The Three Rs of Bioterrorism Training: Recognition, Reporting, Response Ralph M. Shealy, M.D., FACEP

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The Three Rs of Bioterrorism
TrainingRecognition, Reporting, Response
Ralph M. Shealy, M.D., FACEP What Every Nurse
Needs To Know September 10, 2004Mount
Pleasant, South Carolina
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My Perspective

• Emergency Medicine
• Community Academic EDs
• Pre-Hospital Emergency Medicine
• 4,000 Missions
• EMS
• Rescue
• SWAT, Bomb Squad, Dive Team
• HazMat
• Disaster Medicine
• Population Emergencies
• Medical Counter-Terrorism
• Weapons of Mass Destruction
• Homeland Security

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OBJECTIVES

• At the end of this presentation,
• participants will be AWARE of

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• What biological agents are terrorist most likely
  to use?

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• What are their signs and symptoms?

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How can I recognize a DISEASE OUTBREAK?
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• What do I do if I suspect something amiss?

How do I make a report?
What if I am wrong?
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How can I PROTECT MYSELF and my staff from
exposure to dangerous biological agents and
chemicals?
How can I DECONTAMINATE myself, my staff, and
my clinic?
What response can I expect from the GOVERNMENT?
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How do I fit in with plans for COMMUNITY HEALTH
EMERGENCIES?
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What can I do to help public health authorities
FIGHT BACK?

• (And what will be my LIABILITY exposure?)

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Why should I learn about bioterrorism?
There will never be a terrorist event here!
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Besides, my duties have nothing to do with
terrorism!
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SEPTEMBER 11, 2001Changed the way we see
OURSELVES andOUR WORLD.
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The American homeland is VULNERABLE!
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• YOU are a FRONT-LINE DEFENDER!

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Why should I learn about bioterrorism?
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1 What you learn about terrorism applies to ANY
man-made or natural disaster!
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SUCCESS depends uponRELATIONSHIPSPLANS
PROCESSESPRACTICE
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A Disaster

• Threatens public health and safety.
• Disrupts essential services.
• Overwhelms standard procedures.
• Requires extraordinary measures.

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Natural Disasters

• Flood
• Hurricane
• Tornado
• Winter storm
• Earthquake
• Tidal wave
• Volcanic Eruption

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Man Made Disasters Unintentional

• Structural Collapse
• Transportation Accident
• Hazardous Material Spill
• Industrial Accident
• Explosion

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Man Made DisastersIntentional

• Civil Conflict
• War
• Terrorism

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Types of Terrorism

• SMALL ARMS
• EXPLOSIVE
• INCENDIARY
• Chemical
• Biological
• Radiation

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Terrorism is a MAN-MADE DISASTER
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You are likely to experience a COMMUNITY HEALTH
EMERGENCYduring your professional career!
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2 Outbreaks Can Be Global

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

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We are at greater risk from a NATURAL PANDEMIC
than from bioterrorism.What you learn about
bioterrorism applies!
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3 Doomsday Bio-Weapon

• Multiple organisms
• Each is deadly
• All look alike at first
• Require different treatments
• Must treat during prodrome
• Diagnostic features not present early

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• Much of the Soviet Unions biological arsenal
• and the brain trust that created it are not
  accounted for.

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4 Bio-Engineering Nightmare

• Creation of drug resistant organisms
• Introduction of virulence into organisms not
  normally human pathogens

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With rapid global mobility, an outbreak anywhere
could soon become a catastrophe everywhere.
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It is unknown whether we could control such an
outbreak.This is THE major incentive to
improve our biological disaster capabilities.
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Biological Agents of Highest ConcernCategory A
Agents

• Easily disseminated via aerosol
• Susceptible civilian populations
• High morbidity and mortality
• Person-to-person transmission
• Unfamiliar to physicians
• Difficult to diagnose/treat
• Causes panic and social disruption
• Already developed as biological weapon

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Biological Agents of Terror

• Bacteria
• Viruses
• Biological Toxins

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Bacteria

• Anthrax
• Plague
• Tularemia

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Viruses

• Smallpox
• Viral Hemorrhagic Fevers

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Biological Toxins

• Botulinum

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Well discuss these agents from the perspective
of recognition only.Therapeutic recommendations
may change rapidly as facts become available.
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The Ultimate Resource!www.bt.cdc.gov
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Anthrax

• In a BT attack, anthrax is an INHALATIONAL
  DISEASE
• Cutaneous disease is also possible
• Early stages resemble FLU-LIKE ILLNESS.
• FEBRILE RESPIRATORY ILLNESS
• fatigue, sweats, GI involvement, chest pressure
  or pain, strider, severe respiratory distress

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Anthrax

• CXR WIDE MEDIASTINUM
• Gram positive rods.
• Culture positive late

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Plague

• The most likely presentation in a BT attack is
  PNEUMONIC plague.
• High fever, headache, myalgias.
• Abrupt onset of pneumonia with BLOODY SPUTUM and
  a fulminant course.
• Hemorrhagic meningitis.
• Death from respiratory failure, circulatory
  collapse and bleeding diathesis

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Plague

• Yersinia pestis is causative agent.
• Gram negative rod.
• CXR Bronchopneumonia

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Tularemia

• Zoonotic (rabbit fever).
• Natural disease is Cutaneous, ulcerative. In BT
  attack, PNEUMONIC TYPHOIDAL DISEASE.
• Fever, chills, malaise, chest pain,
  nonproductive cough, respiratory distress.

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Tularemia

• Natural disease in rural setting.
• Tularemia in an urban setting with no known risk
  factors or contact with infected animals suggests
  BT.

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Tularemia

• CXR pneumonia, mediastinal lymphadenopathy,
  pleural effusion.
• Gram negative cocco-bacillus, but staining and
  culture are difficult.

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Smallpox

• Malaise, fever, rigors, headache, backache.
• SICK
• Macules, to papules, to PUSTULAR VESSICLES.

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Smallpox

• Face, arms, legs.
• CENTRIFUGAL
• Develop at same time. SYNCHRONOUS

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Smallpox

• The CLINICAL DIAGNOSIS of smallpox is a PUBLIC
  HEALTH EMERGENCY the local or state health
  department and hospital infection control should
  be notified immediately for suspected cases.

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Viral Hemorrhagic Fevers

• Fever, easy bleeding, petechiae, hypotension,
  shock.
• Malaise, myalgias, headache, vomiting, diarrhea.

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Viral Hemorrhagic Fevers

• A thorough TRAVEL AND EXPOSURE HISTORY is key to
  distinguishing naturally occurring from
  intentional viral hemorrhagic fever cases.
• Viral hemorrhagic fevers can be TRANSMITTED VIA
  EXPOSURE TO BLOOD AND BODILY FLUIDS.

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Viral Hemorrhagic Fevers

• CONTACT AND AIRBORNE PRECAUTIONS are recommended
  for health care workers caring for infected
  patients.

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Botulism

• Weakness
• Dry mouth
• Blurred vision, diplopia
• Dysarthria, dysphonia, dysphagia
• SYMMETRICAL DESCENDING FLACCID PARALYSIS
• Respiratory failure

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Botulism

• An outbreak occurring with a common geographic
  factor, but with no common food exposure, would
  suggest a deliberate aerosol exposure.
• BOTULINUM ANTITOXIN must be administered as soon
  as possible for optimum results.

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PERSONAL PROTECTIVEEQUIPMENT

• PROTECTION
• versus
• CONTAINMENT

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PERSONAL PROTECTIVEEQUIPMENT

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

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PERSONAL PROTECTIVEEQUIPMENT

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

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

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

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DECONTAMINATION Environment and Equipment

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

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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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COVERT Bioterrorism is NOT 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

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

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Natural versus Intentional Epidemic

• Many common features.
• You dont need to diagnose terrorism.
• Critical to recognize and report an OUTBREAK!

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Factors Influencing the Time and Place of
Delivery

• Meteorological conditions (temperature
  inversions)
• Time of day (dusk)
• Large number of victims congregated (arena)
• Symbolic target (Senate Office Building)

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Point Delivery Versus Line Delivery

• One hundred ten pounds (110 lbs) of aerosolized
  B. antracis spores dispensed from a line source
  2 km upwind of 500,000 unprotected people would
  kill or incapacitate up to 125,000 people.

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Covert Aerosols

• Agents typically disseminated by aerosols.
• Pulmonary forms of diseases caused by
  bioterrorism agents are typically the most
  virulent (and typically most contagious) form.

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We are familiar with natural diseases.Bio-attack
with the same organisms may look very different!
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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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Recognizing an Outbreak

• Take note of a case or a cluster of cases that
  are DIFFERENT FROM THE NORM.

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Red Flags

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

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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.

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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

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Syndromic Surveillance

• Watches for SYMPTOM COMPLEX.
• Detects an unusually high incidence of similar
  symptoms present in the community at the same
  time.
• Requires seasonal baseline rates of index
  symptoms
• Unexplained variances from the baselines can be
  recognized
• Requires data collection on a daily basis

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Syndromic Surveillance

• In order to be successful, reportable conditions
  must be reported to public health authorities in
  a timely fashion.
• Covert bioterrorism is often not recognized until
  several index cases present critically ill with
  similar symptoms in an unexpected setting.
• The challenge is to recognize the epidemic before
  patients become non-salvageable.

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Importance of Recognizing the Threat

• Agents of bioterrorism commonly 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. (Janitorial Diagnosis)

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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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Human Nature

• Even when we suspect something, we are often
  reluctant to report it for fear of being wrong
  and looking foolish.

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In the case of an epidemic, it is better to
report suspicions and be wrong than to keep
silent and be right.
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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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What should you do if you suspect an outbreak
of an infectious disease in your community?
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• Initial course of action
• is the same in both a
• natural epidemic
• and a
• man-made epidemic.

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S.C. Department of Health and Environmental
Control

• A DHEC Epidemiology Team is on call around the
  clock to investigate potential threats to public
  health.
• Be sure to get a handout with phone numbers for
  the 24/7 Epi Team pager in your DHEC Health
  District!

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What mechanisms are already in place to respond
to a national emergency?
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FBI has responsibility for federal crisis
managementFEMA has responsibility for federal
consequence management.
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Federal Response Plan

• The Federal Response Plan ASSISTS STATE AND LOCAL
  GOVERNMENT when a disaster overwhelms their
  ability to
• Save Lives
• Protect Public Health
• Protect Public Safety
• Protect Property
• Restore Communities
• EVERY DISASTER IS LOCAL!
• ITS OURS FOR 72 HOURS!

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Posse Comitatus

• The involvement of the military in a domestic
  disaster is limited.

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What mechanisms are already in place to respond
to a community emergency in South Carolina?
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Extraordinary Governmental Powers In a Declared
Emergency

• Military, Civil Defense And Veterans
  AffairsS.C. Code of Laws, Section 25, Chapter
  4, and Code of Regulations, 58-101
• The Emergency Health Powers ActSC Code of
  Laws, Title 44, Chapter 4

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SC Law Enforcement Division (SLED) is lead agency
for state homeland security.  
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SC Emergency Preparedness Department (EPD)

• The SC EPD resides in the Office of the Adjutant
  General.
• It operates through an EPD in each county.

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Emergency Operations Center

• The State of South Carolina has an EOC for state
  government functions operated by the Emergency
  Management Division, Office of the Adjutant
  General.
• Each county has an EOC that is the community
  nerve center during an emergency.

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Emergency Operations Center

• All disaster is local.
• The COUNTY EOC makes STRATEGIC decisions for the
  community as a whole.
• Critical community leaders assemble in a secure
  location to make joint decisions face-to-face.
• This model is used nationwide.

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Incident Command System

• The ICS allows multiple agencies from multiple
  jurisdictions to make and implement TACTICAL
  DECISIONS IN LARGE SCALE FIELD OPERATIONS where
  everyone has some degree of authority and some
  degree of responsibility.

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Incident Commander

• Under South Carolina law, the senior fire
  officer at the scene of an emergency involving
  the protection of life or property has authority
  to direct the field operation. (SC ST SEC
  6-11-1420)

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Your Role in Disaster Management

• Disaster planners need to have realistic
  expectations of the health care system.
• Health professionals must bring their knowledge
  and experience to the Emergency Response System.

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Your Role in Disaster Management

• A primary care health professional will most
  likely be the one to first suspect an outbreak of
  infectious disease.
• Prompt reporting of suspicions to public health
  authorities can save lives in an epidemic.

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Health professionals who volunteer to assist DHEC
during a community health emergency are
protected from liability.
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SOUTH CAROLINAEMERGENCY HEALTH POWERS ACT

• ARTICLE 5. SPECIAL POWERS DURING STATE OF PUBLIC
  HEALTH EMERGENCY
• CONTROL OF PERSONS

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SOUTH CAROLINAEMERGENCY HEALTH POWERS ACT

• SECTION 44-4-570. Requiring assistance by
  in-state providers
• (A) The appropriate licensing authority
• may exercise, for such period as the state of
  public health emergency exists the following
  emergency powers regarding licensing of health
  personnel (1) to require health care
  providers to assist in the performance of
  vaccination, treatment, examination, or testing
  of any individual as a condition of licensure or
  the ability to continue to function as a health
  care provider in this State.

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SOUTH CAROLINAEMERGENCY HEALTH POWERS ACT

• (D) Any person appointed pursuant to this
  section who in good faith performs the assigned
  duties is not liable for any civil damages for
  any personal injury as the result of any act or
  omission, except acts or omissions amounting to
  gross negligence or willful or wanton misconduct.
  

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Volunteer now to help in a community health
emergency. Contact the DHEC District Director
serving your county.
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QUESTIONS?
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