Bioterrorism and Vulnerable Populations

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Bioterrorism and Vulnerable Populations

• Melanie Fisher, M.D., M.Sc.
• WVU School of Medicine, 
• Infectious Diseases

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Objectives

• Know the CDC Category A bioterrorism (BT) agents
• Identify vulnerable populations in a
  bioterrorism event
• Anticipate the needs of vulnerable populations
• Initiate careful planning for a BT event to
  include these vulnerable populations

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Category A agents

• Diseases caused by CDCs Category A Agents of
  Bioterrorism
• Anthrax
• Smallpox
• Tularemia
• Plague
• Viral Hemorrhagic Fevers

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Hypothetical Case Scenario

• A 36 year old man presented to a local emergency
  department with fever, chest pain, shortness of
  breath, and appearing very ill
• Chest X-ray showed widened mediastinum
• Within the next 24 hours, numerous additional
  people presented throughout the county with
  similar symptoms

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Chest X-ray showing mediastinal wideningWhat
diagnosis should be suspected?
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Case Scenario (cond.)

• Local and state health departments were
  contacted, and a bioterrorism event was being
  considered in the differential diagnosis
• 48 hrs after the initial patient presented, blood
  cultures were confirmed positive for Bacillus
  anthracis
• Patients included previously healthy adults,
  children (including infants), pregnant women,
  elderly adults, and people with physical or
  mental disabilities

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Case Scenario Questions Raised

• Who are the most vulnerable populations in a
  disaster event?
• How would the management of these persons be
  different from the general population?
• What initial planning is required to meet their
  needs?

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Vulnerable Populations

• Children
• The Elderly
• People with Physical Disabilities
• People with Mental Disabilities
• Pregnant women

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The Management of Vulnerable Populations in a
Bioterrorism Event

• Preparedness for the acute care of victims of
  terrorist incidents must include research,
  planning, and preparation for a widely diverse
  group of patients.
• At any given time in the United States there are
  approximately
• 58 million children under the age of 15
• 13 million people over the age of 75
• 54 million people with disabilities
• 3 million women who are pregnant

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The Management of Vulnerable Populations in a
Bioterrorism Event

• Vulnerable Populations May Require Alternatives
• If there is a terrorist incident or public health
  emergency in your community, look to the public
  health authorities at the local, state, and
  federal level as a primary source for these
  recommendations
• http//www.bt.cdc.gov/
• http//www.fema.gov/

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Vulnerable Populations Children General
Considerations for Treatment

• Pediatrics
• Need to dose by weight
• Need for multiple forms (liquid tablets)
• Some medications and vaccines not licensed for
  use in children of certain ages

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Specific Issues Regarding Medications for
Children

• In general, there are three specific issues for
  decisions regarding medication selection for
  children
• acceptability
• format
• dosage

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Specific Issues Regarding Medications for Children

• Acceptability is the drug or vaccine acceptable
  to use in children?
• Example smallpox vaccine
• Current CDC recommendations caution against its
  use in children
  actual smallpox attack, children may be targets
  so, it may need to be considered

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Specific Issues Regarding Medications for Children

• Format of Medication consider
• liquid vs. pills vs. chewable pills
• Example prophylactic antimicrobials such as
  doxycycline or ciprofloxacin would need to be
  available in an oral suspension form (liquid) for
  children
• Presently, in the U.S., ciprofloxacin can be
  reconstituted to a liquid form with a two week
  shelf life, and doxycycline is available as a
  liquid

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Specific Issues Regarding Medications for Children

• Dosing pediatric doses are different from adult
  doses
• Based on weight, sometimes age
• Example antimicrobial streptomycin is given as
  follows for treatment of tularemia
• Infants 15 mg/kg IM every 12 hr(max dose 2
  grams/ day)
• Older children/Adults 1g IM twice daily

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Special Needs of Children in a Bioterrorism Event

• Some useful medical interventions may be approved
  or designed for adults but not yet approved for
  pediatric use
• Clinicians will have to make decisions about
  non-approved uses, and adapting adult materials
  for children

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Other Issues Regarding Care of Children

• Pediatric psychiatric issues
• Pediatric appropriate messages
• Children separated from parents
• Day care for critical responders

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Considering Children in Emergency Response
Planning

• Planning must consider stockpiles of child
  appropriate materials
• Planning must consider children who are at home,
  in school or daycare, or in transit, and those
  who cannot be reunited with their parents

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Considering Children in Emergency Response
Planning (cond.)

• The document Pediatric Preparedness for
  Disasters and Terrorism A National Consensus
  Conference provides excellent recommendations

Available at http//www.ncdp.mailman.columbia.edu
/pediatric_preparedness.pdf
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Case Scenario Follow-upChildren

• Children exposed to anthrax received age and
  weight based oral suspensions of ciprofloxacin
• Arrangements made to care for children whose
  parents were called to work

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Vulnerable Populations The Elderly General
Considerations for Treatment

• The Elderly
• Medication interactions
• Confusion more common (from medicines etc.)
• Toxicity may be greater with certain drugs (e.g.
  gentamicin)
• Other underlying medical illnesses

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Care of the Elderly

• Special Needs of Geriatric Populations
• Usually, geriatric populations will be treated
  according to guidelines for the general
  population
• Exceptions and cautions
• Medication doses may need to be decreased due to
  reduced renal function in elderly
• (? Creatinine Clearance)

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Care of the Elderly

• Special Needs of Geriatric Populations
• (Cond.)
• Exceptions and cautions
• Potential for drug interactions great because
  elderly often take other medicines
• Elderly patients may have impaired memory,
  confusion. Suggestions
• Helpline for patients
• Carry lists with dosages and schedules of their
  usual medicines

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Case Scenario Follow-upThe Elderly

• For elderly exposed to anthrax, ciprofloxacin
  prophylaxis given at a dose based on their kidney
  function
• Additional nurses helped evaluate elderly for
  other medical problems pharmacists helped with
  medication lists, education

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Vulnerable Populations Physical
DisabilitiesGeneral Considerations for Treatment

• Physical disabilities
• Difficulty accessing care
• Other underlying illnesses common
• May need home or nursing home based treatment

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Care of those with Physical Disabilities

• Emergency Planning for People with Disabilities
• According to the U.S. Census Bureau, Americas
  disability population includes
• 54 million men, women and children with mental,
  emotional and/or physical disabilities that
  impact hearing, vision and mobility.
• People with disabilities should be included in
  emergency preparedness planning and response

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Analyzing Needs within the Community

• National Organization on Disability (NOD)
• Questions for Emergency Management Planners
• What is it like to be a person with a disability
  during and after an emergency?
• Can one hear or understand the warnings?
• Can one quickly exit a home or workplace?
• Do workers/ citizens know where to assemble in
  order to receive assistance if a small area has
  to be evacuated?

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Analyzing Needs within the Community

• National Organization on Disability (NOD)
• Questions for Emergency Management Planners
• Can one move about the community after escaping?
• Are there special necessary or even vital daily
  items (medicines, power supplies, medical
  devices) that are not likely to be available in
  emergency shelters?
• Are basic services like restrooms and showers
  available and accessible to people with
  disabilities?

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National Organization on Disability
(NOD)Suggestions for Emergency Management
Planners

• Identify those in the community who might have
  special needs
• Customize awareness and preparedness messages and
  materials for specific groups
• Educate citizens with disabilities about
  realistic expectations of service
• Learn from the knowledge, experiences of the
  disability community
• Work with institutional and industry-specific
  groups that can offer support to emergency
  professionals

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Planning and Preparing to Protect People with
Disabilities (cond.)

• According to the National Organization on
  Disability (NOD)
• 61 of people with disabilities have not made
  plans to quickly evacuate their homes
• 50 of people with disabilities who are employed
  say no plans have been made for a safe evacuation
  at their workplace
• 58 of people with disabilities do not know whom
  to contact in the event of a disaster

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Case Scenario Follow-upPhysical Disabilities

• At points of distribution for antimicrobial
  prophylaxis, wheelchair access, ramps as well as
  proper toilet facilities were made available
• Personnel were assigned to help hearing and sight
  impaired

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Vulnerable Populations Mental
DisabilitiesGeneral Considerations for Treatment

• Mental disabilities
• Failure to access care
• Single-dose therapy preferable due to compliance
  issues
• May need home or nursing home based treatment

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Care of those with Mental Disabilities

• Issues in the Care of People with Mental
  Disabilities
• Treatment, in general, will be the same as the
  healthy population
• Some important considerations still exist for
  this group regarding
• Medication assistance
• Transportation
• Reluctance to reach or receive care
• Adaptations to changing circumstances

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Care of those with Mental Disabilities

• Issues in the Care of People with Mental
  Disabilities (cond.)
• Patients require their regular psychotropic
  medicines to cope with the medical therapy given
  for the event
• Many psychotropic drugs may interact with other
  medications
• Simple dosing schedules are helpful

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Care of those with Mental Disabilities

• Issues in Seeking and Accessing Care
• Persons with dementia or emotional disease may
  fail to reach care, not recognize medication
  needs, and may need help with transportation
• Alternate access for treatment may help
• Plan for someone to assume responsibility for
  patient who does not have clinical decision
  making capacity
• Community registers of those needing care and
  those responsible are both sensitive and useful

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Case Scenario Follow-upMental Disabilities

• Additional personnel were assigned to assist as
  guides, care givers
• Simple dosing schedules utilized
• Nurses helped assure that patients received their
  usual psychotropic and other medications

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Vulnerable populations Pregnant Women General
Considerations for Treatment

• Pregnancy
• Many drugs must be avoided in pregnancy
• Need to consider preserving health of mother
• Risk to pregnancy vs. risk to mother

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Care of Pregnant Women

• Patients Who Are Pregnant
• Following a disease outbreak, public health
  agencies will issue guidelines for the treatment
  of special populations such as pregnant women
• When guidelines have not yet been issued,
  clinicians will need to make judgments based upon
  the potential risk to the pregnancy from using a
  particular medication and the risk to the mother
  from withholding treatment or prophylaxis. These
  must be judged on a case-by-case basis.

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Care of Pregnant Women

• Patients Who Are Pregnant
• The Journal of the American Medical Association
  (JAMA) has published recommendations for pregnant
  patients based on the balance of risks to
  benefits
• (http//jama.ama-assn.org/cgi/content/full/287/1
  7/2236)
• In addition, nearly every medication has an
  assigned pregnancy category, and this will help
  guide the risk-to-the-pregnancy portion of the
  calculation

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Care of Pregnant Women

• Vaccination Decisions
• Must be judged on a case-by-case basis
• Example
• Should smallpox vaccine be given to pregnant
  women?
• Pre-event setting generally NO
• Post-exposure to actual smallpox event may
  consider giving vaccine if risk of exposure
  significant
• This is a Risk vs. Benefit issue (based on
  changing perceptions of benefits against fixed
  risks)

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Case Scenario Follow-upPregnant Women

• National recommendations given to give
  ciprofloxacin to pregnant women exposed to
  anthrax
• (because threat of the disease greater than the
  potential risk to fetus)
• Follow-up arranged

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VMC / WV Prepares

• Multidisciplinary Response

The response to a terrorist incident requires a
coordinated effort from many agencies working
together with different incident specific
functions or skills. - Public health -
Clinicians - Law enforcement - The Red Cross -
The military - Emergency management - Social
services
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VMC / WV Prepares

• A Bioterrorism event would require a rapid
  response
• by trained professionals
• To help deal with epidemic, bio-terrorist or
  other disaster
• events effectively, efficiently, and
  professionally the
• Virtual Medical Campus (VMC) at West Virginia
• University has developed three courses through a
  grant
• from the U.S. Department of Health and Human
  Services
• (DHHS)/Health Resources and Services
  Administration
• (HRSA).

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VMC / WV Prepares

• WV Prepares Project has 3 online courses
• Terrorism Recognition Reporting
• Multidisciplinary Response
• Acute Care of Patients from WMD Events

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VMC / WV Prepares

• Register Online atwww.vmc.wvu.edu/hrsa/
• VMC Help Desk
• E-mail vmchelp_at_mail.wvu.edu Telephone
  304.293.6353 (M-F), 12 p.m. to 4 p.m.
• HRSA Program Coordinator Karen Blaney
  E-mail KLBlaney_at_mail.wvu.edu Telephone
  304-293-6327

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Summary

• CDC category A agents of Bioterrorism include
  anthrax, smallpox, botulism toxin, plague,
  tularemia, and Viral Hemorrhagic Fevers
• Vulnerable populations in a terrorist attack
  include children, elderly, those with physical or
  mental disabilities, and pregnant women

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Summary (cond.)

• Planning for a BT attack must include special
  needs of vulnerable populations
• More information and training available through
  VMC/WV Prepares Online courses