Recognizing and Reporting Possible Disasters

Modules were developed as part of a grant from the HRSA BTCDP initiative

Basic Biodefense Curriculum Module 22005

Goal of the Module

To prepare students to: Find current information about the signs and

symptoms of exposure to various agents Use information to determine whether they need to

report a suspicious event.

Identify or list examples of agents within each CBRNE (or B-NICE) category

Describe the typical signs and symptoms for each class of agents

Explain how healthcare workers participate in surveillance and monitoring

Describe where to find current and accurate information about CBRNE (or B-NICE) agents

Use algorithms to guide information collecting and reporting

Describe how a suspicious event is reported

Learning Objectives

Disaster Timeline

Early recognition to mitigate (reduce) scope or impact of a full-blown disaster could be considered either a PREVENTION or an early RESPONSE activity.

1. Prevent

Early Recognition

Need to have an approach for deciding when to report a suspected public health threat

Be familiar with natural and accidental risks to your community

Be familiar with agents used to intentionally cause disasters

“The Usual Suspects” Agents Commonly Used as Weapons

B-NICE [bee-nice]:BiologicalNuclear (radioactive)Incendiary (fire)

ChemicalExplosive

CBRNE [see-burn]:ChemicalBiologicalRadioactiveNuclearExplosive

Types of agents and two ways to remember them!

Categorized by Ease of Detection

Overt (Obvious) Agents: Explosives Incendiaries

Covert (Hidden) Agents: Biologicals Chemicals Radioactive materials

Overt – Covert Combinations: Dirty bombs (explosives

with radioactive materials)

???

“E” Explosives

Most commonly used weapon of terror Used in 70% of attacks

Difficult to detect PRIOR to detonation

Blast injuries may be: Immediate or delayed Obvious or hidden

“I” Incendiary Devices

Three Parts of an Incendiary Device: Igniter (fuse) Container (body) Incendiary material (filler)

Injuries caused by: Burns Inhaled smoke and toxic fumes

Injuries usually occur soon after exposure

”E” and “I”… A Deadly Duo

Explosives often cause fires Fires often cause explosions

Watch for injuries and symptoms of both

Could it be a Triple Threat…?Assume a COVERT agent was released by

fire or explosion• Watch for unusual symptoms

Why Terrorists like Covert Agents

DELAYED onset and detection Terrorist escapes before attack detected False claims can be made Accidental secondary exposures

VAGUE, MILD early symptoms Delays in seeking care Early diagnosis is difficult

DETERMINATION is difficult: Causes speculation and panic

Follow the spores…

Psst…Sore Throat. Where should I look?**

**With apologies to Woodward and Bernstein

“C” Chemical Agents

Five Categories of Chemical Agents:

1. Nerve

2. Blister (or Vesicant)

3. Blood

4. Choking

5. Irritants

Chemical Agents

Examples of two-letter codes:Sarin (GB) – nerve agentMustard gas (H or HD) – blister agentCyanide (AC) – blood agent

What are the chemical risks in your community?

“C” Nerve Agents

Chemical agents in this class:Sarin (GB)Soman (GD)Tabun (GA)Agent V (VX) – most potent

“C” Nerve Agents

Rapid onset and often fatal

Signs of nerve agent release Dead animals, birds, or

humans Symptoms like

organophosphate pesticide poisoning

• Body produces excessive secretions (see S.L.U.D.G.E.)

S.L.U.D.G.E. Salivation Lacrimation Urination Defecation GI upset Emesis (or

pulmonary Edema)

“C” Blister Agents

Also called vesicants Example:

Mustard Gas (H, HD) Lewisite (L)

Prevent DNA from working, which kills the cells in the body

Symptoms depend on route of exposure Eyes and lungs most vulnerable Mimics severe burns

Blood Agents Example:

Cyanide (AC) Cyanogen (CK)

Interferes with oxygen transport in cells, which leads to cell death

Symptoms: cyanosis (blue lips, fingers), difficulty breathing, dizziness, headache

Choking Agents

Examples: Chlorine gasPhosgene gas

Suffocation by drowning in own fluids

Symptoms: Inability to breathe Eye irritation

Irritating Agents

Example: Tear gasMACE

Rarely lethal, but can be quite disruptive

cough…. ….cough …

“B” Biological Agents

Two Main Types of Agents: Toxic by-products that act as poisons Microorganisms that cause infectious disease

Bioterrorism: the use of biological toxins or infectious organisms in acts of terrorism Natural outbreaks of infectious disease have many of

the same characteristics

“B” Toxic Biologicals

Similar to Chemical AgentsSecondary exposures from contaminated

items or peopleDo NOT cause infections

Examples:Botulinum toxin Ricin

“B” Toxic Biologicals

Botulinum toxinProduced by Clostridium botulinum bacteriaGroup of several neurotoxic proteinsCauses descending paralysisOnset in 12-36 hours after ingestionEarly Signs:

• droopy eyelids, blurred vision, slurred speech

“B” Toxic Biologicals

RicinDerived from Castor Bean processing

wastesPrevents protein synthesis in cellsOnset and early signs: vary by route of

exposureMore likely used for assassinations than

large scale attacks

“B” Infectious Biologicals

Cause death through infection, not poisoning• Disease may spread to others causing secondary

outbreaks

Attack may mimic a natural outbreak

Onset of symptoms often delayed• Incubation period may take days

Fear that organisms will be altered genetically• Usual treatment or vaccine may not be effective

CDC CATEGORY A

Anthrax (Bacillus anthracis) Botulism (Clostridium botulinum toxin) Plague (Yersinia pestis) Smallpox (Variola major virus) Tularemia (Francisella tularensis) Viral hemorrhagic fevers

• Filoviruses [e.g., Ebola, Marburg] • Arenaviruses [e.g., Lassa, Machupo]

Biologicals most likely to be used as weapons; virulent or easy to disseminate.

CDC CATEGORY B

Brucellosis (Brucella species) Q fever (Coxiella burnetii) Ricin toxin (Castor Bean) Staphylococcal enterotoxin Cholera (Vibrio cholerae) Cryptosporidiosis (Cryptosporidium parvum)

Biologicals that are also potential weapons, but not as virulent as Category A.

(Includes food and water contaminants)

CDC Category C

Hantavirus Nipah virus Other emerging pathogens

Go to CDC website for more information on particular biological agents

Biologicals that are emerging pathogens; not yet of concern, but have potential to become weapons

Symptoms of “B” Exposure

Varies by ROUTE of exposure Topical: skin lesions Inhaled: respiratory symptoms Ingested: gastrointestinal symptoms Injected: systemic, whole body

Forms of infectious diseases based on route: Anthrax

• Topical Anthrax (also called Wool Sorters’ Disease)• Gastrointestinal Anthrax (swallow spores)• Inhalational Anthrax (inhale spores; most deadly form)

Early symptoms – vague, nonspecific Influenza-like Illnesses (ILI)

Late symptoms – more specific, diagnostic, laboratory confirmation

Can you distinguish between the early symptoms of common cold and influenza?

HealthyAcute illness:Disease-specific

symptoms appear

Subclinical:Organisms multiply,

but not yet impacting body

Exposure

Usual contagious period

Recovery:No new symptoms,existing symptoms

resolve, health returns

Healthy(or dead)

Time

Prodromal:Early,

nonspecificsymptoms

appear

HealthyAcute illness:Disease-specific

symptoms appear

Subclinical:Organisms multiply,

but not yet impacting body

Exposure

Usual contagious period

Recovery:No new symptoms,existing symptoms

resolve, health returns

Healthy(or dead)

Time

Prodromal:Early,

nonspecificsymptoms

appear

Timeline for Biological Exposure Symptoms

“R” Radioactive Agents

Radioactive Agents Types of Radiation:

Alpha Beta Gamma

Sources of Exposure: Nuclear bomb Conventional explosives Accidental release

Radioactive Agents

Detecting Radioactive Agents

Look for labels on containers Placards on transportation vehicles

Location Site may contain nuclear or

radioactive products.

Instruments designed to detect radiation: Geiger Counters

Decision-Making Tools

Available in many formats

Provide quick, but not necessarily complete information

Fit many, but not all situations• Still need to use your judgment

Decision-Making Tools CDC: http://www.bt.cdc.gov

SARIN – NIOSH Emergency Response Card Recognizing Chemical Exposure Anthrax – Case definition is found in “Diagnosis

and Evaluation”

US Army (has PDA downloads): http://www.usamriid.army.mil/education/bluebook.htm Isolation Precautions (Found in Appendix B) Differential diagnosis of chemical vs toxin

(Appendix H) (Army procedures may vary from civilian

procedures)

Symptom Approach

Practice Case

Location: Near a Warehouse Fire

Symptoms: No fever Cough and shortness of breath Skin lesions (burns) No GI symptoms

Fever

Breathing

Skin

GI Tract

No

No

Yes

Yes

Epidemiological Approach

Are any of these unusual? Time of Year Combination of symptoms Timing of symptoms Type of population affected Cluster of cases in one area Outbreaks or exposure in other areas

Epidemiological Approach

Approach based on: Knowledge of natural behavior of disease

• Know common diseases (e.g., influenza, chickenpox) Case definitions

• Use descriptions of symptoms and causative agents

Simplified example of how a naturally-occurring disease outbreak might spread from an initial (index) case to close contacts and result in an epidemic.

Index Case

Epidemiological Approach

Gather the following information: Contact information (phone numbers, names) Onset date/time Signs and symptoms Illness in family or acquaintances Recent travel Recent events and activities Food and water sources Animals Unusual packages and envelopes

Seek Information About

Exposure risk Early symptoms Specific symptoms

Transmission Vulnerable

populations

Another Practice Case: Three days after the Fourth of July weekend, Alice, Burt

and Charlie complain that they had the “flu.”

Their early symptoms included severe fever with chills, aching muscles, no energy, and a dry cough, but after several days, they began to feel better.

What type of exposure could this be? Epidemiology approach: July is unusual time of year and no one

else appears to be sick Symptom approach: fever indicates infection or radiation. Other

symptoms very vague or “I-L-I” like Decision: unusual isolated outbreak of infections that should be

checked by physician.

Validating Your Suspicions

Seek more detailed information• Were the three individuals at the same get together – is

there a common source?

Check with colleagues about similar cases• Have other providers heard similar stories from other

patients?

Stick to the facts – avoid starting rumors• Let colleagues know you have an unusual case that you

are checking out

Reporting Unusual Cases

For a public health emergency, you should: 1. Call local health department 2. If no answer and situation is urgent, call 9-1-1

operator

Information to leave: Your name & contact information Reason for calling Facts of situation; no speculation

ReportingPersonal

Awareness

Suspicion

Report to:

ImmediateSupervisor

Local HealthDepartment

State Health Department

CDC (federal)

Disease Identification CoursesReportable Diseases and ProceduresInformation SourcesInfection Control Procedures (PPE)

Check CDC / information sourcesUse appropriate PPE

Reporting Algorithm

Fill in the phone numbers(___)

(___)

Personal Awareness

Suspicion

Report to:

ImmediateSupervisor

Local HealthDepartment

State Health Department

CDC (federal)

Disease Identification CoursesReportable Diseases and ProceduresInformation SourcesInfection Control Procedures (PPE)

Check CDC / information sourcesUse appropriate PPE

Reporting Algorithm

Fill in the phone numbers(___) (___)

(___) (___)

Staying in the Loop

Join CDC Listserv Clinicians’ Listserv: www.cdc.gov/subscribe.html

Check reliable websites Make local contacts Identify experts and key agencies

Gather contact information

Summary

All healthcare workers should remain vigilant for signs of public health threats.

Recognize unusual diseases clusters by knowing signs and symptoms of common and uncommon diseases or exposures Use B-NICE or CBRNE to remember categories of

agents most likely to be weaponized

First, try to validate your suspicions; then contact local authorities.

Authors

Jean Carter Sandra Kuntz Earl Hall Steven Fehrer Steven Glow

Basic Basic BioBio--DefenseDefense

ProjectProject

Emergency Preparedness Curriculum

Jacqueline Elam Michele Sare Lisa Wrobel Michael Minnick

Modules prepared as part of the Montana Basic BioDefense Curriculum For Pharmacy, Nursing, and Allied Health

Funded by the HRSA CFDA 93.996 initiative

Photo Credits

Do not reproduce individual photos or videoclips without permission from original source.

A list of photo credits was included in the instructor’s packet.

To request a copy of the photo credits, send an email to jean.carter@umontana.edu

Basic Basic BioBio--DefenseDefense

ProjectProject

Emergency Preparedness Curriculum

Modules prepared as part of the Montana Basic BioDefense Curriculum For Pharmacy, Nursing, and Allied Health

Funded by the HRSA CFDA 93.996 initiative