Clinical View of a Bioterrorist Response: Recognizing and Responding to Bioterrorism and Other Publi

1
Clinical View of a Bioterrorist
ResponseRecognizing and Responding to
Bioterrorism and Other Public Health
EmergenciesBruce Dubin, DO, JD

• Texas Statewide Bioterrorism Continuing Education
• (Texas BCE) Project
• Developed by
• David Lakey, M.D., Medical Director
• Center for Pulmonary and Infectious Disease
  Control
• University of Texas Health Center at Tyler
• Funded by
• Health Resources and Service Administration

2
The World Has Changed
Anthrax October, 2001
September 11, 2001
SARS, April 2003
Is healthcare prepared?
3
Objectives

• Identify the CDCs Category A, B C agents, and
  the diseases caused by these agents.
• Describe the clinical presentation and treatment
  of Category A agents.
• Discuss chemical agents and treatment modalities
  for these threats.
• Describe decontamination methods, Personal
  Protection Equipment, and isolation precautions
  for biological and chemical threats.
• List Public Health and hospital roles
  responsibilities during a bioterrorist event.

4
Vector, Russia

• In the early 1990s
• A large and sophisticated bioweapons facility
• Housed smallpox, Ebola, Marburg, etc.
• 4,000-person workforce
• 30-building facility
• Ample biosafety level 4 laboratory facilities
• Secured with electric fences and an elite guard
• Autumn of 1997
• A half-empty facility
• Protected by a handful of unpaid guards
• No one could say where the scientists went

Henderson DA. Bioterrorism as a public health
threat. Emerg Infect Dis 19984(3)488-92
5
CDCs Category A Agents

• These are the highest priority agents that pose a
  risk to national security because they
• Can be easily disseminated or transmitted
• Cause high mortality
• Create a major public health impact
• Cause public panic and social disruption
• Require special public health preparedness

6
Category A Agents

• (1) Anthrax
• (2) Plague
• (3) Smallpox
• (4) Tularemia
• (5) Botulinum toxin
• (6) Viral Hemorrhagic Fevers (Ebola, Marburg)

7
Category A Agent

• ANTHRAX

8
Anthrax

• Bacillus anthracis
• A spore forming bacteria
• Infects sheep, goats, and cattle
• Woolsorters disease
• Incubation 2 - 60 days
• Three Forms of Clinical Disease
• a. Inhalational
• b. Cutaneous
• c. Gastrointestinal

9
Cutaneous Anthrax

• Deposition of spores on skin with previous cuts
  or abrasion
• Presentation
• Initially local edema/swelling
• Progresses to an itchy bump, then to a blister
• Finally a painless, depressed scab (eschar)
• Prognosis
• Untreated, mortality is 20
• Treated, mortality is 0

10
Inhalation Anthrax

• Presentation
• Initially non-specific flu-like symptoms
• ( Fever, fatigue, chest pain, muscle aches)
• Abrupt respiratory failure at day 2 to 4 days
• Widened mediastinum and/or pleural effusions on
  chest radiology

11
Gastrointestinal Anthrax

• Presentation
• Upper GI disease
• Oral or esophageal ulcer
• Regional enlargement
• of lymph nodes
• Edema
• Sepsis
• Lower GI Disease
• Nausea, vomiting
• Bloody diarrhea
• Acute abdomen

12
Anthrax Diagnosis

• Determine if exposed
• Cutaneous
• Diagnosed clinically
• Culture from beneath
• the eschar
• Inhalation
• Blood cultures
• Chest radiographs
• Not nasal swabs

13
Anthrax Working through the Diagnosis

• Respiratory viruses, such as influenza
• Influenza vaccination does not rule out influenza
  
• Influenza usually does not produce shortness of
  breath and vomiting
• Influenza often produces a sore throat or
  rhinorrhea.
• Rapid identification tests for influenza

• Widened mediastinum or pleural effusions
• Initially may be subtle or absent
• Not unique to anthrax (histoplasmosis,
  sarcoidosis, tuberculosis, and lymphoma)
• A chest computed tomography (CT) scan is helpful
  for anthrax (hemorrhagic mediastinal lymph nodes)

14
AnthraxProphylaxis for After Exposure

• First determine if exposure is real
• Treat for 60 days
• Doxycycline, ciprofloxacin or another antibiotic
  in its class, and amoxicillin are all effective

15
Anthrax Treatment

• Must treat for 60 days
• Cutaneous disease
• Ciprofloxacin, doxycycline or penicillin
• Inhalation
• Ciprofloxacin, Rifampin, and Clindamycin
• Intensive care
• Meningitis
• Ciprofloxacin and Vancomycin
• Steroids may be beneficial

16
Category A Agent

• PLAGUE

17
Plague

• Yersinia pestis
• 10 cases of naturally occurring plague in U.S.
  per year
• Usually lymph node or blood infection
• Pneumonic plague if used by bioterrorist

18
Plague
Bubonic Pneumonic
19
Plague Clinical Presentation

• Route of infection
• Flea bite ? Bubonic
• Inhalation ? Pneumonic
• Clinical Presentation
• Incubation 2 ? 3 days
• High fevers, chills, headache, coughing up blood,
  shortness of breath, toxic appearing
• Diagnosis
• Staining of sputum (safety pin Gram negative rod)
• Cultures

20
Pneumonic Plague

• Isolation
• Droplet
• Treatment
• Antibiotics (gentamicin, doxycycline, or
  ciprofloxacin)
• Post exposure prophylaxis
• Antibiotics for 7 days

21
Category A Agent

• SMALLPOX

22
Smallpox

• One of the deadliest
• diseases known to
• man
• - Mortality rate 30
• U.S. stopped
• vaccinating in 1972
• Declared eradicated by
• World Health Organization
• in 1979
• A Soviet biological weapons expert and defector
  claimed that the Soviets manufactured 20 tons of
  smallpox

23
Smallpox Clinical Presentation

• Incubation period
• 7 ? 17 days
• Presentation
• Prodrome malaise, fever, chills, vomiting,
  backache
• Day 2?3 red painful rash on the face, arms,
  hands
• Day 8?10 rash progresses to pustules, then scabs

24
Smallpox
25
HistorySmallpox Chickenpox

• Recent contact with smallpox
• Vaccination history
• Prodromal phase of 2-4 days with fever, headache,
  backache, muscle pain, and sometimes pallor

• Recent contact with chickenpox
• Vaccination history
• Prodromal phase of 0-2 days, and much less severe

26
Physical Exam Smallpox Chickenpox

• Centrifugal distribution
• Peaks at 7 to 10 days
• Lesions in same stage of evolution
• 4-6 mm diameter
• Round shape
• Desquamation in 14-21 days
• Lesions on palms and soles

• Central distribution
• Peaks at 3-5 days
• Lesions in different stages of evolution
• 2-4 mm diameter
• Oval shape
• Desquamation in 6-14 days
• Uncommon to have lesions on palms and sole

27
Smallpox Chickenpox
28
The main diagnostic tool for Smallpox is the
history and exam!
29
Smallpox

• Treatment
• Supportive
• ?Cidofovir
• Vaccination
• Prophylaxis
• Vaccination within 4 days (live virus)
• Isolation
• Droplet and airborne for 17 days post exposure

30
Category A Agent

• TULAREMIA

31
Category A Agent

• TOXINS

32
Toxins

• Poisonous chemical compounds from plants,
  animals, or bacteria
• Likely to be delivered by aerosol
• Not contagious
• Toxin acquired by direct contact, ingestion or
  inhalation
• Examples
• - Botulism
• - Ricin (Category B Agent)

33
Botulinum Toxin

• Produced by the Clostridium botulinum
• Protein neurotoxin
• Route of exposure Inhalation or ingestion
• Presentation
• 24 to 36 hours after inhalation
• Afebrile
• Generalized weakness, dizziness, dry mouth,
  blurred vision, double vision, slurred speech,
  difficulty swallowing, descending paralysis, and
  respiratory failure
• Paralysis of facial muscles, and then
• respiratory muscles

34
Botulism Diagnosis

• Clinical diagnosis based on presentation
• Confirmatory diagnosis
• Toxin assay of blood may not be positive after
  inhalation of toxin
• Stool can also be assayed after ingestion of toxin

35
Botulism Treatment

• Supportive care
• Ventilator support for respiratory failure
• Antitoxin
• - Available through state health department
• - Prevents further damage
• - Does not alter current damage

36
Botulism

• Prophylaxis
• No proven prophylaxis at this time
• Investigational Vaccine
• Isolation
• Standard precautions
• Need to contact hospital epidemiologist and
  public health authority immediately

37
Category A Agent

• VIRAL HEMORRHAGIC FEVER

38
Viral Hemorrhagic Fever

• Ebola, Marburg, Lassa fever, Dengue fever,etc
• Naturally occurring disease
• - Produces microvascular damage
• - Transmitted to humans by infected animals or
• arthropod vectors
• - Sporadic outbreaks in Africa, parts of Asia,
• and Europe
• - Case fatality rates
• ? Omsk hemorrhagic fever 0.5
• ? Ebola 90
• VHF viruses as bioterrorism agents
• - Weaponized by several countries
• - Aerosolization

39
Viral Hemorrhagic FeversClinical Features

• Incubation 2 - 21days
• Depends on virus
• Initial Presentation
• Nonspecific prodrome (fever, myalgias, headache,
  abdominal pain, prostration)
• Exam may show only flushing of face and chest,
  conjunctival injection, and petechiae
• Disease progresses to shock and generalized
  mucous membrane hemorrhage

40
Bolivian Hemorrhagic Fever
Marburg Disease
41
Viral Hemorrhagic Fever

• Diagnosis
• Clinical presentation
• High level index of suspicion
• Definitive diagnosis requires testing done at CDC
• Do not wait to confirm the diagnosis before
  notifying the public health authorities

42
Viral Hemorrhagic Fever

• Treatment
• Supportive care
• Ribavirin may be useful
• Prophylaxis none
• Isolation EXTREMELY CONTAGIOUS
• Liquid impervious protective coverings (including
  leg and shoe coverings)
• Double gloves
• N-95 or better respirators
• Face shields or goggles
• Negative pressure room if possible

43
CDCS CATEGORY B AGENTS
44
CDCs Category B Agents

• The second highest priority agents
• Moderately easy to disseminate
• Result in moderate morbidity rates and low
• mortality rates
• Require specific diagnostic capacity and
• disease surveillance

45
CDCs Category B AgentsSome Examples

• 1. Food safety threats
• Water safety threats
• Ricin
• Staphylococcal enterotoxin B
• Viral encephalitis

46
Ricin

• Protein extracted from
• castor beans
• Route of exposure
• Injection, inhalation or
• ingestion
• Presentation
• Inhalation Fever,
• cough, chest pain, shortness of breath, pulmonary
  edema, death
• Ingestion nausea, vomiting, diarrhea,
• gastrointestinal hemorrhage, death

47
CDCs Category C Agents

• The third highest priority agents
• - Readily available
• - Easy to produce and disseminate
• - Potential for high morbidity and mortality
• - Major health impact

48
CDCs Category C AgentsSome Examples

• Emerging infectious disease threats such as
• Nipah virus
• Hantavirus

49
Universal Respiratory Etiquette Strategy for
Healthcare Facilities

• Give surgical masks or other cough barriers to
  respiratory patients
• Provide hand hygiene materials, tissues, and
  no-touch receptacles for respiratory patients in
  waiting areas
• Encourage coughing patients to sit 3 feet away
  from others in common waiting area
• Have staff use masks when caring for febrile
  respiratory patients and use droplet precautions
• Construct barriers or space to separate intake
  staff from patients

www.cdc.gov/ncidod/sars/guidance
50
How can I remember all these diseases?(S-A-F-E-T-
Y)

• S Skin rash with fever
• Smallpox
• A Acute pulmonary syndrome with fever
• Anthrax and plague
• F Flu like syndrome with fever
• Tularemia and SARS
• E Excessive bleeding
• Viral hemorrhagic fevers
• T Toxin effect without fever
• Botulism
• Y Your personal safety and the safety of your
• community depend on recognition and awareness

51
CHEMICAL AGENTS
52
Historical Perspective

• Aum Shinrikyo
• Sarin Gas Release
• June 27, 1994 March 20, 1995
• Matsumoto, Japan Tokyo, Japan
• Courthouse/Residence Subway
• 4 dead 12 dead
• 150 injured gt5000 arrived at hospital

53
Types of Chemical Agents
54
Identification ofCHOKING (Pulmonary)Chemical
Agents

• Phosgene
• Odor Freshly mown grass
• Symptoms Coughing, choking, vomiting

• Chlorine
• Odor Swimming pool
• Symptoms Coughing, choking, vomiting

Treatment symptomatic
55
Identification of BLISTER (Vesicant) Chemical
Agents
Mustard Lewisite Odor Garlic
Geraniums Symptom Onset Delayed Immediate Symp
toms Tearing, eye itching, runny nose, cough,
blisters
Treatment wound care
56
Identification ofBLOOD Chemical Agents

• Cyanide Gas
• Odor Bitter almonds
• Symptom Onset Rapid
• Symptoms Normal skin color, gasping for air
• Treatment Cyanide Antidote Kit

57
Identification ofNERVE Chemical Agents

• Tabun, Sarin, Soman, VX
• Odor Tabun Sarin none or fruity
• Soman none
• VX none/sulfur
• Symptom Onset Rapid
• Symptoms Pinpoint pupils, salivation, runny
  nose, shortness of breath, chest tightness,
  nausea, muscle twitching, seizures, coma, death
• Treatment Atropine and 2-PAM (Pralidoxime)

58
Industrial Accident as Source of Chemical Related
Disaster

• Occurred numerous times in the past
• March 2000, Pasadena, TX
• Oct. 1989, Pasadena, TX
• April 1947, Texas City, TX
• Hazardous materials release
• Toxic fumes
• Radiation
• Biological agents
• Secondary disasters

59
DECONTAMINATION
60
Decontamination

• The removal or deactivation of the agent
• May involve persons, objects, buildings, or the
  environment
• Helps to prevent further exposures and injury

61
Decontaminationfor Biological Agents

• Not needed for all biological agents
• If anthrax is suspected agent, persons exposed
  should use soap and water
• Contaminated objects or buildings should be
  decontaminated by appropriate personnel

62
Decontaminationfor Chemical Agents

• Will require decontamination
• For a vapor or gas, may only need to leave the
  area
• Remove all contaminated clothing as quickly as
  possible, then decontaminate skin
• Appropriate personnel will perform
  decontamination of facilities and environment

63
PERSONAL PROTECTION EQUIPMENT(PPE)
64
Personal Protection Equipment

• Selection based on route of exposure and control
• If inhalation, then respirators and ventilation
  systems
• If skin contact, then
• Barriers
• Appropriate handling techniques
• Protect breaks in skin
• Proper hygienic practices
• No single combination protects against all
  hazards
• Certain PPE can produce significant worker
  hazards by impairing heat dissipation, vision,
  mobility, and communication

65
PPE Selection

• Selection is based on
• What was the agent?
• How was it released?
• Is it a confined space?
• Proximity to release site (Hot/Warm zone)
• Job duties during the event

• Respirators
• For biologicals in the
• form of aerosols
• N, R, P
• Not resistant to oil,
• Resistant to oil
• oil Proof
• 95, 99 and 100
• Designations depending on the filtration
  efficiency
• Fit testing required for all respirators N95 or
  greater

66
What is the Hot Zonein the Field ?

• The area immediately adjacent to the location of
  the incident.
• Minimal triage and limited medical care
  activities take place.
• All staff are in protective gear in this area.

67
What is the Warm Zonein the Field ?

• A distance of at least 300 feet from the outer
  perimeter of the Hot Zone.
• Upwind and uphill from the contaminated area.

68
Respirators
Self Contained Breathing Apparatus
Supplied Air Respirator
Powered Air Purifying Respirator
Air Purifying Respirator
69
When are my gown, gloves, mask and hat
insufficient to protect me?

• 1. Before decontamination of a patient that has
  been contaminated by an unknown substance
• 2. When you are the site of release

70
Public Health HospitalResponsibilities
71
Roles and Responsibilities PRE-EVENTPublic
Health Emergency

• Public Health
• Disease surveillance
• Respond to outbreaks
• Investigation
• Control and prevention
• Laboratory support
• Participate in planning activities
• Training

• Hospitals/ HCW
• Diseases reporting
• Immediately notify public health of unusual group
  expressions of illness or outbreaks
• State laboratory utilization
• Participate in planning activities
• Exercise plans
• Training

72
Roles and Responsibilities DURING a Public
Health Emergency

• Hospitals/ HCW
• Implement notification
• Activate staff
• Implement response plans/guidelines
• Coordinate efforts with public health
• Provide care
• Coordinate health related information
• Public health
• Public
• Media

• Public Health
• Implement notification
• Activate/deploy staff
• Implement response
• plans/guidelines
• Provide treatment and
• control recommendations
• Conduct investigations
• Implement control measures
• Mass vaccination/prophylaxis
• Provide/coordinate health related information
• Healthcare workers
• Public
• Media

73
Roles and Responsibilities POST-EVENT Public
Health Emergency

• Public Health
• Evaluate response
• Review after-action reports
• Coordinate/implement changes to plans and
  procedures
• Implement recovery plans

• Hospitals/ HCWs
• Evaluate response
• Review after-action reports
• Coordinate/implement changes to plans and
  procedures
• Implement recovery plans

74
Know What to Report

• Be familiar with reporting laws
• Diseases/conditions
• Time frames
• Watch for and report
• All unusual group expressions of illness
• Exotic illnesses
• Illness in non-endemic area
• Seasonal disease during wrong time of year
• Pathogen with unusual antimicrobial resistance
  pattern
• Pathogen with other unusual epidemiologic
  features
• Unusual clinical presentation or age distribution
• Animal die off

75
Notification of Public Health System
REPORTER Hospital Laboratory Physician Others
HEALTH DEPARTMENT Local Regional
FEDERAL CDC
STATE

• Report to your most local resource first
• Report in a timely manner
• Report all the needed information
• Clinical
• Demographic
• Laboratory

76
Bioterrorism Training
77
Summary

• The world has changed
• Healthcare workers must be able to recognize
  biological, chemical and other public health
  emergencies
• Healthcare workers must be able to protect
  themselves and their co-workers during a public
  health emergency
• Health care workers need to learn how to properly
  work and support the public health system
• Additional training is available in Texas through
  the Texas Statewide Bioterrorism Continuing
  Education program

78
For Further Information

• BDLS and CDLS/ Texas BCE Contacts per Region
• UT Health Center Tyler (UTHCT)
• Debbie Slaven 903-877-5087
• University of Texas Medical Branch (UTMB)
• Retha Rambin 409-772-4818
• UT Southwestern Medical (UTSW)
• Hal Coggins 214-589-0916
• UT Health Science Center San Antonio (UTHSC-SA)
• Pat Pratt 210-567-7111
• UT Health Science Center Houston (UTHSC-H)
• Bob Joyce 713-500-9427
• Texas Department of Health
• http//www.tdh.state.tx.us/bioterrorism
• Infectious Disease Society of America
• http//www.idsociety.org
• Centers for Disease Control and Prevention
• http//www.bt.cdc.gov

79
Thank you

• This program was developed by faculty of the
  University of Texas Health Center at Tyler in
  conjunction with the University of Texas Medical
  Branch at Galveston as part of the HRSA funded
  Texas Bioterrorism Continuing Education Program
  (Texas BCE).