Bioterrorism Agents

1
Bioterrorism Agents PlagueLesson 6

• Public Health Management

2
Objectives

• Purposes of epidemiological investigations
• Case definitions
• Sentinel events indicating bioterrorism
• Public health response
• Natural Plague
• Bio-terrorist Plague
• Contact management and prophylaxis

3
Principal Purposes of Epidemiologic Investigations

• Characterize cases and confirm outbreak
• Identify
• Causative agent
• Source
• Mode of Transmission
• Identify
• Cases
• Case Contacts

4
Principal Purposes of Epidemiologic Investigations

• Person, place, time
• Risk factors
• Control and Prevention strategies
• Monitor and evaluate response

5
Plague Case DefinitionsSuspect and Probable

• Suspect Case
• Clinically compatible
• Clinical specimens features of Y. pestis
• Probable Case
• Clinically compatible
• Presumptive laboratory results
• Positive DFA
• PCR evidence of Y. pestis
• Single elevated serum antibody titer to F1 antigen

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Plague Case DefinitionsConfirmed

• Confirmed Case
• Confirmatory isolation of Y. pestis
• ?4-fold change in antibody titer to F1 antigen
• IHC staining can be considered when isolation or
  serology not possible

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Early Cases

• Lab confirmation important
• First cases in geographic area
• Treatment and isolation
• Post- or pre-exposure prophylaxis
• Other controls
• Call public health
• immediately

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Natural Disease vs Bioterrorism

• Announced, credible threat
• Observed threat event
• Detection
• Animal cases in unusual settings
• Human cases without link to endemic area

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Natural Disease vs BioterrorismNatural Plague

• Recent endemic exposure
• Handling of sick cat, flea bites in endemic area
• Recent travel to endemic area
• Sporadic, infrequent cases
• Bubonic most common
• presentation

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Natural Disease vs BioterrorismBioterrorist
Plague

• No known endemic exposure
• Point source in urban, crowded setting
• Severe respiratory illness
• Cluster of severe and fatal pneumonia
• Plague cases that dont respond to recommended
  antibiotic treatment

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Control and ContainmentInitial Stages

• Sampling of environment
• Definition of dispersion
• Confirmation of Y. pestis
• Deploy SNS
• Epidemiologic Investigation
• Animal control
• Communications

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Control and ContainmentInitial Stages

• Coordination of activities
• Active surveillance
• Assisted surveillance
• Clinician Information Requests
• Number of plague patients
• Number of plague rule-outs
• Chart review for unrecognized illness

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Chart Reviews

• ER discharges, admits, transfers
• Non-lab confirmed fevers, pneumonias
• Prioritize hospitalized patients
• Follow-up on those transferred out
• Critical for determining extent and source of
  outbreak

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Symptomatic Patient Evaluation

• Seek care febrile respiratory, other plague
  compatible syndromes
• Referral and triage hospitals
• Isolation and respiratory droplet precaution
• All fevers 38.5?C or higher or cough presumptive
  pneumonic plague

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Contact Management

• Contact Within 6-7 feet, or 2 meters, of
  patient in prior 7 days
• Evaluate contacts with fever or cough
• 7 days prophylaxis and symptom monitoring

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Contact ManagementProphylaxis Groups

• Exposed to Y. pestis release
• Household members of respiratory plague
• HCWs with direct patient contact
• First responders
• Patient transporters
• Co-workers, friends,
• others with close
• contact to
• symptomatic respiratory

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Contact ManagementAntibiotics and Monitoring

• Doxycycline is first choice
• Alternatives Tetracyclines, sulfonamides,
  chloramphenicol
• IND for gentamicin,
• ciprofloxacin
• Temperature twice daily
• Unrestricted unless fever or
• cough develops

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Contact Management

• Prophylaxis refusal monitor x 7 days
• Special populations management
• No vaccine with proven efficacy

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Other Management Issues

• Mass prophylaxis clinics
• Monitor news announcements
• Environmental sampling

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Environmental Assessment

• Goals of Assessment
• Infected animals
• Infectious fleas
• Contaminated surfaces, soils, water supplies
• Plague bacteria survive poorly externally
• Short-term risk for humans

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Environmental Testing

• Plague in animals, new regions
• Need for vector or rodent control
• Control and prevention measures
• Need for follow-up surveillance
• Effectiveness of
• control measures

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Review Questions PlagueLesson 6

• Public Health Management

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Plague Review QuestionLesson 6, Question 1

• Mass casualty situation
• Bioterrorist attack with plague
• Public health wants you to interview patients for
  movement in past week
• Why are they doing this to you now?

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Plague Review QuestionLesson 6, Question 1

• Why are they doing this to you now?
• Look like theyre doing something
• Determine source of exposure
• B and D
• Prophylaxis recommendation development

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Plague Review QuestionLesson 6, Question 1

• Why are they doing this to you now?
• B and D
• Determine source of exposure
• Prophylaxis recommendations

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Plague Review QuestionLesson 6, Question 2

• Youre on hospital emergency response team
• Categorizing plague cases at your hospital
• A confirmed case would NOT include

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Plague Review QuestionLesson 6, Question 2

• A confirmed case would NOT include
• Confirmed isolation of Y. pestis
• IHC staining of Y. pestis
• Stained organisms of Y. pestis
• Fourfold or greater increase in antibody titer to
  F1 antigen

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Plague Review QuestionLesson 6, Question 2

• A confirmed case would NOT include
• C. Stained organisms of Y. pestis

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Plague Review QuestionLesson 6, Question 3

• Youre a public health worker
• State epidemiologists asks you to determine if
  plague case is natural or bioterrorist
• Which would best describe naturally occurring
  plague?

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Plague Review QuestionLesson 6, Question 3

• Which would best describe naturally occurring
  plague?
• History of sporadic cases in area
• 1 patient only
• Patient has history of rodent exposure
• All of the above

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Plague Review QuestionLesson 6, Question 3

• Which would best describe naturally occurring
  plague?
• All of the above
• History of sporadic cases
• Only 1 case
• History of rodent exposure

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Plague Review QuestionLesson 6, Question 4

• Plague bioterror event
• Identifying close contacts
• Considering antibiotic prophylaxis
• Which of the following fall is not considered a
  close contact?

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Plague Review QuestionLesson 6, Question 4

• Which of the following fall is not considered a
  close contact?
• Friends in another city
• Patient transporters
• Household members of respiratory
• Co-workers within 6 feet

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Plague Review QuestionLesson 6, Question 4

• Which of the following fall is not considered a
  close contact?
• Friends in another city

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Review QuestionLesson 6, Question 5

• Plague bioterror event
• Large number of casualties
• Youre on local emergency response team
• What activity would you expect from response
  leaders?

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Plague Review QuestionLesson 6, Question 5

• What activity would you expect from response
  leaders?
• Quarantine entire city
• Drop individual investigations
• Symptomatic patients stay home
• Establishment of treatment centers

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Plague Review QuestionLesson 6, Question 5

• What activity would you expect from response
  leaders?
• D. Establishment of treatment centers

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BT Agents Home
6-21. Question
Plague Lesson 6- Public Health Issues
BT Agents

• The best answer is B. It is important that all
  close contacts to a pneumonic plague case receive
  prophylaxis.
• Correct. It is important that all close contacts
  to a pneumonic plague case receive prophylaxis.
• The best answer is B. Even naturally-occurring
  cases of plague should be laboratory confirmed.
  It is also important that all close contacts to a
  pneumonic plague case receive prophylaxis.

Module Plague
6) You work at a public health department in New
Mexico. Your local hospital has a positive test
in their lab for a single case of suspect
pneumonic plague. The patient has a documented
exposure to an ill animal. How will you manage
this patient?
Module Introduction- Module Objectives
Target Audience Continuing Education Credit
Lessons-1) General Overview 2) Clinical
Presentation 3) Differential Diagnosis 4)
Laboratory Issues 5) Medical Management 6) Public
Health Issues 7) Veterinarian Issues 8) Module
Self-Assessment Additional Resources
A. I wont do anything. The patient is being
treated.
B. Look for all close contacts to the patient and
begin on prophylaxis.
C. Stop the referral testing at the public health
lab. We know its plague because there was an
ill animal.
Plague Lesson 6- Public Health Issues
21 of _
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Plague Review QuestionLesson 6, Question 6

• You work in public health in New Mexico
• Local hospital with suspect plague
• Documented exposure to ill animal
• How will you manage this patient?

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Plague Review QuestionLesson 6, Question 6

• How will you manage this patient?
• Nothing. Patient is being treated.
• Manage all close contacts
• Stop referral testing. There was a sick animal.
  We know its plague.

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Plague Review QuestionLesson 6, Question 6

• How will you manage this patient?
• B. Manage all close contacts