BIOTERRORISM June 15, 2006 Christina M. Cabott D.O.

Introduction Bioterrorist event –Release of biological agent into civilian population –Purpose Creating fear Illness Death Disruption of social and economic infrastructure

Introduction Biological agents –Infectious agents Contagious Noncontagious –Biologically produced toxins Act as chemical agents within human body

Agents of Concern Agent selection 1. Potential for public health impact 2. Delivery potential –Estimation of ease for development and dissemination –Potential for person-to-person transmission of infection 3. Public perception (fear) of the agent 4. Special requirements for public health preparedness

Agents of Concern Ranking category –Class A agents: most severe potential for widespread illness and death Variola major (small pox) Bacillus anthracis (anthrax) Yersinia pestis (plague) –Class B agents: less potential –Class C agents: future threats

Class A Agents Variola major (small pox) –Incubation: days –S&S: Initially: fever, severe myalgias, prostration Within 2 days: papular rash on face spreading to extremities → rash on palms and soles → trunk Lesions progress at same rate –Vesicular → pustular → scabs

Class A Agents Bacillus anthracis (Cutaneous anthrax) –Incubation: usually < 1 day, up to 2 weeks –S&S: Macule or papule enlarging into eschar Surrounding vesicles and edema Sepsis possible

Class A Agents Bacillus anthracis (GI anthrax) –Incubation: usually 1-7 days –S&S: Abdominal pain Vomiting GI bleeding leading to sepsis Mesenteric adenopathy on CT

Class A Agents Bacillus anthracis (Oropharyngeal anthrax) –Incubation: usually 1-7 days –S&S: Sore throat Ulcers on base of tongue Marked unilateral neck swelling

Class A Agents Bacillus anthracis (Inhalational anthrax) –Incubation: usually < 1 week –S&S: 1 st stage: fever, dyspnea, cough, headache, vomiting, abdominal pain, chest pain 2 nd stage: dyspnea, diaphoresis, shock Hemorrhagic mediastinitis with widened mediastinum on CXR

Class A Agents Yersinia pestis (Bubonic plague) –Incubation: 2-8 days –S&S: Fever, chills, painful swollen lymph nodes Nodes progress to bubo (possibly suppurative)

Class A Agents Yersinia pestis (Pneumonic plague) –Incubation: 2-3 days –S&S: Fever, chills, cough, dyspnea, nausea, vomiting, abdominal pain Clinical condition consistent with gram-negative sepsis

Class A Agents Yersinia pestis (Primary septicemic plague) –Incubation: 2-8 days –S&S: After bubo formation, clinical condition consistent with gram-negative sepsis, DIC

Class A Agents Clostridium botulinum (Food-born botulism) –Incubation: 1-5 days –S&S: GI symptoms Followed by symmetric cranial neuropathies, blurred vision Progresses to descending paralysis

Class A Agents Clostridium botulinum (Inhalational botulism) –Incubation: hours –S&S: Symmetric cranial nerve palsies Progresses to descending paralysis

Class A Agents Francisella tularensis (Tularemia) –Incubation: 2-5 days –S&S: Abrupt nonspecific febrile illness Progressing to pleuropneumonitis May have mucocutaneous lesions

Class A Agents Filoviruses and arenaviruses (Ebola virus) –Viral hemorrhagic fevers –Incubation: 2 days – 3 weeks, depending on the virus –S&S: Initial: nonspecific febrile illness, sometimes with rash Progresses to hematemesis, diarrhea, shock

Class B Agents Coxiella burnetii (Q fever) –Incubation: 2-3 weeks –S&S: Fever, myalgias, headache 30% develop pneumonia

Class B Agents Brucella spp (Brucellosis) –Incubation: 2-4 weeks –S&S: Fever, myalgias, back pain Possible CNS infections, endocarditis

Class B Agents Burkholderia mallei (Glanders) –Incubation: days –S&S: Suppurative ulcers Pneumonia Pulmonic abscesses Sepsis

Class B Agents Alpha viruses (VEE, EEE, WEE) –Encephalitis –Incubation: variable –S&S: Fever Headache Aseptic meningitis Encephalitis Focal paralysis Seizures

Class B Agents Rickettsia prowazekii (Typhus fever) –Incubation: 7-14 days –S&S: Fever Headache Rash

Class B Agents Chlamydia psittaci (Psitticosis) –Incubation: 6-19 days –S&S: Fever Headache Dry cough Pneumonia Endocarditis

Class B Agents Toxins –Ricin, Staphlococcus, Enterotoxin B Food safety threats –Salmonella, Eschericia coli O157:H7 Water safety threats –Vibrio cholera, Cryptosporidium parvum

Class C Agents Emerging threats –Nipah virus –Hanta virus

Recognition of Bioterrorist Event 1.Patient presents with signs, symptoms, or immediately available diagnostic results that obviously indicate a suspect disease process.

Recognition of Bioterrorist Event 2. Patient presents with protean symptoms, but an astute clinician establishes enough criteria (suspicious historical information, signs, symptoms, short turn- around lab results, public health corroborative information, etc.) to designate the patient as a presumptive case until diagnostic confirmation can be accomplished.

Recognition of Bioterrorist Event 3. Patient presents, is evaluated and admitted or released, but not suspected as being a victim of bioterrorism. Diagnostic test results (blood cultures, immunoassays, etc.) subsequently establish a diagnosis, potentially even post mortem.

Recognition of Bioterrorist Event 4. Multiple patients present over a defined period with similar symptoms or historical characteristics, raising the suspicions of a practitioner and causing that individual to report the concern. Further investigation with diagnostic testing and/or public health epidemiological investigation of the cohort establishes the cause.

Recognition of Bioterrorist Event 5. Public health surveillance systems establish unusual patterns of signs, symptoms, or disease in the community and correlate with further investigation to establish the etiology.

Recognition of Bioterrorist Event Emergency physician should know –Basic pathological principles for each agent –Modes of dissemination and transmission –Disease signs and symptoms –Recommended diagnostic testing –Recommended therapy Immunizations, medicines, or prophylaxis –Infectious control practices

Recognition of Bioterrorist Event Pictorial resources Confirmatory tests Respond to notification of potential disease by another health or medical professional Querying the source for methodology of testing that produced the concern

Recognition of Bioterrorist Event Exposure to an unidentified substance Source substance and where obtained Coordination with outside agencies, such as law enforcement and public health Patient exposure risk stratification

Design and Implementation of Community Surveillance Systems 1.Clinical duties are minimally affected -Does not consume valuable clinician or support staff time and attention 2.Financial investment is not carried by the hospital or professional staff

Design and Implementation of Community Surveillance Systems 3.Patient privacy and hospital proprietary issues are addressed appropriately 4.Participation in the system provides direct benefit to the acute care medical community -All pertinent epidemiologic information is disseminated in real time to the practitioners

Initial Response to a Potential Bioterrorist Threat Within hospital environment –Infection control procedures –Notification of hospital departments Administration Infectious disease Infection control Laboratory services Security Environmental services

Initial Response to a Potential Bioterrorist Threat Within hospital environment –Activation of Emergency Operations Plan (EOP) Preplanned surge capacity configuration Security dept – aid in protection of facility and staff Media relations Outside of hospital environment –Notification of jurisdictional public health department

Initial Response to a Potential Bioterrorist Threat Information that needs to be conveyed to public health department –1. Diagnosed or suspected agent of concern –2. Whether it is a presumed or definitive diagnosis and how many diagnosis were made –3. Patient demographics (including occupation) –4. Recent history of travel or participation in special events (i.e. mass gatherings, high-profile events, or at- risk gatherings)

Initial Response to a Potential Bioterrorist Threat Information that needs to be conveyed to public health department –5. Patient condition –6. Initial testing performed and further diagnostic testing being conducted –7. Treatment being provided –8. Public health assistance required (including testing) –9. Preferred method of contacting hospital or treating physicians for follow-up

Initial Response to a Potential Bioterrorist Threat Local Health Department Regional or State Public Health Departments Local Law Enforcement FBI CDC World Health Organization (WHO)

Initial Response to a Potential Bioterrorist Threat Protective equipment –Gowns, gloves, respiratory masks Patient isolation Patient decontamination –Removal of clothing –Soap and warm water –NO bleach

Integration with Local Department of Health Development of community wide patient evaluation and treatment protocol –Screening –Testing –Treatment methodologies –Patient and public education

Integration with Local Department of Health Clear and concise definition for the suspicious agent Reporting requirements (surveillance) for suspected or diagnosed cases –Type of information –Method of reporting (e.g. phone, fax, Internet) –Contact methods (e.g. 24 hr access for technical advice)

Treatment, Prophylaxis, and Immunizations Agent: Variola major Vaccination: Vaccinia vaccination –Not recommended for general public use –Contraindicated in immunocompromised pts and pts with eczema –Useful in preventing disease if given within 4 days of exposure

Treatment, Prophylaxis, and Immunizations Agent: Variola major Prophylaxis: Vaccinia immunoglobin –Within 2-3 days of exposure –Limited supplies available –Consider giving it to those with contraindications to the vaccine Treatment: –Mainly supportive

Treatment, Prophylaxis, and Immunizations Agent: Bacillus anthracis Vaccination: Anthrax vaccination –6 part series at 0,2, and 4 week, then 6,12, and 18 months –Annual boosters required –Not available to the public –Animal models: efficatious in inhalational anthrax

Treatment, Prophylaxis, and Immunizations Agent: Bacillus anthracis Prophylaxis: –Cipro or doxy for 60 days –Amoxicilin if strain not resistant to treatment Treatment: –Cipro or doxy (amoxicillin if strain not resistant) in combo with 2 others, including clindamycin, rifampin, imipenem, aminoglycoside, chloramphenicol, vancomycin, streptomycin, and some macrolides

Treatment, Prophylaxis, and Immunizations Agent: Yersinia pestis Vaccination: none Prophylaxis: –Cipro or doxy for 7 days –Alt: chloramphenicol Treatment: –Streptomycin or gentamycin –Alt: doxy, cipro, chloramphenicol

Treatment, Prophylaxis, and Immunizations Agent: Clostridium botulinum Vaccination: –Not available to public –Pentavalent toxoid of C botulinum toxin types A-E –3-part series, with yearly booster Prophylaxis: none

Treatment, Prophylaxis, and Immunizations Agent: Clostridium botulinum Treatment: –Antitoxin: from local public health agency –Antitoxin may preserve remaining neurologic function, BUT does not reverse paralysis –May require prolonged, assisted mechanical ventilation and supportive care

Treatment, Prophylaxis, and Immunizations Agent: Francisella tularensis Vaccination: –Live, attenuated vaccine under FDA investigation Prophylaxis: –Cipro or doxy for 14 days

Treatment, Prophylaxis, and Immunizations Agent: Francisella tularensis Treatment: –Streptomycin or gentamycin –Alt: doxy, cipro, chloramphenicol

Treatment, Prophylaxis, and Immunizations Agent: Filoviruses and arenaviruses (e.g. Ebola virus) Vaccination: none Prophylaxis: none Treatment: –Supportive therapy –Ribavirin may have applicability in arenaviruses

Treatment for Bioterrorism General Emergency Operation Plans –Need to have enough staff to handle large surge in general patient volume Specialty requirements –Patient with unusual medical conditions –Patients who may be contagious –Contamination risks to staff and other patients

Treatment for Bioterrorism Disease containment –Isolation –Designation of staff to care for infected vs. noninfected patients –Proper personal protective equipment

Treatment for Bioterrorism Management of personnel –Need more personnel to care for more patients –Staff reluctance to care for potentially infectious patients

Treatment for Bioterrorism Logistics –Limited supply of drugs and medical supplies –Sharing of critical supplies, staff, and equipment among local hospitals –National Pharmaceutical Stockpile

Treatment for Bioterrorism Patient Management –Addressing requirements of each patient encounter –Preprinted instructions Category of risk stratification Why patient placed in that category How disease transmitted Measures to prevent spread Early signs and symptoms of disease Appropriate steps if symptoms occur

Treatment for Bioterrorism Patient Management –Appropriate follow-up –Proper record keeping –Organization of charts

Treatment for Bioterrorism Vaccinations –Not to be given in a pre-event setting to general public Recommended therapies –Usually not for pregnant or lactating women –Usually not approved for children –Should be given if risk of infection and its consequences exceeds risks of the medications or vaccines

Treatment for Bioterrorism Fatality Management –Bodies are considered evidence –Processed through coroner or medical examiner

Sources of Expert Information Local poison control center CDC’s emergency response center