OUTBREAK

1

• OUTBREAK!
• RECOGNIZING THE THREAT
• and
• SOUNDING THE ALARM
• Ralph M. Shealy, M.D., FACEP
• Co-Director, Bioterrorism Training Network
• South Carolina AHEC
• Francis Marion University
• Florence, S.C.
• August 12, 2005

2
Why should I learn about bioterrorism?
There will never be a terrorist attack here!
3
What we should really be concerned about
4
What we should really be concerned about is
an OUTBREAK of Infectious Disease!
5
Remember the Influenza Pandemic of 1917?
6
Remember the Influenza Pandemic of 1917? Twenty
to forty million deaths from respiratory
failure.
7
Surely it would be different now!
8
Surely it would be different now! Modern
technology.
9
Surely it would be different now! Modern
technology. Advances in critical care.
10
Surely it would be different now! Modern
technology. Advances in critical care. ICU
beds.
11
Surely it would be different now! Modern
technology. Advances in critical care. ICU
beds. Ventilators.
12
How many vacant ICU beds do you have in your
hospital?
13
In an era of rapid global travel, an infectious
disease outbreak can be a global catastrophe.
14

• Do you live and work with people who

15

• Visit relatives in Brooklyn?

16

• Visit relatives in Brooklyn?
• Change planes at OHare?

17

• Visit relatives in Brooklyn?
• Change planes at OHare?
• Deploy to the Middle East?

18
Remember the SARS Outbreak of 2003?
19
Remember the SARS Outbreak of 2003? Came from
China
20
Remember the SARS Outbreak of 2003? Came from
China Shut down Toronto
21
SARS first reported in Asia in February 2003.
Over a few months, spread to over two dozen
countries in North America, South America,
Europe, and Asia before it was contained.
Over 8,000 people worldwide became sick.
Almost 800 died.
22
Remember who died of SARS?
23
Remember who died of SARS? Unprotected
healthcare workers!
24
(No Transcript)
25
The earth may be on the brink of a worldwide
epidemic from a bird flu virus that may mutate
to become as deadly and infectious as viruses
that killed millions during three influenza
pandemics of the twentieth century.
26
We havent even mentioned bioterrorism yet!
27
Chimera The Doomsday Bio-weapon

• Disseminated multiple simultaneous deadly
  epidemics
• Each could be spread person-to-person
• Each required a different treatment
• Each could only be treated effectively in the
  early stages
• All look like the flu at first
• Diagnostic features not present until late

28

• Since the fall of the Soviet Union, some of its
  biological arsenal and the scientists who created
  it have not been accounted for.

29
Bio-Engineering Nightmare

• Humans have
• Created drug resistant organisms
• Introduced virulence into organisms that are
  normally not human pathogens

30
Outbreaks Can Be Global

• In an age of rapid global travel, an outbreak
  that originates far from home can quickly arrive
  in your community.

31
We are at risk from a NATURAL or a
MAN-MADEEPIDEMICoriginatingANYWHERE!
32
The CONSEQUENCES could be essentially the
same.
33
A Disaster

• Threatens public health and safety.

34
A Disaster

• Threatens public health and safety.
• May destroy infrastructure.

35
A Disaster

• Threatens public health and safety.
• May destroy infrastructure.
• Disrupts essential services.

36
A Disaster

• Threatens public health and safety.
• May destroy infrastructure.
• Disrupts essential services.
• Overwhelms routine methods of operation.

37

• Every DISASTER is LOCAL!

38

• Every DISASTER is LOCAL!
• Its OURS for 72 hours!

39
YOU are a FRONT-LINE DEFENDER against threats
to South Carolinas HEALTH and SAFETY!
40
We MUST Think OUTSIDE THE BOX!
41
We MUST Think OUTSIDE THE BOX!Extraordinary
measures required.
42
We MUST Think OUTSIDE THE BOX!Extraordinary
measures required. Scope of practice changes.

43
We MUST Think OUTSIDE THE BOX!Extraordinary
measures required. Scope of practice changes.
Standard of care changes.
44
Altered Standards of Care in Mass Casualty
Events Office of Public Health Emergency
Preparedness U.S. Department of Health and
Human Services http//www.ahrq.gov/research/altst
and/altstand.pdf
45

• Changes in the usual standards of care will be
  required to achieve the goal of saving the most
  lives in a mass casualty event. RATHER THAN
  DOING EVERYTHING POSSIBLE TO SAVE EVERY LIFE, it
  will be necessary to allocate scarce resources in
  a different manner to SAVE AS MANY LIVES AS
  POSSIBLE.

46
A communitys success in a disaster will depend
on Effective RELATIONSHIPS
47
A communitys success in a disaster will depend
on Effective RELATIONSHIPS across DISCIPLINES

48
A communitys success in a disaster will depend
on Effective RELATIONSHIPS across DISCIPLINES
and JURISDICTIONS.
49

• Community Health Professionals
• Public Health
• Hospitals
• Emergency Management
• Law Enforcement
• Fire Service
• EMS
• Rescue
• Public Works
• Business and Industry
• Local, State and Federal Government
• Military

50
Success will depend on Coordinated PLANNING
51
Success will depend on Coordinated PLANNING
Effective PROCEDURES
52
Success will depend on Coordinated PLANNING
Effective PROCEDURESPRACTICE to test and refine
plans
53
Natural Epidemic or Man-made Epidemic?
54
Natural Epidemic or Man-made Epidemic? INITIAL
course of action is the SAME!
55
We must RECOGNIZE IT
56
We must RECOGNIZE IT REPORT IT
57
We must RECOGNIZE IT REPORT IT and RESPOND
EFFECTIVELY
58
Recognize an Outbreak

• Case or a cluster of cases
• that are
• DIFFERENT
• FROM THE NORM

59
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.

60
Red Flags

• Whenever an experienced clinician thinks,
• Hmmmm.Something ODD about this!

61
Clues to an Outbreak

• Symptoms
• Appear in an AGE GROUP that is not typical

62
Clues to an Outbreak

• Symptoms
• Appear in an AGE GROUP that is
• not typical
• Fall outside of their USUAL SEASON

63
Clues to an Outbreak

• Symptoms
• Appear in an AGE GROUP that is not typical
• Fall outside of their USUAL
• SEASON
• MORE SEVERE than expected

64
Clues to an Outbreak

• Symptoms
• Appear in an AGE GROUP that is
• not typical
• Fall outside of their USUAL
• SEASON
• MORE SEVERE than expected
• FAIL TO RESPOND to the usual treatment

65
Clues to an Outbreak

• A cluster of patients with
• SYMPTOMS DEVELOPING IN UNISON, as though they
  were all exposed at the same time.

66
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.

67

• Same SYMPTOMS.

68

• Same SYMPTOMS.
• Same TIME.

69

• Same SYMPTOMS.
• Same TIME.
• Same PLACE.

70

• Same SYMPTOMS.
• Same TIME.
• Same PLACE.
• Could this be an OUTBREAK?!

71
Biological Agents of Highest ConcernCategory A
Agents

• Easily disseminated, infectious via aerosol
• Susceptible civilian populations
• Cause high morbidity and mortality
• Person-to-person transmission
• Unfamiliar to providers difficult to
  diagnose/treat
• Cause panic and social disruption
• Previous development for biologic weapons

72
Biological Agents of Terror

• Bacteria
• Viruses
• Biological Toxins

73
Bacteria

• Anthrax
• Plague
• Tularemia

74
Viruses

• Smallpox
• Viral Hemorrhagic Fevers

75
Biological Toxins

• Botulinum

76

• Success in an outbreak does not depend on
  memorizing technical aspects of microbiology and
  pharmacology.

77

• Success in an outbreak does not depend on
  memorizing technical aspects of microbiology and
  pharmacology.
• Technical data and scientific understanding
  CHANGE.

78

• Success in an outbreak does not depend on
  memorizing technical aspects of microbiology and
  pharmacology.
• Technical data and scientific understanding
  CHANGE.
• The MOST RECENT INFORMATION will quickly become
  available when you need it.

79
The Ultimate Resource!www.bt.cdc.gov
80
Most forms of terrorism are obvious.
81
COVERT Bioterrorism is NOT OBVIOUS.

82
Overt Biological Attack

• Attack announced

83
Overt Biological Attack

• Attack announced
• Credit claimed

84
Overt Biological Attack

• Attack announced
• Credit claimed
• Motive explained

85
Overt Biological Attack

• Attack announced
• Credit claimed
• Motive explained
• Agent identified

86
Overt Biological Attack

• Attack announced
• Credit claimed
• Motive explained
• Agent identified
• Lights and Sirens response

87
Overt Biological Attack

• Attack announced
• Credit claimed
• Motive explained
• Agent identified
• Lights and Sirens response
• ANTHRAX LETTERS an example

88
Covert Bioterrorism

• Clandestine sneak attack.

89
Covert Bioterrorism

• Clandestine sneak attack.
• Agent widely disseminated

90
Covert Bioterrorism

• Clandestine sneak attack.
• Agent widely disseminated
• Causes high morbidity and mortality

91
Covert Bioterrorism

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

92
Covert Bioterrorism

• Organisms unfamiliar to healthcare providers

93
Covert Bioterrorism

• Organisms unfamiliar to healthcare providers
• Initial symptoms non-specific

94
Covert Bioterrorism

• Organisms unfamiliar to healthcare providers
• Initial symptoms non-specific
• Best treated in early stages, when difficult or
  impossible to diagnose

95
Covert Bioterrorism

• Organisms unfamiliar to healthcare providers
• Initial symptoms non-specific
• Best treated in early stages, when difficult or
  impossible to diagnose
• Hard to treat when characteristic signs are
  apparent

96
Covert Bioterrorism

• Community providers are front line of defense!!
• EARLY RECOGNITION AND APPROPRIATE RESPONSE will
  avert great loss of life.

97
Syndromic Surveillance

• Watches for SYMPTOM COMPLEX.

98
Syndromic Surveillance

• Watches for SYMPTOM COMPLEX.
• Detects an unusually HIGH INCIDENCE of similar
  symptoms present in the community at the same
  time.

99
Syndromic Surveillance

• Watches for SYMPTOM COMPLEX.
• Detects an unusually HIGH INCIDENCE of similar
  symptoms present in the community at the same
  time.
• Unexplained VARIANCES FROM THE BASELINES can be
  recognized

100
Syndromic Surveillance

• Requires seasonal BASELINE RATES of index
  symptoms

101
Syndromic Surveillance

• Requires seasonal BASELINE RATES of index
  symptoms
• In order to be successful, reportable conditions
  must be REPORTED IN A TIMELY FASHION to public
  health authorities.

102
During an Unrecognized Outbreak

• Disease is transmitted person to person.

103
During an Unrecognized Outbreak

• Disease is transmitted person to person.
• Health providers and laboratory workers put at
  risk

104
During an Unrecognized Outbreak

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

105
Natural vs. Intentional Epidemic

• Many features in common.

106
Natural vs. Intentional Epidemic

• Many features in common.
• You dont need to
• DIAGNOSE TERRORISM.

107
Natural vs. Intentional Epidemic

• Many features in common.
• You dont need to
• DIAGNOSE TERRORISM.
• You dont need to
• IDENTIFY A CAUSITIVE ORGANISM.

108
Natural vs. Intentional Epidemic

• Many features in common.
• You dont need to
• DIAGNOSE TERRORISM.
• You dont need to
• IDENTIFY A CAUSITIVE ORGANISM.
• CRITICAL TO
• RECOGNIZE AND REPORT
• an OUTBREAK!

109

• Even when we suspect something,
• we are often
• RELUCTANT to REPORT
• for fear of
• BEING WRONG
• and
• LOOKING FOOLISH.

110
In the case of an outbreak, it is better to
REPORT SUSPICIONS and be wrong than to delay
reporting until youre sure!
111

• Recognize and report POSSIBLE threats
• Public authorities will sort it out

112

• A DHEC Epidemiology Team is on call around the
  clock to investigate potential threats to public
  health.
• SC DHEC 24/7 Disease Reporting
• 888-847-0902

113
(No Transcript)
114
If precautions are observed, health
professionals can work safely in an environment
containing biological agents of terror.
115
PERSONAL PROTECTIVEEQUIPMENT

• PROTECT
• Eyes
• Mucous membranes
• Respiratory tract
• Skin defects

116
PERSONAL PROTECTIVEEQUIPMENT

• WEAR
• Protective Eyewear
• N 95 mask
• Gloves
• Gown or scrubs

117
PERSONAL PROTECTIVEEQUIPMENT

• In other words
• HEPA filtered air
• through fit tested mask
• with splash protection.

118
SPACE SUITSare for CHEMICALS,for
CONTAINMENT,andfor the Movies!
119
DECONTAMINATION OF EXPOSED PERSONS

• Showering thoroughly with SOAP AND WATER is
  adequate.
• Use of bleach not necessary.

120
DECONTAMINATION Environment and Equipment

• Five percent
• sodium hypochlorite solution
• for thirty minutes.

121
SUMMARY
122
An OUTBREAK of infectious disease ORIGINATING
ANYWHERE on the globe can become a PUBLIC
HEALTH CRISIS in YOUR home town.
123
Whether the outbreak is of NATURAL ORIGIN or is
the result of DELIBERATE human action, the
CONSEQUENCES can be essentially THE SAME.
124

• The SUCCESS of a community
• in a DISASTER depends upon
• strong RELATIONSHIPS
• between DISCIPLINES
• and across JURISDICTIONS.

125
Collaborative PLANNING, effective PROCESSES,
and repeated PRACTICE are keys to success.
126
PRIMARY HEALTH PROVIDERS are well positioned to
DETECT an OUTBREAK of infectious disease. YOU
are our FIRST LINE OF DEFENSE.
127
Report ANY SUSPICION of an infectious disease
OUTBREAK to public health authorities. THEY
will investigate. FEAR of making an unfounded
report can COST LIVES.
128
FAITHFUL use of ROUTINE PRECAUTIONS offers
ADEQUATE PROTECTION against biological agents of
terror.
129
(No Transcript)
130
SC AHEC Terrorism 101

• The Bacteria
• The Viruses
• The Toxins
• Radiation
• Explosions/Blasts
• Chemical Agents
• Sounding the Alarm
• The Forensic Proces
• Psychosocial Issues

• Interdisciplinary Planning
• Pharmacological Issues
• Personal Protective Equipment
• Decontamination
• Agricultural Bioterrorism

131
QUESTIONS?