Clinical Recognition

1
Clinical Recognition Management of Persons
Exposed to Agents of Biological Terrorism

• Jeffrey S. Duchin, MD
• Communicable Disease Control, Epidemiology and
  Immunization Section
• Public Health - Seattle King County
• Assistant Professor, Division of Allergy
  Infectious Diseases
• University of Washington

2
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 physicians - difficult to
  diagnose/treat
• Cause panic and social disruption
• Previous development for BW

3
Biological Agents of Highest Concern Category
A Agents

• Variola major (Smallpox)
• Bacillus anthracis (Anthrax)
• Yersinia pestis (Plague)
• Francisella tularensis (Tularemia)
• Botulinum toxin (Botulism)
• Filoviruses Arenaviruses (Viral hemorrhagic
  fevers)
• Report ALL suspected or confirmed illness due to
  these agents to Public Health immediately.

4
Biological Agents of 2nd Highest
ConcernCategory B Agents

• Coxiella burnetti (Q-fever)
• Brucella species (brucellosis)
• Burkholderia mallei (glanders)
• Alphaviruses (Venezuelan, Western and Eastern
  encephalomyelitis viruses)
• Ricin toxin from Ricinus communis (castor bean)
• Epsilon toxin from Clostridium perfringens
• Staphlococcus enterotoxin B

5
Biological Agents of 2nd Highest ConcernFood- or
waterborne Category B Agents

• Salmonella species
• Shigella dysenteriae
• Escherichia coli 0157H7
• Vibrio cholera
• Cryptosporidium parvum

6
Recognition of BT EventEpidemiologic Clues

• Increase in persons ill with a similar or unusual
  syndrome
• Increase in unexplained disease or deaths
• Single case of disease due to an uncommon agent
• Unexpected geographic or seasonal distribution of
  disease
• Unusual age distribution (varicella, measles in
  adults)
• Illness in persons with common ventilation system
  or other exposure
• Atypical route of transmission - aerosol botulism
• Unusual illness among animals preceding or
  accompanying human illness

7
Anthrax Overview

• Primarily disease of herbivores
• Soil reservoir
• Humans usually infected by contact with infected
  animals or contaminated animal products
• Woolsorters disease (inhalation anthrax)
• No person-to-person transmission of inhalational
  anthrax

CDC
8
Anthrax Cutaneous
9
Anthrax Cutaneous
USAMRICD
10
Anthrax Cutaneous

• Most common (95)
• Inoculation of spores under skin
• Incubation hours - 7 days
• Pruritic papule ? vesicle ? ulcer, (painless
  eschar with edema), may be surrounded by vesicles
• Regional lymphadenitis
• Death 20 untreated rare if treated

USAMRIID
11
Anthrax Gastrointestinal

• Ingestion of contaminated meat
• Incubation hours - 7 days
• Fever, acute gastroenteritis, vomiting, bloody
  diarrhea
• Intestinal eschar similar to cutaneous anthrax
  lesion
• hemorrhagic
• Progression to generalized toxemia
• Mortality rate 50 to 100 despite Rx

CDC
12
Anthrax Inhalational

• Inhalation of spores
• Incubation 1 - 43 days
• Initial symptoms 2-5 days
• fever, cough, myalgia, malaise
• Terminal symptoms
• high fever, dyspnea, cyanosis
• hemorrhagic mediastinitis effusions
• hemorrhagic meningitis
• rapid progression to shock/death
• Mortality rate 100 despite aggressive Rx

CDC
13
Anthrax Diagnosis

• Inhalational Disease
• Overwhelming flu-like illness
• CXR - widened mediastinum, pneumonia not common
• Blood cultures, Gram stain alert the lab
• No test to detect inhalational anthrax anthrax
  before disease develops
• Nasal Swabs serology used in epidemiological
  investigations
• Cutaneous Disease
• Gram stain and culture skin biopsy

14
B. anthracis Gram staindemonstrating spores
15
Anthrax Treatment

• Antibiotics
• Ciprofloxacin 400mg IV q12 hs x 60 days
• Doxycycline (if susceptible) 100mg IV q12 hs
• PCN (if susceptible) 4mU q4 hs amoxicillin 500mg
  q8h
• Supportive care
• Cover cutaneous anthrax lesions
• Standard precautions, no need for quarantine
• Duration of treatment dependent on form of
  anthrax and/or vaccine use
• Early treatment improves prognosis

16
Anthrax Post-Exposure Prophylaxis

• Start oral antibiotics lt24 hours after exposure
• Ciprofloxacin 500mg PO q12 hs
• Doxycycline (if susceptible) 100mg PO q12 hs
• Amoxicillin (if susceptible) 500 mg PO q12 hs
• Antibiotics for 60 days without vaccine use
• Antibiotics for 30 days with 3 doses of vaccine

17
Anthrax Vaccine

• Current U.S. vaccine (FDA Licensed)
• Culture supernatant (PA) of attenuated
  non-encapsulated strain
• Protective against cutaneous (human data) and
  possibly inhalational anthrax (animal data)
• Injections at 0, 2, 4 weeks, then 6, 12, 18
  months yearly boosters
• 3 dose schedule (0, 2, 4 weeks ) may be effective
• 83 serologic response after 3 doses, 100 after
  5
• Limited availability

18
Anthrax VaccineAdverse Effects

• Up to 30 with mild discomfort (tenderness,
  redness, swelling, or itching) at inoculation
  site for up to 72 hours
• lt2 with more severe local reactions, potentially
  limiting use of the arm for 1-2 days
• Systemic reactions uncommon

19
Smallpox Overview

• 1980 - Global eradication
• Humans were only known reservoir
• Person-to-person transmission (aerosol/contact)
• Up to 30 mortality in unvaccinated

CDC -Variola major
20
Smallpox Clinical Features

• Prodrome (incubation 7-17 days)
• Acute onset of fever, malaise, headache,
  backache, vomiting, occasional delirium
• Transient erythematous rash
• Exanthem
• Begins face, hands, forearms
• Spread to lower extremities then trunk over 7
  days
• Synchronous progression macules ? vesicles ?
  pustules ? scabs
• Lesions on palms /soles

USAMRICD
21
Smallpox Complications

• Encephalitis (1 in 2,000 cases)
• Keratitis, corneal ulceration
• Blindness in 1 of cases
• Infection in pregnancy
• High perinatal fatality
• Congenital infection

22
Smallpox Vaccine

• Made from live Vaccinia virus
• 15.4 million doses in U.S. Stores
• Intradermal inoculation with bifurcated needle
  (scarification)
• Pustular lesion or induration surrounding central
  lesion (scab or ulcer) 6-8 days post-vaccination
• Low grade fever, axillary lymphadenopathy
• Scar (permanent) demonstrates successful
  vaccination
• Immunity not life-long

WHO
23
Smallpox Vaccine Complications

• Most common
• Inadvertent auto-inoculation (skin, eye)
• Less Common
• Post-vaccination encephalitis (2.8/million), 25
  fatal
• Progressive vaccinia (lt1/million)
• Generalized vaccinia (100/million)
• Eczema vaccinatum (4.5/million)
• Fetal vaccinia
• Vaccinia necrosum (0.7/million)
• Primary vaccination ? 1 death/million
• Revaccination ? 0.2 deaths/million

24
Smallpox Vaccination Complications
WHO
25
Smallpox Vaccinia Immune Globulin (VIG)

• Treatment of adverse reactions (AR)
• Approximately 25 ARs/100,000 vaccinations
• AR rate may be increased in immunocompromised
  populations
• Post-exposure prophylaxis
• Pregnant patients VIG vaccinia vaccine
• Eczema VIG vaccina vaccine
• Immunocompromised patients no consensus on
  VIG alone vs. VIG vaccinia vaccine
• Current supplies very limited

26
SmallpoxMedical Management

• Supportive care
• Strict respiratory contact isolation
• Patient infectious until all scabs have separated
• Notify Public Health and hospital epidemiology
  immediately for suspected case
• Identification of contacts within 17 days of the
  onset of cases symptoms

27
Smallpox Management of Contacts

• Immediate vaccination or boosting of ALL
  potential contacts including health care workers
• Vaccination within 4 days of exposure may prevent
  or lessen disease
• 17-21 day observation for fever or rash
• Passive immunization (VIG)
• Potential use for contacts at high risk for
  vaccine complications (pregnancy, dermatoses,
  immunosuppression)

28
Plague Overview

• Natural vector - Rodent Flea
• Mammalian hosts
• rats, squirrels, chipmunks, rabbits, and
  carnivores
• Enzootic or Epizootic
• About 10-15 cases/year in U.S.
• Mainly SW states
• Bubonic most common form

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Plague Clinical Forms

• Bubonic
• Inguinal, axillary, or cervical LN most common
• 80 can become bacteremic
• 60 mortality overall if untreated
• Primary or secondary septicemic
• 100 mortality untreated
• Pneumonic
• From aerosol or septicemic spread to lungs
• Person-to-person transmission by respiratory
  droplet
• 100 mortality untreated

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Plague Bubonic

• Incubation 2-6 days
• Sudden onset HA, malaise, myalgia, fever, tender
  LNs
• Regional lymphadenitis (Buboes)
• Cutaneous findings
• possible papule, vesicle, or pustule at
  inoculation site
• Purpuric lesions - late

Source USAMRICD
31
Plague Septicemic

• Primary or secondary
• Secondary from bubonic or pneumonic infection
• Severe endotoxemia
• Systemic inflammatory response syndrome
• Shock, DIC, ARDS

32
Plague Pneumonic

• Incubation 1-3 days
• Sudden onset HA, malaise, fever, myalgia, cough
• Pneumonia progresses rapidly to dyspnea,
  cyanosis, hemoptysis
• Death from respiratory collapse/sepsis

Source USAMRICD
33
Plague Medical Management

• Antibiotic therapy
• Preferred gentamicin or streptomycin
• Alternatives doxycycline, ciprofloxacin,
  chloramphenicol (meningitis/pleuritis)
• Supportive therapy
• Isolation and droplet precautions for pneumonic
  plague until sputum cultures negative
• Antibiotic resistant strains have been documented

34
Plague Prophylaxis

• Pneumonic plague contacts (e.g.
  respiratory/droplet exposure)
• Oral doxycycline, ciprofloxcin, TMP/SMX x 7 days
• Vaccine no longer manufactured in U.S.

35
Recognition of BT EventSurveillance/Detection

• Detect unusual medical events sooner rather than
  later
• Depends on ability to identify a greater than
  expected number of cases or syndromes
• Physicians, emergency departments, clinics,
  hospitals, and clinical laboratories must be
  alert to unusual clusters of disease syndromes
  compatible with naturally occurring or BT-related
  outbreaks
• Identify experts to assist with
  evaluation/diagnosis
• Infectious disease specialists hospital
  epidemiology team
• Public Health

36
Recognition of BT EventDiagnosis and Treatment

• Get appropriate history risk factors, contacts,
  (threat?)
• Be familiar with infection control measures
• Medical and laboratory staff must be familiar
  with reporting procedures for potential outbreaks
  and procedures for handling submitting samples
  for diagnostic testing by clinical DOH labs
• Be familiar with treatment and/or preventive
  therapy guidelines

37
Recognition of BT EventResponse

• Activate hospital biological disaster response
  plan
• Whos in-charge?
• Determine resources needed for response
• Medical, nursing, other professional and support
  staff
• Antibiotics and other pharmaceuticals
• Ventilators and related respiratory support
  equipment
• Hospital and ICU beds post-mortem management
• Triage, security and crowd control
• Communication - internal and external
• Public relations/media

38
Recognition of BT EventResponse

• Mass treatment and/or prophylaxis
• Activate internal plan for mass treatment and/or
  prophylaxis
• Obtain additional resources when demand exceeds
  supplies
• Contact Public Health- Seattle King County for
  additional information and to report suspected
  cases
• 206-296-4774

39
Public Health - Seattle King County BT
Resources

• Public Health 24-hour CD phone line 206-296-4774
• Public Health - Seattle King County Web Site
  http//www.metrokc.gov/health/bioterrorism/
• CDC Bioterrorism Web Site www.bt.cdc.gov/
• USAMRIID's Medical Management of Biological
  Casualties Handbook www.usamriid.army.mil/educati
  on/bluebook.html
• ACIP/CDC Recommendations for Healthcare
  Facilities www.acip.org/bioterror/

40
Influenza A H5N1, Hong Kong - 1997Bird Flu -
a close call?18 infected, 6 died...
41
Tularemia Overview

• Disease of Northern Hemisphere
• About 200 cases/year in U.S.
• South central and Western states
• Associated with rabbits, hares, ticks
• majority of cases in summer
• Low infectious dose
• 1 to 10 organisms by aerosol or intradermal route
• No person-to-person transmission

42
Tularemia Clinical Forms

• Ulceroglandular
• Ulcer with regional adenopathy
• Glandular
• Regional adenopathy without skin lesion
• Oculoglandular
• Painful purulent conjunctivitis with adenopathy
• Typhoidal
• Septicemia, no adenopathy
• Possible presentation for BT
• Pneumonic (primary or secondary)
• Possible presentation for BT

43
Tularemia Pneumonic

• Incubation 3-5 days (range 1-21 days)
• Abrupt onset fever, chills, headaches, myalgia,
  non-productive cough
• Segmental/lobar infiltrates, hilar adenopathy,
  effusions
• Mortality 30 untreated lt 10 treated

USAMRICD
44
Tularemia Treatment and Prophylaxis

• Treatment
• Preferred gentamicin or streptomycin
• Alternatives doxycycline, chloramphenicol,
  ciprofloxacin
• Prophylaxis
• Fever watch for 7 days (preferable)
• Doxycycline or ciprofloxacin x 14 days if febrile
• Vaccine investigational, not available

45
Botulism Overview

• Caused by toxin from Clostridium botulinum
• toxin types A, B, E, most commonly associated
  with human disease
• most potent lethal substance known to man (lethal
  dose 1ng/kg)
• C. botulinum spores found in soil worldwide
• Approximately 100 reported cases/year in the U.S.
• No person-to-person transmission

46
Botulism Clinical Forms

• Foodborne
• toxin produced anaerobically in improperly
  processed or canned, low-acid foods contaminated
  by spores
• Wound
• toxin produced by organisms contaminating wound
• Infant
• toxin produced by organisms in intestinal tract
• Inhalation botulism
• no natural occurrence, developed as BW weapon

47
Botulism Clinical Presentation

• Incubation 18-36 hours (dose dependent)
• Afebrile, alert, oriented, normal sensory exam
• Early nausea, vomiting, diarrhea ? constipation
• Cranial nerve abnormalities
• Ptosis, blurry vision, diplopia, dysphonia,
  dysphagia, decreased salivation
• Motor symptoms ? progressive
• Bilateral descending flaccid paralysis ?
  respiratory paralysis
• Death 60 untreated, lt5 treated

48
Botulism Differential Diagnoses

• Neuromuscular disorders
• Stroke syndrome
• Myasthenia gravis
• Guillain-Barre syndrome (Miller-Fisher variant)
• Tick paralysis
• Atropine poisoning
• Paralytic shellfish/puffer fish poisoning
• Diagnosis based on clinical presentation followed
  by laboratory confirmation

49
Botulism Treatment/Prophylaxis

• Ventilatory assistance, supportive care
• Botulinum antitoxin
• Trivalent equine product against types A,B, and E
  currently available from CDC through local public
  health
• Most effective if given early - prevents
  progression only
• Antibiotics (PCN) for infant/wound botulism
• Recovery may be prolonged
• Investigational vaccine not available

50
Viral Hemorrhagic Fevers (VHF) Overview

• Caused by several different virus families
• Filoviruses (Ebola, Marburg)
• Arenaviruses (Lassa, Junin, Machupo, Sabia,
  Guanarito)
• Bunyaviruses
• Flaviviruses
• Natural vectors - virus dependent
• rodents, mosquitoes, ticks
• No natural occurrence in U.S.

CDC
51
Viral Hemorrhagic FeverClinical Presentation

• Usual patient history
• Foreign travel to endemic or epidemic area
• Rural environments or nosocomial exposure
• Contact with arthropod or rodent reservoir
• Domestic animal blood exposure
• Incubation
• Typical 5-10 days
• Range 2-16 days

52
Viral Hemorrhagic FeverClinical Presentation

• Symptoms
• Fever, headache, malaise, dizziness
• Myalgias
• Nausea/vomiting
• Initial signs
• Flushing, conjunctival injection
• Periorbital edema
• Positive tourniquet test
• Hypotension

53
Viral Hemorrhagic Fever Clinical Presentation

• Other signs/symptoms
• Prostration
• Pharyngeal, chest, or abdominal pain
• Mucous membrane bleeding, ecchymosis
• Shock
• Usually improving or moribund within a week
• Exceptions HFRS, arenaviruses
• Bleeding, CNS involvement, marked SGOT elevation
  indicate poor prognosis
• Mortality agent dependent (10 to 90)

54
Viral Hemorrhagic Fever Differential Diagnosis

• Bacterial
• Typhoid fever, meningococcemia, rickettsioses,
  leptospirosis
• Protozoa
• Falciparum malaria
• Other
• Vasculitis, TTP, Hemolytic Uremic Syndrome (HUS),
  heat stroke

55
Viral Hemorrhagic Fever Treatment

• Supportive care
• Cautious sedation and analgesia
• Correct coagulopathies
• No antiplatelet drugs or IM injections
• Ribavirin effective for
• Arenaviruses
• Bunyaviridae (CCHF, Hantaan, RVF)

56
Viral Hemorrhagic FeverPatient Isolation

• Single room w/ adjoining anteroom (if available)
• Handwashing facility with decontamination
  solution
• Negative air pressure
• Strict barrier precautions including protective
  eyewear/faceshield
• Disposable equipment /sharps in rigid containers
  with disinfectant then autoclave or incinerate
• All body fluids disinfected
• MMWR - Management of patients with suspected VHF
  http//www.cdc.gov/epo/mmwr/preview/mmwrhtml/00037
  085.htm

57
Viral Hemorrhagic FeverContact Management

• Casual contacts - no known risk
• Close contacts
• Household, physical, nursing, or lab
• Record temp b.i.d. for 3 weeks post-exposure
• Consider prophylaxis (ribavirin) if temp gt101oF
  or other systemic symptoms within 3 weeks
• High-risk contacts
• Mucous membrane, penetrating injury with exposure
  to body fluids or tissue
• Consider post-exposure prophylaxis

58
Staphlococcal Enterotoxin B

• Latent period 3-12 hours
• Febrile respiratory syndrome without chest X-ray
  abnormalities
• Sudden onset fever, chills, headache, myalgia,
  nonproductive cough some patients with shortness
  of breath and chest pain
• High exposures cause shock and death
• Nausea, vomiting and diarrhea if toxin swallowed
• Clinical disgnosis - fever, dyspnea, normal chest
  X-ray
• Supportive care
• Standard precautions - toxin not dermally active,
  secondary aerosol not a hazard from patients

59
Ricin

• Latent period 4-8 hours
• Sudden onset fever, chest tightness, cough,
  dyspnea, nausea and arthralgias
• Followed by airway necrosis and pulmonary
  capillary leak in 18-24 hours and severe
  respiratory distress, hypoxemia and death in
  24-36 hours
• Supportive care
• Standard precautions - secondary aerosols not a
  hazard

60
Q-fever

• Coxiella burnetti
• Acute non-differentiated febrile illness with
  fever, fatigue, myalgias a minority with cough,
  pleuritic chest pain hepatitis
• Incubation period 2-14 days
• Diagnosis by serology
• Standard precautions
• Treatment - tetra/doxycycline

61
Brucellosis

• Fever, headache, myalgias, back pain, sweats,
  chills, malaise
• Osteoarticular infections - large joint or
  sacroiliac arthritis
• Pulmonary and GI symptoms
• Incubation period 5-50 days
• Diagnosis by culture - requires prolonged
  incubation
• Standard precautions
• Treatment - six weeks doxycycline rifampin

62
Glanders

• Pseudomonas mallei
• Fever, headache, rigors, myalgias, pleuritic
  chest pain, cervical adenopathy,
  hepatosplenomegaly, generalized papular/pustular
  rash
• Acute pulmonary disease can lead to bacteremia
  and sepsis
• Incubation period 10-14 days
• Diagnosis by culture, chest X-ray, serology
• Standard precautions, contact precautions for
  skin rash
• Treatment - prolonged antibiotic therapy

63
Recognition of BT EventSyndromic Approach

• Respiratory Syndrome
• Rash Syndrome
• Neurologic Syndrome
• Gastrointestinal (GI) Syndrome
• Non-specific, Undifferentiated Febrile Illness

64

Syndromic Surveillance forBioterrorism
65
Components
Syndromic Surveillance

• Aberration Detection Surveillance
• Collaboration with University of Washington
  School of Public Health and Community Medicine,
  Clinical Informatics Research Group
• Enhanced Surveillance Activities

66
Aberration Detection
Syndromic Surveillance Project

• Hospital Emergency Department Discharge data
• Primary Care Clinic Discharge Data
• Seattle Emergency Medical Services Calls (911)
• Medical Examiner (ME) - Unexplained Deaths

67
Hospital Emergency Department and Primary Care
Clinic Discharge Data
Syndromic Surveillance Project

• Data extracted from clinical discharge diagnosis
  databases at three hospitals and nine primary
  care clinics
• Transmitted electronically
• Analyzed using CDC aberration detection program

68
Syndromic Surveillance Project
69
Seattle Emergency Medical Services Calls (911)
Syndromic Surveillance Project

• The number and type of triage protocols are
  monitored during each 24 hour period
• Analyze using CDC Aberration Detection
  Software-CUSUM and Figure 1

70
Syndromic Surveillance Project
911 Triage Protocols

• Abdominal Pain Sick Unknown
• Breathing Problems Person Down
• Convulsions/Seizures Headache
• CVA/Stroke DOA
• Chest Discomfort Dizzy/Fainting

71
Syndromic Surveillance Project
72
Syndromic Surveillance Project
Medical Examiner (ME) Unexplained Death
Surveillance

• Data source daylog from the King County ME
• Definition Unexplained death in a previously
  healthy person aged 1-49 years with hallmarks of
  infectious disease
• Daylog is reviewed daily for deaths meeting the
  definition of unexplained death
• Data is analyzed using aberration detection
  system developed by Washington DOH which uses
  death certificate ICD-9 codes to define historic
  baseline

73
Enhanced Surveillance Activities
Syndromic Surveillance Project

• Number and type of calls from Hospital Based
  Consulting Nurse Hotlines
• Year-Round Influenza Surveillance

74
Active Surveillance for School Absenteeism During
Influenza Season
Syndromic Surveillance Project

• Ten schools participated
• Schools received weekly reminders to report when
  the absenteeism exceeded 10

75
Consulting Nurse Hotlines
Syndromic Surveillance Project

• Two Hospital Based Consulting Nurse Hotlines
  participate
• Total Calls and the proportion of calls for
  symptoms of influenza like illness (ILI) are
  monitored
• Flu
• Sore Throat
• Colds
• Cough
• Fever

76
Year Round Influenza Surveillance
Syndromic Surveillance Project

• King County Lab participates in CDCs National
  Respiratory and Enteric Virus Surveillance System
  
• 12 primary care providers submit specimens
  year-round from persons with ILI
• Providers receive periodic e-mail reminders to
  submit specimens from persons with ILI

77
Future Plans
Syndromic Surveillance Project

• Refine aberration detection system flag
  thresholds
• Determine epidemiologic response to flags
• Expand surveillance to include
• WA Poison Center
• GIS capability
• Additional emergency departments
• Additional primary care facilities
• 911 data from King County (outside Seattle)

78
Clinical Surveillance Sites Data Collection
Methods
Syndromic Surveillance Project

• Site-specific data extraction software
• Conversion to standardized representation
• Secure internet-based transmission to central
  data repository

79
Bioterrorism ResponsePublic Health Planning
Strategies

• Byron C. Byrne
• Bioterrorism Response Coordinator
• Public Health - Seattle King County

80
Bioterrorism ResponsePublic Healths Central
Role

• Statutory responsibility
• RCW 70.05.070 Duties of Local Health Officer
• (3) control and prevent the spread of any
  dangerous, contagious,oar infectious diseases
  that may occur within his or her jurisdiction.

81
Bioterrorism ResponsePublic Healths Central
Role

• Lead agency
• Local Comprehensive Emergency Management Plans
• ESF - 8
• Health, Medical and Mortuary Services

82
Bioterrorism ResponsePublic Healths Central
Role

• Public expectation
• If a bioterrorism event occurs in this country,
  it will unfold at the local level an local public
  health official will be accountable for
  appropriate public health response in their
  communities.
• Effective Elements of Bioterrorism Preparedness
  A Planning Primer for Local Public Health
  Agencies - NACCHO

83
Bioterrorism ResponsePublic Healths Central
Role

• Coordinate countywide preparedness and response
• Depends on collaboration with key community
  partners
• Detection and evaluation of biological event
• Requires robust surveillance, epidemiology, and
  disease investigation infrastructure

84
Bioterrorism ResponsePublic Healths Central
Role

• Facilitate medical management of expose persons
• Prophylaxis, treatment, and infections control
  advice/strategies
• Fatality Management
• Victims
• Death certificates

85
Bioterrorism ResponsePublic Healths Central
Role

• Provide information
• Public
• Media
• Government Officials

86
Bioterrorism Response Plan Considerations

• Purpose Orchestrate response
• Needs based
• Current resources/capabilities vs. desired
  resources/capabilities
• Based on valid assumptions
• Fire departments
• National Guard
• Federal agencies

87
Bioterrorism Response Plan Considerations

• Reflect roles and responsibilities of partners
• New partners
• First responders
• Morticians/ funeral home operators
• Local elected officials
• Local Emergency Management/EOCs
• Media

88
Bioterrorism Response Plan Considerations

• In writing
• Formalize
• Important information
• Review/ Revise
• Training
• Drill/ Exercise
• Crib Notes

89
Bioterrorism PreparednessPublic Health - Seattle
King County Experience

• Organize BERT team
• Surveillance
• Epidemiological investigation
• Response
• Research planning information
• See references

90
Bioterrorism PreparednessPublic Health - Seattle
King County Experience

• Determine audience, content and style BERT and
  adjunct members
• PH EOC Staff
• Other response agencies
• Ready Reference
• Phone lists, tables, charts, diagrams, spread
  sheets

91
Bioterrorism PreparednessPublic Health - Seattle
King County Experience

• Build on existing plans and documents
• Communicable Disease Section, Emergency Response
  Manual
• Public Health Emergency/Disaster Operations Plan

92
Bioterrorism PreparednessPublic Health - Seattle
King County Experience

• Develop a response concept

93
Syndromic Surveillance
Case reports from Hospital/Clinician
Smart Sentinel Observer
Public Health Seattle King County
Local Emergency Management Office
Local Law Enforcement
B.E.R.T
State Emergency Management Office
State Department of Health
FBI Field Office
CDC
FBI Headquarters
Non-routine communication Routine
communication
94
Public Health Response to A Biological Event

• BIOLOGICAL EVENT
• Smart Sentinel Observers
• Syndromic Surveillance
• Case Reports from hospital or clinician

TASK 1 Threat Assessment/Focused Investigation
TASK 2 Treatment Plan
TASK 3 Implement Initial Medical Treatment Plan
TASK 4 Ongoing Surveillance
TASK 5 Implement Ongoing Treatment Plan
TASK 6 Recovery/Restoration
95
TASK 1 THREAT ASSESSMENT/FOCUSED INVESTIGATION

• Public Health Bio Response team activated
• Agency notification
• Expanded surveillance
• Agent identification
• Means of transmission release point
• At-risk population location
• Terrorist implications
• Initial briefing communication

96
TASK 2 THREAT ASSESSMENT/FOCUSED INVESTIGATION

• Target population location
• Medical RX and/or prophylaxis
• Control measures

97
TASK 3 IMPLEMENT INITIAL MEDICAL TREATMENT PLAN

• Mass case/Mass prophylaxis
• Pharmaceuticals
• Equipment
• Facilities
• Staffing
• Supplies/Support
• Security
• Media Assurance

98
TASK 4 ONOING SURVEILLANCE

• Identify new cases
• Track total cases
• Revise estimate of potential exposed
• Characterize stage of outbreak

99
TASK 5 IMPLEMENT ONGOING TREATMENT PLAN

• Healthcare system resource utilization
• Complete post-exposure treatment of at risk
  patient
• 2nd wave patients
• Worried well
• Deaths

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TASK 6 RECOVERY/RESTORATION

• Community physical, mental and emotional needs
• Environment issues
• Public Healths operations return to pre-incident
  state

101
Bioterrorism PreparednessPublic Health - Seattle
King County Experience

• Drill
• Evaluate
• Revise
• Refine
• Recycle

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Bioterrorism Preparedness Planning Resources

• Documents
• Elements of Effective Bioterrorism
  Preparedness A Planning Primer for Local
  Health Agencies
• www.naccho.org
• Improving Local and State Agency Response To
  Terrorist Incidents Involving Biological
  Weapons
• SBBCOM

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Bioterrorism Preparedness Planning Resources

• Web sites
• CDC www.bt.cdc.org
• Johns Hopkins www.hopkins-biodefence .org
• Public Health www.metrokc.gov/health/bioterrorism

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Bioterrorism Preparedness Planning Resources

• Contacts
• Byron Byrne - PH-SKC [phone]
  byron.byrne_at_metrokc.gov
• Bill Edstrom - Spokane Regional PH [phone]
  WEdstrom _at_spokanecounty.org
• Julie Wicklund - DOH [phone]
• julie.wicklund _at_ doh.wa.gov