Recognizing and Reporting Possible Disasters Modules were developed as part of a grant from the HRSA BTCDP initiative Basic Biodefense Curriculum Module

Goal of the Module To prepare students to: Find current information about the signs and symptoms of exposure to various agents Use information to determine whether they need to report a suspicious event.

Identify or list examples of agents within each CBRNE (or B-NICE) category Describe the typical signs and symptoms for each class of agents Explain how healthcare workers participate in surveillance and monitoring Describe where to find current and accurate information about CBRNE (or B-NICE) agents Use algorithms to guide information collecting and reporting Describe how a suspicious event is reported Learning Objectives

Disaster Timeline Early recognition to mitigate (reduce) scope or impact of a full- blown disaster could be considered either a PREVENTION or an early RESPONSE activity. 1. Prevent

Early Recognition Need to have an approach for deciding when to report a suspected public health threat Be familiar with natural and accidental risks to your community Be familiar with agents used to intentionally cause disasters

“The Usual Suspects” Agents Commonly Used as Weapons B-NICE [bee-nice]: Biological Nuclear (radioactive) Incendiary (fire) Chemical Explosive CBRNE [see-burn]: Chemical Biological Radioactive Nuclear Explosive Types of agents and two ways to remember them!

Categorized by Ease of Detection Overt (Obvious) Agents: Explosives Incendiaries Covert (Hidden) Agents: Biologicals Chemicals Radioactive materials Overt – Covert Combinations: Dirty bombs (explosives with radioactive materials) ???

“E” Explosives Most commonly used weapon of terror Used in 70% of attacks Difficult to detect PRIOR to detonation Blast injuries may be: Immediate or delayed Obvious or hidden

“I” Incendiary Devices Three Parts of an Incendiary Device: Igniter (fuse) Container (body) Incendiary material (filler) Injuries caused by: Burns Inhaled smoke and toxic fumes Injuries usually occur soon after exposure

”E” and “I”… A Deadly Duo Explosives often cause fires Fires often cause explosions Watch for injuries and symptoms of both Could it be a Triple Threat…? Assume a COVERT agent was released by fire or explosion Watch for unusual symptoms

Why Terrorists like Covert Agents DELAYED onset and detection Terrorist escapes before attack detected False claims can be made Accidental secondary exposures VAGUE, MILD early symptoms Delays in seeking care Early diagnosis is difficult DETERMINATION is difficult: Causes speculation and panic Follow the spores… Psst…Sore Throat. Where should I look?** **With apologies to Woodward and Bernstein

“C” Chemical Agents Five Categories of Chemical Agents: 1.Nerve 2.Blister (or Vesicant) 3.Blood 4.Choking 5.Irritants

Chemical Agents Examples of two-letter codes: Sarin (GB) – nerve agent Mustard gas (H or HD) – blister agent Cyanide (AC) – blood agent What are the chemical risks in your community?

“C” Nerve Agents Chemical agents in this class: Sarin (GB) Soman (GD) Tabun (GA) Agent V (VX) – most potent

“C” Nerve Agents Rapid onset and often fatal Signs of nerve agent release Dead animals, birds, or humans Symptoms like organophosphate pesticide poisoning Body produces excessive secretions (see S.L.U.D.G.E.) S.L.U.D.G.E. Salivation Lacrimation Urination Defecation GI upset Emesis (or pulmonary Edema)

“C” Blister Agents Also called vesicants Example: Mustard Gas (H, HD) Lewisite (L) Prevent DNA from working, which kills the cells in the body Symptoms depend on route of exposure Eyes and lungs most vulnerable Mimics severe burns

Blood Agents Example: Cyanide (AC) Cyanogen (CK) Interferes with oxygen transport in cells, which leads to cell death Symptoms: cyanosis (blue lips, fingers), difficulty breathing, dizziness, headache

Choking Agents Examples: Chlorine gas Phosgene gas Suffocation by drowning in own fluids Symptoms: Inability to breathe Eye irritation

Irritating Agents Example: Tear gas MACE Rarely lethal, but can be quite disruptive cough…. ….cough …

“B” Biological Agents Two Main Types of Agents: Toxic by-products that act as poisons Microorganisms that cause infectious disease Bioterrorism: the use of biological toxins or infectious organisms in acts of terrorism Natural outbreaks of infectious disease have many of the same characteristics

“B” Toxic Biologicals Similar to Chemical Agents Secondary exposures from contaminated items or people Do NOT cause infections Examples: Botulinum toxin Ricin

“B” Toxic Biologicals Botulinum toxin Produced by Clostridium botulinum bacteria Group of several neurotoxic proteins Causes descending paralysis Onset in hours after ingestion Early Signs: droopy eyelids, blurred vision, slurred speech

“B” Toxic Biologicals Ricin Derived from Castor Bean processing wastes Prevents protein synthesis in cells Onset and early signs: vary by route of exposure More likely used for assassinations than large scale attacks

“B” Infectious Biologicals Cause death through infection, not poisoning Disease may spread to others causing secondary outbreaks Attack may mimic a natural outbreak Onset of symptoms often delayed Incubation period may take days Fear that organisms will be altered genetically Usual treatment or vaccine may not be effective

CDC CATEGORY A Anthrax (Bacillus anthracis) Botulism (Clostridium botulinum toxin) Plague (Yersinia pestis) Smallpox (Variola major virus) Tularemia (Francisella tularensis) Viral hemorrhagic fevers Filoviruses [e.g., Ebola, Marburg] Arenaviruses [e.g., Lassa, Machupo] Biologicals most likely to be used as weapons; virulent or easy to disseminate.

CDC CATEGORY B Brucellosis (Brucella species) Q fever (Coxiella burnetii) Ricin toxin (Castor Bean) Staphylococcal enterotoxin Cholera (Vibrio cholerae) Cryptosporidiosis (Cryptosporidium parvum) Biologicals that are also potential weapons, but not as virulent as Category A. (Includes food and water contaminants)

CDC Category C Hantavirus Nipah virus Other emerging pathogens Go to CDC website for more information on particular biological agents Biologicals that are emerging pathogens; not yet of concern, but have potential to become weapons

Symptoms of “B” Exposure Varies by ROUTE of exposure Topical: skin lesions Inhaled: respiratory symptoms Ingested: gastrointestinal symptoms Injected: systemic, whole body Forms of infectious diseases based on route: Anthrax Topical Anthrax (also called Wool Sorters’ Disease) Gastrointestinal Anthrax (swallow spores) Inhalational Anthrax (inhale spores; most deadly form)

Early symptoms – vague, nonspecific Influenza-like Illnesses (ILI) Late symptoms – more specific, diagnostic, laboratory confirmation Can you distinguish between the early symptoms of common cold and influenza? Healthy Acute illness: Disease-specific symptoms appear Subclinical: Organisms multiply, but not yet impacting body Exposure Usual contagious period Recovery: No new symptoms, existing symptoms resolve, health returns Healthy (or dead) Time Prodromal: Early, nonspecific symptoms appear Healthy Acute illness: Disease-specific symptoms appear Subclinical: Organisms multiply, but not yet impacting body Exposure Usual contagious period Recovery: No new symptoms, existing symptoms resolve, health returns Healthy (or dead) Time Prodromal: Early, nonspecific symptoms appear Timeline for Biological Exposure Symptoms

“R” Radioactive Agents Radioactive Agents Types of Radiation: Alpha Beta Gamma Sources of Exposure: Nuclear bomb Conventional explosives Accidental release

Radioactive Agents

Detecting Radioactive Agents Look for labels on containers Placards on transportation vehicles Location Site may contain nuclear or radioactive products. Instruments designed to detect radiation: Geiger Counters

Decision-Making Tools Available in many formats Provide quick, but not necessarily complete information Fit many, but not all situations Still need to use your judgment

Decision-Making Tools CDC: SARIN – NIOSH Emergency Response Card Recognizing Chemical Exposure Anthrax – Case definition is found in “Diagnosis and Evaluation” US Army (has PDA downloads): Isolation Precautions (Found in Appendix B) Differential diagnosis of chemical vs toxin (Appendix H) (Army procedures may vary from civilian procedures)

Symptom Approach

Practice Case Location: Near a Warehouse Fire Symptoms: No fever Cough and shortness of breath Skin lesions (burns) No GI symptoms Fever Breathing Skin GI Tract No Yes

Epidemiological Approach Are any of these unusual? Time of Year Combination of symptoms Timing of symptoms Type of population affected Cluster of cases in one area Outbreaks or exposure in other areas

Epidemiological Approach Approach based on: Knowledge of natural behavior of disease Know common diseases (e.g., influenza, chickenpox) Case definitions Use descriptions of symptoms and causative agents Simplified example of how a naturally-occurring disease outbreak might spread from an initial (index) case to close contacts and result in an epidemic. Index Case

Epidemiological Approach Gather the following information: Contact information (phone numbers, names) Onset date/time Signs and symptoms Illness in family or acquaintances Recent travel Recent events and activities Food and water sources Animals Unusual packages and envelopes

Seek Information About Exposure risk Early symptoms Specific symptoms Transmission Vulnerable populations

Another Practice Case: Three days after the Fourth of July weekend, Alice, Burt and Charlie complain that they had the “flu.” Their early symptoms included severe fever with chills, aching muscles, no energy, and a dry cough, but after several days, they began to feel better. What type of exposure could this be? Epidemiology approach: July is unusual time of year and no one else appears to be sick Symptom approach: fever indicates infection or radiation. Other symptoms very vague or “I-L-I” like Decision: unusual isolated outbreak of infections that should be checked by physician.

Validating Your Suspicions Seek more detailed information Were the three individuals at the same get together – is there a common source? Check with colleagues about similar cases Have other providers heard similar stories from other patients? Stick to the facts – avoid starting rumors Let colleagues know you have an unusual case that you are checking out

Reporting Unusual Cases For a public health emergency, you should : 1. Call local health department 2. If no answer and situation is urgent, call operator Information to leave: Your name & contact information Reason for calling Facts of situation; no speculation

Reporting

Staying in the Loop Join CDC Listserv Clinicians’ Listserv: Check reliable websites Make local contacts Identify experts and key agencies Gather contact information

Summary All healthcare workers should remain vigilant for signs of public health threats. Recognize unusual diseases clusters by knowing signs and symptoms of common and uncommon diseases or exposures Use B-NICE or CBRNE to remember categories of agents most likely to be weaponized First, try to validate your suspicions; then contact local authorities.

Authors Jean Carter Sandra Kuntz Earl Hall Steven Fehrer Steven Glow Jacqueline Elam Michele Sare Lisa Wrobel Michael Minnick Modules prepared as part of the Montana Basic BioDefense Curriculum For Pharmacy, Nursing, and Allied Health Funded by the HRSA CFDA initiative

Photo Credits Do not reproduce individual photos or videoclips without permission from original source. A list of photo credits was included in the instructor’s packet. To request a copy of the photo credits, send an to Modules prepared as part of the Montana Basic BioDefense Curriculum For Pharmacy, Nursing, and Allied Health Funded by the HRSA CFDA initiative