Scenario Day 0

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Protocol
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Response to BT Plague

• Early recognition and reporting
• Case-finding
• Fever or cough in known outbreak
• Early initiation of treatment
• Isolation of cases
• Contact tracing and case investigation
• Initiate post-exposure prophylaxis
• Monitor exposed for symptoms
• Antibiotic susceptibility testing

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Plague following a BT attack

• The pathogenesis and clinical manifestations of
  plague following a BT attack would be notably
  different than naturally occurring plague
• Inhaled aerosolized Y. Pestis would cause primary
  pneumonic plague
• The time from exposure to aerosolized plague
  bacilli until development of first symptoms in
  humans and nonhuman primates has been found to be
  1 to 6 days and most often, 2 to 4 days
• The first sign of illness would be expected to be
  fever with cough and dyspnea, sometimes with the
  production of bloody, watery, or less commonly,
  purulent sputum
• Prominent gastrointestinal symptoms, including
  nausea, vomiting, abdominal pain, and diarrhea,
  might be present

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Public Health Action

• When a plague case is reported
• Confirm cases
• Confirmation of an intentional or unintentional
  exposure and Notification Procedure
• Activate the BT response teams
• Protect employee health

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Case Finding

• Develop a working case definition
• Conduct enhanced passive surveillance and active
  surveillance
• Confirm new cases
• Develop line list of cases

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Contact tracing

• Direct contacts are defined as any person who has
  had face-to-face contact (within 2 meters) with a
  suspected, probable, or confirmed case of plague
  during the infectious period
• Interview all suspected, probable, and confirmed
  cases and identify all persons who had direct
  contact with the case since the cases onset of
  symptoms (henceforth referred to as a
  case-contact). Continue interviews daily and
  record contacts until case is no longer
  infectious.
• For each case develop a line list of all
  case-contacts including all household members of
  case-contacts using plague contact tracing forms

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Surveillance of case-contacts and exposed
population

• Assure that all case-contacts and exposed
  individuals are interviewed within 24 hours and
  refer them to a clinical center for post exposure
  prophylaxis (PEP), as necessary.
• For large populations, alert the public about the
  location of clinical centers for treatment or PEP
  through media announcements.

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Surveillance of exposed

• Conduct surveillance of all exposed individuals
  for
• 7 days
• If an exposed individual does not have
  signs/symptoms of plague by end of 7 days, then
  discontinue surveillance. Interview all exposed
  individuals to verify they have no symptoms, and
  if so, indicate status of exposed individual as
  closed on Exposed Individual Line Listing Form
• If exposed individual develops fever (gt38.5 C) or
  cough then assure referral for parenteral therapy
  after cultures are obtained, and assure
  implementation of appropriate infection control
  and preventive interventions. Enter status of
  exposed individual as a case and move to Case
  Line List. Begin contact tracing for this new
  case

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Surveillance of case-contacts

• Place all case-contacts under surveillance for 7
  days from day of suspected or known direct
  contact with a confirmed case
• If case-contact does not have signs/symptoms of
  plague by end of 7 days, then discontinue
  surveillance. Interview all case-contacts daily
  to verify they have no symptoms, and if so, after
  seven days, indicate status of case as closed
  on Contact Line List Form
• If case-contact develops fever (gt38.5C) or cough,
  then assure referral for parenteral therapy, and
  assure implementation of appropriate infection
  control and preventive interventions. Enter
  status of case-contact as case on Case Line List.
  Begin contact tracing for this new case

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Surveillance Indicators

• Time between suspicion of plague and first report
  to public health.
• Proportion of investigations with risk factor and
  exposure data collection.
• Time between suspicion of plague and completion
  of clinical history.
• Time between suspicion of plague and completion
  of risk factor and exposure data collection for
  BT event.
• Time from suspicion of plague and identification
  of source of exposure in a BT event.

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Scenario
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Scenario Day 0

• Day 0. On Friday, April 14, 2005, the Boston
  Celtics play the NY Knicks at the Hartford Civic
  Center. It is an evening game, lasting from 8 to
  10 pm.
• The arena is packed 16,000 spectators attend.
  Attendees come from all over Connecticut to see
  the two regional rivals.

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Scenario Day 2

• On Sunday morning, April 16, at 8 am, a
  30-year-old man comes in to the emergency
  department at Hartford Hospital, complaining of
  shortness of breath, fever, chest pain, and
  cough. He looks very ill.
• An X-ray shows pneumonia of several lobes of his
  lungs.
• He is admitted, and starts to cough up blood.

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Scenario Day 2

• By 230, Dr. Cooper is on the phone to the DPH
  answering service. The answering service calls
  Dr. Jim Hadler, who is on call.
• With Dr. Coopers help, a history of the
  patients movements in the preceding week is
  obtained from the mans roommate and his family,
  all of whom live in Hartford. It includes a
  history of attendance at the basketball game two
  days earlier.
• Arrangements are made to get a sputum and blood
  specimen to the laboratory within the next hour
  for testing for plague. As part of this, Dr.
  Hadler calls Dr. Kati Kelley, who activates the
  laboratory.

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Epidemiology Actions Day 2

• Dr. Hadler asks Dr. Cartter to take over on-call
  duty, mobilize a team of his staff to help and
  notify each local health department about suspect
  cases in their jurisdictions.
• Each local health department will be asked to
  identify household contacts, to notify them of
  possible exposure and to be prepared to get
  antibiotics if plague is confirmed.

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Epidemiology Actions Day 2

• Dr. Cartter will also notify Dr. Melchreit, who
  will be in charge of working with Dr. Cartter and
  his staff to monitor contact notifications made
  by local health departments and whether or not
  each contact has been given antibiotic
  prophylaxis.
• Dr. Hadler will take charge of notifying Len
  Guercia, CDC and developing HAN communications to
  all local health departments and hospitals.

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Epidemiology Actions Day 2

• Dr. Cartter forms 2 DPH Epidemiology teams a
  surveillance team to continue monitoring for new
  cases of plague, including in animals and a case
  investigation team to verify that suspect cases
  do have plague.
• With Dr. Melchreit, a contact investigation/
  local health liaison team is formed to monitor
  each strongly suspected case of plague to assure
  that contacts are identified, enrolled in a
  database and immediately receive antibiotic
  prophylaxis.

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Epidemiology Actions Day 2

• Another WANS message is sent to local health
  departments asking them to participate in a
  midnight conference call during which the
  situation will be described and just in time
  training will occur.
• The training includes information about plague,
  symptoms and transmission, definition of
  contacts, use of an interview form and what to do
  with the form once it is complete.

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Epidemiology Actions -- Day 3

• At 6 a.m., 38 epidemiologists from the DPH ID
  Section and Environmental Epi Section report to
  work, receive just-in-time training, including an
  update, job action sheets and assignments to one
  of the epi teams.
• Regional epis are assigned to oversee the
  central contact database and be lead liaisons for
  their regions with LHD epis/ nurses/ sanitarians
  who have responsibility for contact
  investigation, counseling and referral for
  antibiotics.

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Epidemiology Actions -- Day 3

• The CDC team arrives at 10 am. CDC staff are
  assigned to the three DPH epidemiology teams and
  assume leadership of those teams
• This frees DPH staff for more support work,
  including providing field assistance to local
  health departments with many cases and training
  of persons working on the hotline.

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Epidemiology Actions -- Day 3

• Some LHDs are overwhelmed by the number of
  contact investigations others have few cases.
  There is a need to share staff among health
  departments and for DPH staff to provide direct
  assistance to some.
• Because many case-patients are too critically ill
  to be interviewed, LHDs have been spending a lot
  of time tracking down persons who might have been
  contacts. Some have made home visits when
  telephones were not answered.

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Epidemiology Actions -- Day 4

• Connecticut now has 511 confirmed or suspect
  cases and Massachusetts 189, but scattered cases
  have been reported from as far away as
  Philadelphia.
• Dr. Hadler reports that 50 contact investigations
  from previously reported cases are still
  outstanding
• Plan is worked out that includes assistance
  between health departments and DPH staff to
  assure that all get completed that day.

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By the end of the week,

• Nearly 1,100 suspected or confirmed patients are
  reported. Field epidemiologists have interviewed
  8,721 patients in Connecticut, and have found 257
  cases, 291 of which are primary cases exposed at
  the Civic Center, and 56 of which are secondary
  transmission cases.
• The outbreak takes two weeks to investigate and
  control. There are many deaths 291 from
  Connecticut, 99 from Massachusetts, and 25 from
  other states.

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