Northwest Center for Public Health Practice University of Washington School of Public Health and Community Medicine 1 Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce

UW Northwest Center for Public Health Practice 2 AcknowledgementsAcknowledgements This presentation, and the accompanying instructor’s manual, were prepared by Jennifer Brennan Braden, MD, MPH, at the Northwest Center for Public Health Practice in Seattle, WA, for the purpose of educating public health employees in the general aspects of bioterrorism preparedness and response. Instructors are encouraged to freely use all or portions of the material for its intended purpose. The following people and organizations provided information and/or support in the development of this curriculum. A complete list of resources can be found in the accompanying instructor’s guide. Patrick O’Carroll, MD, MPH Project Coordinator Centers for Disease Control and Prevention Judith Yarrow Design and Editing Health Policy and Analysis; University of WA Washington State Department of Health Jeff Duchin, MD Jane Koehler, DVM, MPH Communicable Disease Control, Epidemiology and Immunization Section Public Health - Seattle and King County Ed Walker, MD; University of WA Department of Psychiatry

UW Northwest Center for Public Health Practice 3 Diseases of Bioterrorist Potential: Overview CDC, AFIP

UW Northwest Center for Public Health Practice 4 Diseases of Bioterrorist Potential Learning Objectives Develop an awareness of the potential agents that might be used in a bioterrorism event Develop an awareness of the potential agents that might be used in a bioterrorism event Identify contagious agents Identify contagious agents Describe the types of illness caused by the agents Describe the types of illness caused by the agents Identify agents that might require public health to provide immunizations or antibiotics to exposed persons Identify agents that might require public health to provide immunizations or antibiotics to exposed persons Describe how to respond if a suspicious package or substance is received Describe how to respond if a suspicious package or substance is received Develop an awareness of the potential agents that might be used in a bioterrorism event Develop an awareness of the potential agents that might be used in a bioterrorism event Identify contagious agents Identify contagious agents Describe the types of illness caused by the agents Describe the types of illness caused by the agents Identify agents that might require public health to provide immunizations or antibiotics to exposed persons Identify agents that might require public health to provide immunizations or antibiotics to exposed persons Describe how to respond if a suspicious package or substance is received Describe how to respond if a suspicious package or substance is received

Biological Agents of Highest Concern Category A Agents Smallpox (Variola major) Smallpox (Variola major) Anthrax (Bacillus anthracis) Anthrax (Bacillus anthracis) Plague (Yersinia pestis) Plague (Yersinia pestis) Tularemia (Francisella tularensis) Tularemia (Francisella tularensis) Botulism (Botulinum toxin) Botulism (Botulinum toxin) Viral hemorrhagic fevers (Filoviruses & Arenaviruses) Viral hemorrhagic fevers (Filoviruses & Arenaviruses) Smallpox (Variola major) Smallpox (Variola major) Anthrax (Bacillus anthracis) Anthrax (Bacillus anthracis) Plague (Yersinia pestis) Plague (Yersinia pestis) Tularemia (Francisella tularensis) Tularemia (Francisella tularensis) Botulism (Botulinum toxin) Botulism (Botulinum toxin) Viral hemorrhagic fevers (Filoviruses & Arenaviruses) Viral hemorrhagic fevers (Filoviruses & Arenaviruses) 5

Biological Agents of 2nd Highest Concern Category B Agents Q-fever (Coxiella burnetti) Q-fever (Coxiella burnetti) Brucellosis (Brucella species) Brucellosis (Brucella species) Glanders (Burkholderia mallei) Glanders (Burkholderia mallei) Venezuelan, Western and Eastern encephalomyelitis (Alphaviruses) Venezuelan, Western and Eastern encephalomyelitis (Alphaviruses) Ricin toxin from Ricinus communis (castor bean) Ricin toxin from Ricinus communis (castor bean) Epsilon toxin from Clostridium perfringens Epsilon toxin from Clostridium perfringens Staphlococcus enterotoxin B Staphlococcus enterotoxin B Q-fever (Coxiella burnetti) Q-fever (Coxiella burnetti) Brucellosis (Brucella species) Brucellosis (Brucella species) Glanders (Burkholderia mallei) Glanders (Burkholderia mallei) Venezuelan, Western and Eastern encephalomyelitis (Alphaviruses) Venezuelan, Western and Eastern encephalomyelitis (Alphaviruses) Ricin toxin from Ricinus communis (castor bean) Ricin toxin from Ricinus communis (castor bean) Epsilon toxin from Clostridium perfringens Epsilon toxin from Clostridium perfringens Staphlococcus enterotoxin B Staphlococcus enterotoxin B 6

Biological Agents of 2nd Highest Concern Food- or Waterborne Category B Agents Salmonella species Salmonella species Shigella dysenteriae Shigella dysenteriae Escherichia coli 0157:H7 Escherichia coli 0157:H7 Vibrio cholera Vibrio cholera Cryptosporidium parvum Cryptosporidium parvum Salmonella species Salmonella species Shigella dysenteriae Shigella dysenteriae Escherichia coli 0157:H7 Escherichia coli 0157:H7 Vibrio cholera Vibrio cholera Cryptosporidium parvum Cryptosporidium parvum 7

UW Northwest Center for Public Health Practice 8 Types of Illnesses These Agents Can Cause “Flu-like” illness (fever, sweats, nausea) “Flu-like” illness (fever, sweats, nausea) Cough and/or pneumonia Cough and/or pneumonia Skin ulcers (anthrax, tularemia, plague) Skin ulcers (anthrax, tularemia, plague) Rashes (smallpox, ebola) Rashes (smallpox, ebola) Paralysis (botulism) Paralysis (botulism) Diarrhea & vomiting ( food- and water-borne agents) Diarrhea & vomiting ( food- and water-borne agents) Headache, confusion Headache, confusion “Flu-like” illness (fever, sweats, nausea) “Flu-like” illness (fever, sweats, nausea) Cough and/or pneumonia Cough and/or pneumonia Skin ulcers (anthrax, tularemia, plague) Skin ulcers (anthrax, tularemia, plague) Rashes (smallpox, ebola) Rashes (smallpox, ebola) Paralysis (botulism) Paralysis (botulism) Diarrhea & vomiting ( food- and water-borne agents) Diarrhea & vomiting ( food- and water-borne agents) Headache, confusion Headache, confusion

UW Northwest Center for Public Health Practice 9 Contagious Agents (Person-to-Person Transmission) Smallpox Smallpox Plague pneumonia Plague pneumonia Some viral hemorrhagic fevers (e.g., ebola) Some viral hemorrhagic fevers (e.g., ebola) Food- and water-borne agents (e.g., salmonella & shigella) Food- and water-borne agents (e.g., salmonella & shigella) Smallpox Smallpox Plague pneumonia Plague pneumonia Some viral hemorrhagic fevers (e.g., ebola) Some viral hemorrhagic fevers (e.g., ebola) Food- and water-borne agents (e.g., salmonella & shigella) Food- and water-borne agents (e.g., salmonella & shigella)

UW Northwest Center for Public Health Practice 10 Agents That May Require Antibiotics or Immunization to Prevent Disease Antibiotics Antibiotics Anthrax Anthrax Plague Plague Tularemia Tularemia Q Fever Q Fever Brucellosis Brucellosis Antibiotics Antibiotics Anthrax Anthrax Plague Plague Tularemia Tularemia Q Fever Q Fever Brucellosis Brucellosis Immunization Immunization Smallpox Smallpox Anthrax Anthrax

UW Northwest Center for Public Health Practice 11 Decontamination: Category A Critical Agents Decontamination of exposed persons Decontamination of exposed persons Showering or washing thoroughly with soap and water adequate for most; bleach not necessary Showering or washing thoroughly with soap and water adequate for most; bleach not necessary Decontamination of facilities and equipment Decontamination of facilities and equipment May not be necessary for surfaces contaminated by agents with short survival time (i.e., plague, botulism) May not be necessary for surfaces contaminated by agents with short survival time (i.e., plague, botulism) Other agents may require bleach solution, sporicidal chemicals, incineration, and/or autoclaving Other agents may require bleach solution, sporicidal chemicals, incineration, and/or autoclaving Decontamination of exposed persons Decontamination of exposed persons Showering or washing thoroughly with soap and water adequate for most; bleach not necessary Showering or washing thoroughly with soap and water adequate for most; bleach not necessary Decontamination of facilities and equipment Decontamination of facilities and equipment May not be necessary for surfaces contaminated by agents with short survival time (i.e., plague, botulism) May not be necessary for surfaces contaminated by agents with short survival time (i.e., plague, botulism) Other agents may require bleach solution, sporicidal chemicals, incineration, and/or autoclaving Other agents may require bleach solution, sporicidal chemicals, incineration, and/or autoclaving

UW Northwest Center for Public Health Practice 12 Infection Control: Category A Critical Agents Infection control Infection control Standard precautions – all cases Standard precautions – all cases Airborne & contact precautions – smallpox and viral hemorrhagic fevers Airborne & contact precautions – smallpox and viral hemorrhagic fevers Droplet precautions – pneumonic plague Droplet precautions – pneumonic plague Infection control Infection control Standard precautions – all cases Standard precautions – all cases Airborne & contact precautions – smallpox and viral hemorrhagic fevers Airborne & contact precautions – smallpox and viral hemorrhagic fevers Droplet precautions – pneumonic plague Droplet precautions – pneumonic plague

UW Northwest Center for Public Health Practice 13 Infection Control Standard Precautions Standard Precautions – all cases Standard Precautions – all cases Disposable, non-sterile gloves Disposable, non-sterile gloves Hand washing after glove removal Hand washing after glove removal Disposable gown or apron, faceshield if splashing anticipated Disposable gown or apron, faceshield if splashing anticipated Change protective gear between cases Change protective gear between cases Standard Precautions – all cases Standard Precautions – all cases Disposable, non-sterile gloves Disposable, non-sterile gloves Hand washing after glove removal Hand washing after glove removal Disposable gown or apron, faceshield if splashing anticipated Disposable gown or apron, faceshield if splashing anticipated Change protective gear between cases Change protective gear between cases

UW Northwest Center for Public Health Practice 14 Infection Control Contact Precautions Standard precautions plus: Standard precautions plus: Wear gloves and gown, change after contact with infectious material Wear gloves and gown, change after contact with infectious material Dedicate non-critical patient care items (e.g., stethoscope) to a single patient or disinfect between patients Dedicate non-critical patient care items (e.g., stethoscope) to a single patient or disinfect between patients Standard precautions plus: Standard precautions plus: Wear gloves and gown, change after contact with infectious material Wear gloves and gown, change after contact with infectious material Dedicate non-critical patient care items (e.g., stethoscope) to a single patient or disinfect between patients Dedicate non-critical patient care items (e.g., stethoscope) to a single patient or disinfect between patients

UW Northwest Center for Public Health Practice 15 Infection Control Droplet and Airborne Precautions Droplet Precautions Droplet Precautions Standard Precautions plus: Standard Precautions plus: Wear mask when w/in 6 ft of patient Wear mask when w/in 6 ft of patient Droplet Precautions Droplet Precautions Standard Precautions plus: Standard Precautions plus: Wear mask when w/in 6 ft of patient Wear mask when w/in 6 ft of patient Airborne Precautions Airborne Precautions Standard Precautions plus: Standard Precautions plus: Patient in negative air pressure room Patient in negative air pressure room Wear respiratory protection (such as a HEPA filter mask) Wear respiratory protection (such as a HEPA filter mask)

UW Northwest Center for Public Health Practice 16 Mail Safety Recognizing Suspicious Packages Excessive postage Excessive postage Handwritten or poorly typed addresses Handwritten or poorly typed addresses Incorrect titles Incorrect titles Title, but no name Title, but no name Misspellings of common words Misspellings of common words Oily stains, discolorations, or odor Oily stains, discolorations, or odor No return address No return address Excessive weight Excessive weight Lopsided or uneven envelope Lopsided or uneven envelope Excessive postage Excessive postage Handwritten or poorly typed addresses Handwritten or poorly typed addresses Incorrect titles Incorrect titles Title, but no name Title, but no name Misspellings of common words Misspellings of common words Oily stains, discolorations, or odor Oily stains, discolorations, or odor No return address No return address Excessive weight Excessive weight Lopsided or uneven envelope Lopsided or uneven envelope Protruding wires or aluminum foil Protruding wires or aluminum foil Excessive security material such as masking tape, string, etc. Excessive security material such as masking tape, string, etc. Visual distractions Visual distractions Ticking sound Ticking sound Marked with restrictive endorsements ("Personal“,"Confidential“) Marked with restrictive endorsements ("Personal“,"Confidential“) City or state in the postmark does not match the return address City or state in the postmark does not match the return address

UW Northwest Center for Public Health Practice 17 Mail Safety Handling Suspicious Packages or Letters with a Threatening Message Do not shake or empty contents Do not shake or empty contents PLACE the envelope or package in a plastic bag or other type of container to prevent leakage of contents PLACE the envelope or package in a plastic bag or other type of container to prevent leakage of contents LEAVE the room and CLOSE the door or section off the area to prevent others from entering LEAVE the room and CLOSE the door or section off the area to prevent others from entering WASH your hands with soap and water WASH your hands with soap and water Contact local law enforcement Contact local law enforcement Do not shake or empty contents Do not shake or empty contents PLACE the envelope or package in a plastic bag or other type of container to prevent leakage of contents PLACE the envelope or package in a plastic bag or other type of container to prevent leakage of contents LEAVE the room and CLOSE the door or section off the area to prevent others from entering LEAVE the room and CLOSE the door or section off the area to prevent others from entering WASH your hands with soap and water WASH your hands with soap and water Contact local law enforcement Contact local law enforcement

UW Northwest Center for Public Health Practice 18 Hoaxes and Evaluation of Suspicious Powders If a suspicious substance is received If a suspicious substance is received Cover substance (do not try to clean up any spilled contents) Cover substance (do not try to clean up any spilled contents) Leave the room and close the door Leave the room and close the door Turn off air conditioning system Turn off air conditioning system Wash hands with soap & water Wash hands with soap & water Report to local law enforcement (call 911) Report to local law enforcement (call 911) Notify building security Notify building security If a suspicious substance is received If a suspicious substance is received Cover substance (do not try to clean up any spilled contents) Cover substance (do not try to clean up any spilled contents) Leave the room and close the door Leave the room and close the door Turn off air conditioning system Turn off air conditioning system Wash hands with soap & water Wash hands with soap & water Report to local law enforcement (call 911) Report to local law enforcement (call 911) Notify building security Notify building security

UW Northwest Center for Public Health Practice 19 Hoaxes and Evaluation of Suspicious Powders, cont. Additional steps to take if exposed to a suspicious powder or substance Additional steps to take if exposed to a suspicious powder or substance Remove contaminated clothing & place in plastic bag or other sealed container Remove contaminated clothing & place in plastic bag or other sealed container Shower with soap & water (bleach is not necessary) Shower with soap & water (bleach is not necessary) Make a list of all people exposed or in the same room/area as the substance Make a list of all people exposed or in the same room/area as the substance Additional steps to take if exposed to a suspicious powder or substance Additional steps to take if exposed to a suspicious powder or substance Remove contaminated clothing & place in plastic bag or other sealed container Remove contaminated clothing & place in plastic bag or other sealed container Shower with soap & water (bleach is not necessary) Shower with soap & water (bleach is not necessary) Make a list of all people exposed or in the same room/area as the substance Make a list of all people exposed or in the same room/area as the substance

UW Northwest Center for Public Health Practice 20 Summary of Key Points Most of the biological agents of concern produce an initial non-specific or “flu-like” illness. Most of the biological agents of concern produce an initial non-specific or “flu-like” illness. Standard precautions should be used with all patients following a bioterrorism incident. Standard precautions should be used with all patients following a bioterrorism incident. Additional precautions are required with a few biological agents, where person-to-person transmission is possible. Additional precautions are required with a few biological agents, where person-to-person transmission is possible. Most of the biological agents of concern produce an initial non-specific or “flu-like” illness. Most of the biological agents of concern produce an initial non-specific or “flu-like” illness. Standard precautions should be used with all patients following a bioterrorism incident. Standard precautions should be used with all patients following a bioterrorism incident. Additional precautions are required with a few biological agents, where person-to-person transmission is possible. Additional precautions are required with a few biological agents, where person-to-person transmission is possible.

UW Northwest Center for Public Health Practice 21 Summary of Key Points Notify building security and local law enforcement if a suspicious package or substance is received. Notify building security and local law enforcement if a suspicious package or substance is received. If exposed to a suspicious substance, remove contaminated clothing, and wash with soap and water. If exposed to a suspicious substance, remove contaminated clothing, and wash with soap and water. Notify building security and local law enforcement if a suspicious package or substance is received. Notify building security and local law enforcement if a suspicious package or substance is received. If exposed to a suspicious substance, remove contaminated clothing, and wash with soap and water. If exposed to a suspicious substance, remove contaminated clothing, and wash with soap and water.

UW Northwest Center for Public Health Practice 22 ResourcesResources Centers for Disease Control & Prevention Centers for Disease Control & Prevention Bioterrorism Web page: Bioterrorism Web page: CDC Office of Health and Safety Information System (personal protective equipment) CDC Office of Health and Safety Information System (personal protective equipment) USAMRIID -- includes link to on-line version of Medical Management of Biological Casualties Handbook USAMRIID -- includes link to on-line version of Medical Management of Biological Casualties Handbook Johns Hopkins Center for Civilian Biodefense Studies Johns Hopkins Center for Civilian Biodefense Studies Centers for Disease Control & Prevention Centers for Disease Control & Prevention Bioterrorism Web page: Bioterrorism Web page: CDC Office of Health and Safety Information System (personal protective equipment) CDC Office of Health and Safety Information System (personal protective equipment) USAMRIID -- includes link to on-line version of Medical Management of Biological Casualties Handbook USAMRIID -- includes link to on-line version of Medical Management of Biological Casualties Handbook Johns Hopkins Center for Civilian Biodefense Studies Johns Hopkins Center for Civilian Biodefense Studies

UW Northwest Center for Public Health Practice 23 ResourcesResources Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information St. Louis University Center for the Study of Bioterrorism and Emerging Infections St. Louis University Center for the Study of Bioterrorism and Emerging Infections Public Health - Seattle & King County Public Health - Seattle & King County Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information St. Louis University Center for the Study of Bioterrorism and Emerging Infections St. Louis University Center for the Study of Bioterrorism and Emerging Infections Public Health - Seattle & King County Public Health - Seattle & King County

UW Northwest Center for Public Health Practice 24 ResourcesResources Washington State Department of Health Washington State Department of Health Communicable Disease Epidemiology Communicable Disease Epidemiology (206) OR (206) OR (877) (24 hour emergency) (877) (24 hour emergency) Association for Professionals in Infection Control Association for Professionals in Infection Control MMWR Rec & Rep. Case definitions under public health surveillance. MMWR Rec & Rep. Case definitions under public health surveillance. Washington State Department of Health Washington State Department of Health Communicable Disease Epidemiology Communicable Disease Epidemiology (206) OR (206) OR (877) (24 hour emergency) (877) (24 hour emergency) Association for Professionals in Infection Control Association for Professionals in Infection Control MMWR Rec & Rep. Case definitions under public health surveillance. MMWR Rec & Rep. Case definitions under public health surveillance. 1997;46(RR-10):

UW Northwest Center for Public Health Practice 25 Quick References for Health Care Providers Johns Hopkins Center for Civilian Biodefense Johns Hopkins Center for Civilian Biodefense Saint Louis Center for the Study of Bioterrorism and Emerging Infections Saint Louis Center for the Study of Bioterrorism and Emerging Infections Santa Clara County Health Department Santa Clara County Health Department Washington State Department of Health Washington State Department of Health Johns Hopkins Center for Civilian Biodefense Johns Hopkins Center for Civilian Biodefense Saint Louis Center for the Study of Bioterrorism and Emerging Infections Saint Louis Center for the Study of Bioterrorism and Emerging Infections Santa Clara County Health Department Santa Clara County Health Department Washington State Department of Health Washington State Department of Health