May show characteristic “safety-pin” May show characteristic “safety-pin” bipolar stainingbipolar staining

• Sudden # Gm(neg) pneumoniaSudden # Gm(neg) pneumonia

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Plague pneumoniaNormal Chest X-Ray

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Plague - TreatmentPlague - TreatmentPreferredPreferred: : Start within first 24 hours for 10 daysStart within first 24 hours for 10 days• Streptomycin 1 g IM q12h Streptomycin 1 g IM q12h

– 15 mg/kg/dose for children15 mg/kg/dose for children– AvoidAvoid in pregnant women in pregnant women

• Gentamicin 5 mg /kg IM or IV qdGentamicin 5 mg /kg IM or IV qd– Or 2 mg/kg load the 1.7 mg/kg q8hOr 2 mg/kg load the 1.7 mg/kg q8h– For children use 2.5 mg/kg q8hFor children use 2.5 mg/kg q8h

AlternativeAlternative• Doxycycline 100 mg IV q12hDoxycycline 100 mg IV q12h

– 2.2 mg/kg/dose q12h for children2.2 mg/kg/dose q12h for children• Ciprofloxacin 400 mg IV q12h Ciprofloxacin 400 mg IV q12h

– Other fluoroquinolones probably effectiveOther fluoroquinolones probably effective– For children 15 mg/kg/dose q12hFor children 15 mg/kg/dose q12h

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Plague - Infection ControlPlague - Infection Control

ProphylaxisProphylaxis: : Treat for 7 daysTreat for 7 days• Doxycycline 100 mg PO bidDoxycycline 100 mg PO bid

– 2.2 mg/kg for children2.2 mg/kg for children

• Ciprofloxacin 500 mg PO bidCiprofloxacin 500 mg PO bid– 20 mg/kg for children20 mg/kg for children– other fluoroquinolones probably effectiveother fluoroquinolones probably effective

IsolationIsolation• Droplet precautions (Yes, P-to-P)Droplet precautions (Yes, P-to-P)

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SmallpoxSmallpox


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Smallpox - GeneralSmallpox - General• One of the deadliest diseaseOne of the deadliest disease

– Mortality rate of 30%Mortality rate of 30%

• US stopped vaccinating in 1972US stopped vaccinating in 1972• Declared eradicated by WHODeclared eradicated by WHO

– In 1980, however...In 1980, however...

• Bioattack Bioattack – Aerosolized virus or by exposure to purposefully Aerosolized virus or by exposure to purposefully

infected terroristsinfected terrorists

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Smallpox - Clinical FeaturesSmallpox - Clinical Features

• Incubation periodIncubation period– 7-17 day (average 12d), Weaponized 3-5 d7-17 day (average 12d), Weaponized 3-5 d

• Severe prodrome Severe prodrome Key difference!Key difference!– 2-3 day of fever, severe myalgias, prostration, occ. 2-3 day of fever, severe myalgias, prostration, occ.

n/v, deleriumn/v, delerium– 10% with light facial erythematous rash10% with light facial erythematous rash

• Distinctive rash Distinctive rash – Initially on face and extremities Initially on face and extremities – Including palms and solesIncluding palms and soles– Spreads to trunk Spreads to trunk

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Small Pox - Clinical FeaturesSmall Pox - Clinical Features

• Rash Rash – Macules Macules papules papules vesicles vesicles pustules pustules– Unlike chicken pox, lesions Unlike chicken pox, lesions don’t don’t appear in “crops”appear in “crops”

• All lesions in an area are in the same stage of All lesions in an area are in the same stage of developmentdevelopment

• Lesions are firm, deep, frequently umbilicatedLesions are firm, deep, frequently umbilicated• Rash scabs over in 1-2 weeksRash scabs over in 1-2 weeks

SmallpoxSmallpoxChickenpoxChickenpox


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SmallpoxSmallpoxThe main diagnostic tool for smallpoxThe main diagnostic tool for smallpox


is the history and physical!is the history and physical!

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Smallpox - TreatmentSmallpox - Treatment• VaccinationVaccination

– In the early stages of diseaseIn the early stages of disease

• Supportive careSupportive care– Penicillinase-resistant antibiotics Penicillinase-resistant antibiotics (for secondary infection)(for secondary infection)

– Daily eye rinsing Daily eye rinsing – Adequate hydration and nutritionAdequate hydration and nutrition

• FDA has not approved specific therapyFDA has not approved specific therapy– Topical idoxuridine for corneal lesions (Dendrid)Topical idoxuridine for corneal lesions (Dendrid)

– Cidofovir ?Cidofovir ?

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Smallpox - Infection ControlSmallpox - Infection Control

ProphylaxisProphylaxis• Vaccine is effective if given within 3 days of Vaccine is effective if given within 3 days of

exposureexposureIsolationIsolation• Airborne and contact precautionsAirborne and contact precautions• Febrile illness after potential exposure should Febrile illness after potential exposure should

prompt isolation prompt isolation beforebefore rash starts rash starts

Immediate contact your hospital epidemiologist and Immediate contact your hospital epidemiologist and the public health authoritiesthe public health authorities

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TularemiaTularemiaFrancisella tularensisFrancisella tularensis


Gram Neg. CoccobacillusGram Neg. Coccobacillus

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Tularemia - GeneralTularemia - General• Endemic in North America and EurasiaEndemic in North America and Eurasia• Sporadic human cases spread by ticks or Sporadic human cases spread by ticks or

biting fliesbiting flies– Occasionally from direct contact with infected Occasionally from direct contact with infected

animals (ulceroglandular)animals (ulceroglandular)

• Bioattack Bioattack – Aerosolized bacteria Aerosolized bacteria – Typhoidal tularemia & (+ / - ) pneumoniaTyphoidal tularemia & (+ / - ) pneumonia

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Tularemia - Clinical FeaturesTularemia - Clinical Features

• BioattackBioattack– 3-5 day incubation (range 1-14 days)3-5 day incubation (range 1-14 days)– Acute febrile illness with prostrationAcute febrile illness with prostration– ~80% will have radiographic evidence of ~80% will have radiographic evidence of

pneumonia pneumonia – May have associated conjunctivitis or skin May have associated conjunctivitis or skin

ulcer & regional adenopathyulcer & regional adenopathy

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Tularemia - DiagnosisTularemia - Diagnosis

• Culture of blood and sputumCulture of blood and sputum– May take weeks to isolate and IDMay take weeks to isolate and ID

• Gram negative coccobacillusGram negative coccobacillus– Confirmation may require reference laboratoryConfirmation may require reference laboratory– Potential hazard to laboratory personnelPotential hazard to laboratory personnel

Laboratory must be notified if tularemia Laboratory must be notified if tularemia is suspectedis suspected

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Tularemia - TreatmentTularemia - TreatmentPreferredPreferred Treatment time varies with AbxTreatment time varies with Abx• Streptomycin 1 g IM q12hStreptomycin 1 g IM q12h

– 15 mg/kg for children15 mg/kg for children• Gentamicin 5 mg / kg IM or IB q dayGentamicin 5 mg / kg IM or IB q day

– for children use 2.5 mg/kg q8hfor children use 2.5 mg/kg q8hAlternativeAlternative• Doxycycline 100 mg IV q12hDoxycycline 100 mg IV q12h

– 2.2 mg/kg for children2.2 mg/kg for children• Ciprofloxacin 400 mg IV q12hCiprofloxacin 400 mg IV q12h

– Children 15 mg/kgChildren 15 mg/kg– Other fluoroquinolones probably effectiveOther fluoroquinolones probably effective

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Tularemia - Infection ControlTularemia - Infection Control

ProphylaxisProphylaxis: : Treat for 14 daysTreat for 14 days• Doxycycline 100 mg PO bidDoxycycline 100 mg PO bid

– 2.2 mg/kg for children2.2 mg/kg for children

• Ciprofloxacin 500 mg PO bidCiprofloxacin 500 mg PO bid– 15-20 mg/kg for children15-20 mg/kg for children

• TetracyclineTetracyclineIsolation:Isolation:• Standard precautions (Not P-to-P)Standard precautions (Not P-to-P)

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Viral Hemorrhagic FeversViral Hemorrhagic Fevers

Ebola virusEbola virusSource: www.cdc.govSource: www.cdc.gov

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VHF - GeneralVHF - General• Naturally occurring disease Naturally occurring disease

– Transmitted to humans by contact with infected animals or Transmitted to humans by contact with infected animals or arthropod vectors.arthropod vectors.

– Sporadic outbreaks in Africa, parts of Asia and Europe Sporadic outbreaks in Africa, parts of Asia and Europe (Outside of Africa, likely BT event)(Outside of Africa, likely BT event)

• VHF viruses as bioterrorism agentsVHF viruses as bioterrorism agents– Weaponized by several countries Weaponized by several countries – AerosolizationAerosolization

• Case fatality ratesCase fatality rates– Omsk hemorrhagic feverOmsk hemorrhagic fever 0.5%0.5%– EbolaEbola 90%90%

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VHF - Clinical FeaturesVHF - Clinical Features• Incubation 2 - 21days Incubation 2 - 21days

– Depends on virusDepends on virus

• Initial presentationInitial presentation– Nonspecific prodrome (fever, myalgias, headache, abdominal Nonspecific prodrome (fever, myalgias, headache, abdominal

pain, prostration)pain, prostration)– Exam may show only flushing of face and chest, conjunctival Exam may show only flushing of face and chest, conjunctival

injection, and petechiaeinjection, and petechiae

• Disease progresses to generalized mucous membrane Disease progresses to generalized mucous membrane hemorrhage and shock occurshemorrhage and shock occurs

Marburg DiseaseMarburg Disease Bolivian Hemorrhagic FeverBolivian Hemorrhagic Fever

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VHF - DiagnosisVHF - Diagnosis• Ancillary testing:Ancillary testing:

– Thrombocytopenia, leukopenia, AST elevation Thrombocytopenia, leukopenia, AST elevation commoncommon

• Definitive diagnosis requires detection of Definitive diagnosis requires detection of antigens or antibodiesantigens or antibodies– Testing done at CDCTesting done at CDC

Do Do notnot wait to confirm the diagnosis before wait to confirm the diagnosis before notifying the local public health authoritiesnotifying the local public health authorities

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VHF - TreatmentVHF - Treatment

• Supportive careSupportive care

• Ribavirin may be usefulRibavirin may be useful– Best early in the course of illnessBest early in the course of illness– Adults and children: 30 mg/kg IV load Adults and children: 30 mg/kg IV load

(max 2 g) (max 2 g) • then 16 mg/kg (max 1g) q6h x 4 daysthen 16 mg/kg (max 1g) q6h x 4 days• then 8 mg/kg (max 500 mg) IV q8h for 6 daysthen 8 mg/kg (max 500 mg) IV q8h for 6 days

– Oral dosing regimen is availableOral dosing regimen is available

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VHF - Infection ControlVHF - Infection ControlProphylaxisProphylaxis::

None at this timeNone at this timeVaccine in primates being testedVaccine in primates being tested

IsolationIsolation: : Key!Key!– Blood and bodily fluids Blood and bodily fluids extremelyextremely infectious infectious– Liquid-impervious protective coverings, including Liquid-impervious protective coverings, including

leg and shoe coveringsleg and shoe coverings– Double gloves, Face shields or gogglesDouble gloves, Face shields or goggles– N-95 or better respiratorsN-95 or better respirators– Negative pressure roomNegative pressure room

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Emerging Infectious Emerging Infectious DiseasesDiseases

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Pandemic Pandemic

A Global Epidemic!A Global Epidemic!

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Past flu pandemicsPast flu pandemics

A(H1N1) A(H2N2) A(H3N2)1918: “Spanish Flu” 1957: “Asian Flu” 1968: “Hong Kong Flu”

20-40 m deaths

675,000 US deaths

1-4 m deaths

70,000 US deaths

1-4 m deaths

34,000 US deaths

Credit: US National Museum of Health and Medicine

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Put another way …Put another way …

Life expectancy-USA, 1900-28

30

40

50

60

70

1900 .1903 .1906 .1909 .1912 .1915 .1918 .1921 .1924 .1927 .

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Pandemic InfluenzaPandemic Influenzawww.cdc.govwww.cdc.gov

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Pandemic InfluenzaPandemic Influenza

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Pandemic Influenza Healthcare Pandemic Influenza Healthcare WorkforceWorkforce

• Who is going to show up for Who is going to show up for work?work?

• The reports, articles and plans The reports, articles and plans are alarming!are alarming!

• Will you?Will you?

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ContainmentContainment• Limit travel Limit travel • Isolate ill and quarantine exposedIsolate ill and quarantine exposed• Trace contactsTrace contacts• Curfews & cancel public gatheringsCurfews & cancel public gatherings• Prophylaxis & treatmentProphylaxis & treatment

– Neuramidase inhibitors ?Neuramidase inhibitors ?– Vaccine ?Vaccine ?

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D: DetectionD: Detection I:I: Incident Command Incident CommandS:S: Safety & Security Safety & Security

A:A: Assess HazardsAssess Hazards

S:S: Support Support

T:T: Triage & Triage & TreatmentTreatment

E:E: Evacuation EvacuationR:R: Recovery Recovery

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DetectionDetection

There may not be a “scene”There may not be a “scene”

May be hard to detectMay be hard to detect

Long Incubation periodLong Incubation period

Symptoms manifest slowlySymptoms manifest slowly

Non-specific symptomsNon-specific symptoms

Beware of multiple people with similarBeware of multiple people with similar

Complaints, particularly in the “healthy” Complaints, particularly in the “healthy” populationpopulation

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D: D: DetectionDetection

II:: Incident CommandIncident CommandS:S: Safety & Security Safety & SecurityA:A: Assess Hazards Assess HazardsS:S: Support SupportT:T: Triage & Treatment Triage & TreatmentE:E: Evacuation EvacuationR:R: Recovery Recovery

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Incident CommandIncident Command

• Absence of a “scene” if covertAbsence of a “scene” if covert• Lead role of law enforcement Lead role of law enforcement • Unified command of law enforcement and public Unified command of law enforcement and public

healthhealth• Special public health emergency powersSpecial public health emergency powers

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SecuritySecurity

• Hospital ingress and egress Hospital ingress and egress – Must be able to secure hospitalMust be able to secure hospital

• Most bioattacks likely covertMost bioattacks likely covert– Patients will come in through ERPatients will come in through ER– ER becomes the “scene” ER becomes the “scene”

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Suspicious PackageSuspicious Package• Do not openDo not open suspicious suspicious

packagespackages• Secure areaSecure area

– Shut off ventilation if Shut off ventilation if possiblepossible

• Alert appropriate Alert appropriate authoritiesauthorities

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Assessing HazardsAssessing Hazards• Protective isolation & quarantineProtective isolation & quarantine

• Epidemiologic assessmentEpidemiologic assessment

• Environmental assessmentEnvironmental assessment

• Laboratory diagnosis of ill personsLaboratory diagnosis of ill persons

• Role of immunization, prophylaxis and treatmentRole of immunization, prophylaxis and treatment

• Little role for decontaminationLittle role for decontamination

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Personal Protective EquipmentPersonal Protective Equipment

• Degree of protectionDegree of protection– ControversialControversial

• CDC guidelines CDC guidelines – Very conservativeVery conservative

• N-95 respirators, gloves, fluid-impervious N-95 respirators, gloves, fluid-impervious gowns gowns – Better than nothingBetter than nothing

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SupportSupport• Initially, local management issue!Initially, local management issue!• Local hospital capacityLocal hospital capacity• Local healthcare providersLocal healthcare providers• Is your local community ready?Is your local community ready?

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SupportSupportLocal Hospital Capacity Local Hospital Capacity

• Pre-event planning essential for “surge”Pre-event planning essential for “surge”• Surge facilities for medical care expansionSurge facilities for medical care expansion• Expect being overrun with “worried well”Expect being overrun with “worried well”• Involvement of local pharmacies Involvement of local pharmacies

Coordination & AugmentationCoordination & Augmentation

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Support:Support:Strategic National StockpileStrategic National Stockpile

• Pre-positioned material Pre-positioned material managed by CDC and managed by CDC and DHSDHS

• Medications, antidotes, Medications, antidotes, vaccines, PPE, vaccines, PPE, equipment,et al.equipment,et al.

• 12 hour Push Packages12 hour Push Packages• Vendor managed Vendor managed

inventoryinventory• Local coordination of Local coordination of

receipt criticalreceipt critical

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TriageTriageThree types of patients:Three types of patients:

(1). Ill and need definitive treatment(1). Ill and need definitive treatment(2). Exposed but not ill: may need prophylaxis and (2). Exposed but not ill: may need prophylaxis and

quarantinequarantine(3). Not exposed: need reassurance(3). Not exposed: need reassurance

Difficult to distinguish between groups 2 & 3!Difficult to distinguish between groups 2 & 3!

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EvacuationEvacuation• Dedicated treatment facilitiesDedicated treatment facilities

• Isolation of patientsIsolation of patients

• Surge capacity implicationsSurge capacity implications

• Hospital becomes a “scene”Hospital becomes a “scene”

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RecoveryRecovery• Law enforcementLaw enforcement

• Evidence, apprehension, prosecution,...Evidence, apprehension, prosecution,...

• Public healthPublic health

• Stop spread, identify source, treatment options,...Stop spread, identify source, treatment options,...

• Mental healthMental health

• Wide-spread panic, “worried-well”, responders,...Wide-spread panic, “worried-well”, responders,...

• Environmental healthEnvironmental health

• Viability of weaponized release, “nature” effects, Viability of weaponized release, “nature” effects,

soiled materials,...soiled materials,...

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SummarySummaryNow you can:Now you can:

• Describe the difference between biological events and Describe the difference between biological events and bioterrorism (BT)bioterrorism (BT)

• Discuss public health BT surveillanceDiscuss public health BT surveillance• Identify the CDC BT Category A agentsIdentify the CDC BT Category A agents• Identify emerging infectious diseasesIdentify emerging infectious diseases• Compare and contrast BT and other CBRNE WMD Compare and contrast BT and other CBRNE WMD

utilizing the utilizing the DISASTERDISASTER paradigm paradigm

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Questions?Questions?

Documents

“Preparing Our Communities”