Recognizing the Threat and Sounding the Alarm

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Recognizing the ThreatandSounding the Alarm
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Acknowledgements

• South Carolina Area Health Education Consortium
  (AHEC)
• Funded by the Health Resources and Services
  Administration.
• Grant number 1T01HP01418-01-00
• P.I. David Garr, MD, Executive Director AHEC
• BT Project Director Beth Kennedy, Associate
  Program Director AHEC
• Core Team
• BT Co-director Ralph Shealy, MD
• BT Project Manager Deborah Stier Carson, PharmD
• BT CME Director William Simpson, MD
• IT Coordinator Liz Riccardone, MHS
• Web Master Mary Mauldin, PhD
• P.R Coordinator Nicole Brundage, MHA
• Evaluation Specialist Yvonne Michel, PhD
• Financial Director Donald Tyner, MBA

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Acknowledgment

• This material has been prepared for SC AHEC
  Bioterrorism Training Networkby
• Ralph M. Shealy, M.D., FACEPCo-Director of SC
  AHEC Bioterrorism Training Network
• Medical Director for Operations, Charleston
  County EMS
• Medical Director, Charleston County Rescue Squad

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Objectives

• Differentiate between an overt biological attack
  and a covert biological attack.
• Enumerate six characteristics of a disease
  outbreak.
• List three reasons why it is important to report
  even the suspicion of an infectious disease
  outbreak without waiting until the specific
  diagnosis is proved.

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Objectives

• Describe the appropriate action to take if you
  suspect an infectious disease outbreak in your
  community.
• Relate the role of law enforcement in a
  bioterrorism incident.

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There was a time when it was easy to know who
your enemies were.
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There was a time when it was easy to know when
you were under attack 
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Everyone knew when to raise the alarm, when to
call for help.
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Most forms of terrorism are obvious.
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Overt versus Covert Biological Attack

• Overt
• Attack announced
• Credit claimed
• Motive explained
• Agent identified
• Lights and Sirens response evoked
• Anthrax letters an example

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Overt versus Covert Biological Attack

• Covert
• Clandestine sneak attack.
• Agent widely disseminated
• Causes high morbidity and mortality
• Preferably transmitted person to person

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Covert Bioterrorism

• Unfamiliar to healthcare providers
• Initial symptoms non-specific
• Treatable only in early stages, when difficult or
  impossible to diagnose
• Too late to treat when characteristic signs are
  apparent

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Covert Bioterrorism

• Community providers are front line of defense!!
• Early recognition and appropriate response will
  avert great loss of life and civil disruption.

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Natural versus Intentional Epidemic

• Many common features, therefore
• Not important for the provider to focus on
  terrorist attack.
• CRITICAL to recognize and report outbreak as
  potential public health emergency.

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Disease Outbreak

• Incidence of a symptom complex at a rate
  exceeding normal baseline
• For a disease that is not supposed to occur (such
  as smallpox), a single case constitutes an
  outbreak.

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Responding to an Outbreak

• Your actions when faced with a case or a cluster
  of cases that is different from the norm makes
  all the difference.

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Clues to an Outbreak

• A cluster of patients with
• Symptoms developing in unison, as though they
  were all exposed at the same time.
• Exposure to the same enclosed space, the same
  ventilation system, the same food or water
  source.
• An unusual syndrome

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Clues to an Outbreak

• The symptoms
• Appear in an age group that is not typical
• Fall outside of their usual season.
• Fail to respond to the usual treatments.
• Is more severe than expected.

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Clues to an Outbreak

• The number of cases is greater than expected

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Recognizing the Threat

• Often, agents of bioterrorism produce vague,
  non-specific symptoms resembling flu-like
  illnesses.
• Most health providers who saw such a patient
  would send them home with supportive and
  symptomatic treatment.
• Those later in the course of the illness might
  appear much sicker.

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We Do What We Are Trained

• History Physical
• Differential Diagnosis
• Laboratory studies
• Imaging studies
• Empirical therapy
• Refine therapy based on laboratory and imaging
  studies
• Consultations if diagnosis is unclear or if
  special expertise is required.

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During an Unrecognized Outbreak

• Disease is transmitted person to person.
• Health providers and laboratory workers put at
  risk
• Disease progresses in the infected

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During an Unrecognized Outbreak

• Even if we suspect an exotic disease, we are
  reluctant to make the diagnosis until we have all
  the facts.
• When you hear hoof beats, think horses, not
  zebras!

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Diagnosis by Familiarity

• Common things occur commonly.
• Yersinia pestis? Pulmonary anthrax?
• Unlikely!

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• Recognize and report potential threats
• Public authorities will investigate whether your
  observations are an actual threat or not.

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Suspecting an Exotic Organism

• Clinical suspicion is sufficient to
• trigger notification of public health
  authorities.
• initiate the critical first steps in patient
  management.
• launch a public health investigation.

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What should you do if you suspect an outbreak
of an infectious disease in your community?
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S.C. Department of Health and Environmental
Control

• DHEC Epidemiology team is on call around the
  clock to investigate potential threats to public
  health.

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SC AHEC Bioterrorism Network

• You will be given the telephone number for the 24
  hour epidemiology pager in your county.

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Law Enforcement Officials

• Play critical role in preparing for and
  responding to terrorist attacks.
• Collect and share intelligence to prevent and
  interdict terrorist actions

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Law Enforcement Officials

• Should an event occur, they
• restore order
• collect and preserve evidence
• identify and apprehend suspects

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• The FBI is the law enforcement agency with
  jurisdiction over all matters related to
  terrorism.

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FBI

• Every state has an FBI Joint Terrorism Task Force
  with representatives from state and local law
  enforcement agencies.
• Special Agent Roger Stanton in Columbia is the
  FBI Weapons of Mass Destruction Coordinator for
  South Carolina.
• Each FBI region in South Carolina has a WMD
  Coordinator

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SC AHEC Bioterrorism Network

• You will be given the telephone number for the
  FBI WMD Coordinator in your county.

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FBI

• If DHEC finds reason to suspect potential
  deliberate dissemination of disease, the FBI will
  be notified.
• A private citizen may report concerns to the FBI
  directly.
• FBI Joint Terrorism Task Force will collaborate
  with DHEC,which will advise clinicians.

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Cases
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Case 1

• EMS call 72 year old female complaining of
  shortness of breath, fever, cough, hemoptysis
• Hx Spouse and sibling also sick with similar
  symptoms. Recently drove to Florida resort. All
  became ill while driving home.
• PE
• Severely ill. Pale, temperature 104o. Rapid,
  shallow respirations. Elevated pulse rate.
• Cough productive of bloody sputum. Breath sounds
  coarse.
• Signs of dehydration present
• Pulse oxymeter showed a pO2 of 90 on 100 oxygen
  by non-rebreather mask

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Case 1 (continued)

• Medics donned HEPA filter respirators.
  Respiratory precautions.
• The hospital was alerted by radio of incoming
  potentially contagious patients.
• The EMS Safety Officer alerted the DHEC District
  epidemiology team, who in turn alerted the
  hospital infection control nurse.
• Patients hospital course was monitored by DHEC.

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Case 2

• Suspicious object in the mail.
• Characteristics of a letter bomb.
• Envelope abnormally stiff and of non-standard
  dimensions
• Hard disc-shaped object fixed in one corner (disc
  battery?)
• Excessive postage
• Hand written address
• Name of the recipient was misspelled
• Return address was an unknown P.O. Box

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Case 2 (continued)

• Bomb squad deemed it a credible threat.
• X-rayed where it lay.
• Opened by bomb technician.
• Found to be a holiday letter with a religious
  medal.

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Moral (Case 1)Being teased for creating Much
Ado About Nothing is better than being avoided
because you have Plague.

• The medics recognized a cluster of respiratory
  disease suggesting origination from a common
  source.
• The findings were consistent with Yersinia pestis
  (Pneumonic Plague), which is not a naturally
  occurring disease in the southeastern United
  States.
• They took measures to protect themselves, warned
  the hospital, and notified appropriate
  authorities.
• Even though they were ridiculed by the ED nurse,
  their actions were not only appropriate, but also
  exemplary.

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Moral (Case 2)Being embarrassed is better than
being dead.

• Although the health professional was terribly
  embarrassed by the entire event, he recognized
  that the identifying characteristics of a letter
  bomb were undeniably present and activated a
  widely published protocol.
• His actions were supported by the bomb squad
  commander even though the object proved to be
  benign.

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Summary

• Of all forms of terrorism, covert attacks with
  biological weapons may be the most difficult to
  recognize.
• Community healthcare professionals may be in the
  best position to recognize an outbreak of
  infectious disease.

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Summary

• It is not necessary to prove that a biological
  attack has occurred, it is only necessary to
  suspect that an outbreak of infectious disease
  has occurred and report it.
• DHEC has an epidemiologist on call at all times.
  
• It is up to public authorities to determine
  whether the threat is real or not.

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