BIOTERRORISM
June 15, 2006
Christina M. Cabott D.O.
Introduction
• Bioterrorist event
– Release of biological agent into civilian
population
– Purpose
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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: 12-14 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:
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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:
• 1st stage: fever, dyspnea, cough, headache,
vomiting, abdominal pain, chest pain
• 2nd 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: 12-72 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: 10-14 days
– S&S:
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Suppurative ulcers
Pneumonia
Pulmonic abscesses
Sepsis
Class B Agents
• Alpha viruses (VEE, EEE, WEE)
– Encephalitis
– Incubation: variable
– S&S:
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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:
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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 turnaround 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
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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
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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
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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
CDC
FBI
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
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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
• http://jama.ama-assn.org
• http://www.bt.cdc.gov
• http://chemdef.apgea.army.mil/textbook/contents.asp
• http://www.apic.org
• Local poison control center
• CDC’s emergency response center
1-770-488-7100