and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health,...

90
and and Presented by Dr. Roslyn Bascombe-Adams “Leaders” - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho Rios, Jamaica

Transcript of and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health,...

Page 1: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

and and

Presented by Dr. Roslyn Bascombe-Adams

“Leaders” - International Course for Managers on Health,

Disasters and Development

February 18th 2003, Ocho Rios, Jamaica

Page 2: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

OverviewOverview

Why Consider NBC-warfare?What are Potential Chemical Agents?Guide to managing Chemical Agents .What are likely Bio-terrorism Agents?Guide to managing “common” Bio-

terrorism Agents.Considerations for contingency planning.

Page 3: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Definition of Biological TerrorismDefinition of Biological Terrorism

The use or threatened use of biological or biologically-related toxins against civilians, with the objective of causing illness, death or

Eric K. Noji, M.D., M.P.H.

Page 4: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Disaster RisksDisaster Risks

NATURAL

Hurricanes/Cyclones Tidal waves/Tsunamis Landslides Floods Earthquakes Fires Volcanic eruptions

TECHNOLOGICAL

Vehicle/Aircraft accidents Explosions/Bombing Fires Oil spills Chemical exposure Germ warfare Nuclear explosions

Page 5: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Is there a credible risk of Is there a credible risk of BNC warfare?BNC warfare?

The world today…– Terrorists (high profile events, crowds, critical infrastructure..) – Doomsday cults– Insurgents

U.S.A. ‘s current war policiesConsider flight paths of large airlinesGeneva convention/duty to respond to vessel in

distress

Page 6: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Do we OWE it to ourselves to Do we OWE it to ourselves to prepare?prepare?

Fore-warnedFore-warned is is

Fore-armed!Fore-armed!

??????????

Page 7: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Chemical AgentsChemical Agents

Blister agents– Mustard gas, phosgene oxime

Nerve Agents– Sarin, Ricin, Tabun, GF, VX,

Pulmonary Agents– Phosgene, chlorine

Pesticides– Organophosphates

Page 8: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Agents of Most ConcernAgents of Most Concern

BLISTER AGENTS

NERVE AGENTS

Page 9: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Coping with Chemical AgentsCoping with Chemical AgentsIDENTIFYCOMMUNICATESECUREDECONTAMINATETRIAGETREATRECEIVE/DISPOSE

Page 10: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Identifying Chemical AgentsIdentifying Chemical Agents

Usually overt attack/incidentBurns to skin and mucosa, usu. within 2 minsCardio-pulmonary injury/failureShockNeurological damage Trauma

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 11: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

1. Blister Agents1. Blister Agents Used before (WW2) Burns to skin & mucus membranes (within 2 mins)

Tracheo-bronchial damage (SOB, wheezing, pulmonary edema)

More morbidity Supportive care Mortality 20-30% Death usually secondary to immune suppression seen 5-7

days post-exposure

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 12: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

2. Nerve Agents2. Nerve AgentsUsed before (Gulf war, Japan subway)Massive cholinergic neurological stimulation“SLUDGE” syndrome (salivation, lacrimation [excess tears],

urination,diarrhoea, gastric emptying [vomiting])Miosis (pinpoint pupils)FasciculationsSeizuresFlaccid paralysis

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 13: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Coping with Chemical AgentsCoping with Chemical Agents- Communication -- Communication -

FIRST LINE KEY PLAYERS – AIRPORT CONTROLLER– PORT & MARINE OPERATER– 911 DISPATCHER– EMT– DUTY NURSE– PHYSICIAN– MILITARY

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

 

 

Page 14: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

E.g. E.g. Schematic of Communication Schematic of Communication CascadeCascade

if indicated Poison Control Chief of Staff CEO

Duty Doctor ER Director CMO CDCInitiator

Duty Nurse Triage Nurse/EMT’s Charge Nurse Nurse Supervisor

Clin. Coordin Prog. Manager

Security Manager

 

Page 15: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Coping with Chemical ExposureCoping with Chemical Exposure-Securing--Securing-

Scene safety done by Police and FireDue concern is given to exposed population,

rescuers, victims, propertyWorking Areas must be recognized and

respected– Strictly restricted area– Restricted area– Reserved area– Media area

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 16: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Coping with Chemical ExposureCoping with Chemical Exposure-Securing--Securing-

If MCM activated– Hospital security :

Cordons ER Controls lower parking lot Discourages non-essential pedestrian flow

– Police needed for traffic & crowd control – Military

Page 17: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Coping with Chemical AgentsCoping with Chemical Agents-Decontamination--Decontamination-

Fire service has Hazmat branch and 10 responsibility Emergency Staff may be needed in a 2o responsePolice may be needed in a 20 response e.g.

explosives present, social disruptionFor rescue safety purposes, decontamination takes

priority over care-giving.

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 18: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Coping with Chemical AgentsCoping with Chemical Agents-Decontamination--Decontamination-

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Impact zone

Decon Zone

Advanced Medical Post (AMP)

Page 19: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Coping with Chemical ExposureCoping with Chemical Exposure- Triaging -- Triaging -

Assess need to activate MCM planGet additional

– Staff– Oxygen– Nebulizers– Antidote– Medications– Safety gear, (Level II protective gear)

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 20: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Coping with Chemical AgentsCoping with Chemical Agents-Triaging--Triaging-

Triage will follow standard MCM practices– RED immediate priority– Yellow urgent priority– Green non-urgent– Black deadRemember: triage to treat on site and then triage to

transport

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 21: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Coping with Chemical ExposureCoping with Chemical Exposure - Treating -- Treating -

Treat as clinically indicatedOxygenNebulizationAtropine IV for “SLUDGE”, until bronchial

secretions decreases. 3-5mg/5-10 minutes2-PAM (pralidixime) 1-3 mg IV for flaccid

paralysis (may repeat in 3 hrs)

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 22: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Coping with Chemical exposureCoping with Chemical exposure- Receiving/Disposition -- Receiving/Disposition -

This will depend on number and severity of victims

Dispose as clinically indicated– Ward– ICU– “Other” Holding Areas/Clinics– Discharge– Morgue/Make-shift morgue

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 23: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Biological AgentsBiological AgentsUse before

– Sieges of middle ages– Smallpox blankets given to Native Americans– Germany in WW I– Japan in WW II– 1984 Salmonella poisoning, Oregon– 1995 Iraq used anthrax/botulism toxin weapons– 1995 Aum Shinrikyo tried anthrax and failed– 1997 – 1999 Multiple Anthrax hoaxes

Page 24: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Biological AgentsBiological Agents

Likely to be covertDelayed impact because of incubation periodHealth care workers in the forefront as initiatorsPublic health surveillance has prominent roleEarly communication is key

Page 25: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Close Cooperation with Close Cooperation with clinicians, healthcare and first clinicians, healthcare and first

responder communitiesresponder communitiesEmergency departments, urgent care centersInfection control unitsPhysician networks, private officesHospitals, HMOsMedical examinersPoison controlLaw enforcement, fire, other first responders

Eric K. Noji, M.D., M.P.H.

Page 26: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Potential Biological agentsPotential Biological agents

CATEGORY A AGENTS (CDC)Bacillus anthracis – AnthraxClostridium botulinum – BotulismYersinia pestis – PlagueVariola major – SmallpoxFrancisella tularensis – tularemiaViral Hemorrhagic fevers

Page 27: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

AnthraxAnthrax

Gram positive bacillusMay be

– Inhalational ( incub. 2-60 days, average 5) 80-90% mortality (treated)

– Cutaneous (incub. 1-7 days) 20% mortality (untreated)

– Gastro-intestinal (incub.1-7 days) 50% mortality(untreated)

Page 28: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Anthrax - Soviet IncidentAnthrax - Soviet Incident

An accident at a Soviet military compound in Sverdlovsk (microbiology facility) in 1979 resulted in an estimated 68 deaths downwind, of ~ 79 infected

Biological Warfare

research, production and storage facility

Biological Warfare

research, production and storage facility

Path of airborne Anthrax

Path of airborne Anthrax

MOSCOW Sverdlov

sk

Page 29: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

ANTHRAXANTHRAX

WHAT TO DO?IdentifyContainCommunicateTriageTreatReceive/Dispose

Page 30: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

AnthraxAnthrax

High index of suspicion neededTravel history or exposure to suspect sourceInfectious contacts (for cutaneous)Employment historyActivities over the preceding 3-5 days

Page 31: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.
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Cutaneous Anthrax, face CDC

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 34: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Cutaneous Anthrax CDC

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

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Cutaneous AnthraxCutaneous Anthrax

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 39: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Cutaneous AnthraxCutaneous AnthraxDifferential DiagnosisDifferential Diagnosis

Spider biteEcthyma gangrenosumUlceroglandular tularemiaPlagueStaphlococcus cellulitisStreptococcal cellulitis

Page 40: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

AnthraxAnthrax

GASTROINTESTIONAL ANTHRAXGenerally follows ingestion of contaminated ,

under-cooked meatAcute inflammation of GI tractNausea, vomiting, loss of appetiteLater, abdo pain, hemoptysis, severe diarrhea

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 41: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Anthrax SporesAnthrax Spores

Page 42: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Aerosol / Infectivity Relationship

18-20

15-18

7-12

4-6(bronchioles)

1-5 (alveoli)

Infection Severity

Particle Size (Micron, Mass

Median Diameter)The ideal aerosol

contains a homogeneous

population of 2 or 3 micron particulates that

contain one or more viable organisms

Maximum human respiratory infection

is a particle that falls

within the 1 to 5 micron size

Less Severe

More Severe

Page 43: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Inhalational AnthraxInhalational Anthrax1 – 60 day incubation period Fever, myalgias, cough, and fatigueInitial improvement Abrupt onset of respiratory distress,

shockNonspecific physical findings Pneumonia is rareCXR - may show widened

mediastinum +/-bloody pleural effusion

50 % of cases have associated hemorrhagic meningitis

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 44: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Inhalation Anthrax widened mediastinum 22 hours before death

CDC/Dr. P.S. Brachman, 1961Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 45: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Hemorrhagic Meningitis from Inhalation Anthrax

CDC, 1966

Page 46: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Inhalational AnthraxInhalational AnthraxDifferential DiagnosisDifferential Diagnosis

Mycoplasmal pneumoniaLegionnaires DiseasePsittacosisTularemiaQ feverViral PneumoniaHistoplasmosis (fibrous mediastinitis)Coccidioidomycosis

Page 47: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

AnthraxAnthraxIf highly clinical suspect or confirmed case, open

lines of communicationIf suspect package/letter

– Contain physically– Do not shake/empty contents– If spills occurred, cover immediately. Never try to

clean up a spill!– Wash hands with soap and water– Close windows/doors/ shut down A/C and leave room– List all contacts for future reference and follow-up.

Identify/Communicate/Contain/Decontaminate/Triage/Treat/Receive/Dispose

Page 48: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

ANTHRAXANTHRAX

Considered highly infectious if spores are inhaled (2500-5000 or more spores needed)

Low re-infectivity after spores fallHazmat precautions are initiated to prevent or

minimize inhalation anthrax from suspect packages

Identify/Communicate/Contain/Decontaminate/Triage/Treat/Receive/Dispose

Page 49: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

AnthraxAnthraxFor suspect/confirmed patient(s) or persons

exposed to suspicious powder– Remove all clothing and accessories ASAP and bag in

plastic– Shower with soap and water ASAP

For suspect package/room– Hazmat team will secure area, remove object, seal

room, initiate testing source

Identify/Communicate/Contain/Decontaminate/Triage/Treat/Receive/Dispose

Page 50: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

ANTHRAXANTHRAX

Unlikely to have MCM-type situation

Manage according to clinical indications

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 51: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

ANTHRAXANTHRAXPROPHYLAXIS

Started on clinical suspicion OR exposure to confirmed powder OR beginning of suspect symptoms following possible exposure

Immunization (at 0, 2, 4 weeks) plus meds x 1 mth Ciprofloxicin (caution in children, elderly & pregnancy)

Doxycycline ?Amoxicillin Nasal swabs useful only with highly credible exposure &

no discrete environmental source to test.

Identify/Communicate/Contain/Decontaminate/Triage/Treat/Receive/Dispose

Page 52: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

ANTHRAXANTHRAXFor Cutaneous Anthrax, as with post-exposure

prophylaxis:

Cipro 500 mg po bid x 60 days

Or

Doxy 100 mg po bid x 60 days

Except there are

1. Signs of systemic involvement

2. Extensive edema

3. Head lesions

4. Neck lesionsIdentify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 53: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

ANTHRAXANTHRAXFor Inhalation and Gastro-intestinal anthrax,

1. Ciprofloxcin 400 mg IV Q8-12HOR

Doxycycline 100 mg IV Q12H

PLUS

2. Rifampin 600 mg po bid

3. Clindamycin 600 mg IV bid

(vancomycin, penicillin, chloramphenicol, imipenem,clarithromycin)

Consider SteroidsIdentify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

Page 54: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

BOTULISMBOTULISM

Gram positive bacillusProduces potent neurotoxin which inhibits

release of acethylcholineCharacteristic flaccid paralysisUsually food-borneCan be aerosolized

Page 55: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

BOTULISMBOTULISMIDENTIFY High index of suspicion Incubates 12-36 hrs after ingestion, 24 –72 hrs after

inhalation Fully alert, responsive patient Symmetrical cranial neuropathies Descending weakness No sensory deficit Respiratory dysfunction

Identify/Contain/Communicate/Triage/Treat/Receive/Dispose

Page 56: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

BOTULISMBOTULISM

CONTAINNot transmitted person to personRoutine immunization not requiredStandard precautions to manage

Identify/Contain/Communicate/Triage/Treat/Receive/Dispose

Page 57: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

BOTULISMBOTULISM

COMMUNICATIONOpen crisis channelsDuty doctor +/- charge nurse

TRIAGEAs clinically indicated

Identify/Contain/Communicate/Triage/Treat/Receive/Dispose

Page 58: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

BOTULISMBOTULISMTREATMENTBotulism antitoxin availableToxin may be found in serum, stool samples,

gastric secretionsRoutine blood tests of limited valueMay need ventilator support from 2-3 months

Identify/Communicate/Triage/Treat/Receive/Dispose

Page 59: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

PLAGUEPLAGUE

Gram negative bacillusUsually transmitted by infected fleasCan be aerosolized/weaponizedInhaled version causes PNEUMONIC

rather than bubonic plagueIncubation 2-8 days by fleas but 1 – 3 days

by aerosol

Page 60: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

PLAGUEPLAGUEIDENTIFY Fever, cough, chest pain Haemopytsis Muco-purulent sputum Bronchopneumonia on X-ray

Identify/Contain/Communicate/Triage/Treat/Receive/Dispose

Page 61: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Plague Disease ComplexPlague Disease Complex

Inhalational

SystemicToxicity

Respiratory failure & circulatory collapse/Death

Liverenzymes

6% latemeningitis

Fulminant Pneumonia

Fever, URI syndrome

Sudden onset

Fever/rigors

Tender bubo1 - 10 cm

APTTecchymosis

DIC

Stridor, cyanosis,productive cough,Hemoptysis,bilateral infiltrates

Pharyngitis

2 -3 days

2 - 10 days

24 hrs

9%

Erythema

Page 62: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

PlaguePlague

Late complications of septicemia orpneumonic plague may include acral gangrene of digitsnose, earlobes,penis

Identify/Contain/Communicate//Triage/Treat/Receive/Dispose

Page 63: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Pneumonic PlaguePneumonic PlaguePrevention of Secondary Prevention of Secondary

InfectionInfection Secondary

transmission is possible and likely• Standard, contact, and aerosol precautions for at least 48 hrs until sputum cultures are negative or pneumonic plague is excluded

Identify/ Contain/Communicate/Decontaminate/Triage/Treat/Receive/Dispose

Page 64: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

PLAGUEPLAGUE

CONTAINRemove clothes, bag, shower thoroughly Person-to-person spread by large dropletsStandard and Droplet precautionsContagious until 48 - 72 hours of antibioticsNo vaccines available

Identify/ Contain/Communicate/Decontaminate/Triage/Treat/Receive/Dispose

Page 65: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

PLAGUEPLAGUE

COMMUNICATEActivate crisis linesInvolve infection control practitioner ASAP

Identify/ Contain/Communicate/Triage/Treat/Receive/Dispose

Page 66: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

PLAGUEPLAGUE

TREATMENTDoxycycline 100 mg bidCiprofloxicin 500 mg bidInitiate post-exposure prophylaxis ASAP to

seven days following last exposure or until exclusion

Blood, sputum, tracheal aspirate cultures

Identify/ Contain/Communicate/Triage/Treat/Receive/Dispose

Page 67: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

SMALLPOXSMALLPOX

Acute viral illnessHigh morbidity in non-immune personsIncubates 7-17 days (average 12)

Page 68: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

SMALLPOXSMALLPOX

IDENTIFYFlu-like illness 2-4 day prodromeSkin lesionsProminent on face (in contrast to truncal

distribution of chickenpox)Synchronous onset rash

Identify/ Contain/Communicate/Triage/Treat/Receive/Dispose

Page 69: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.
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Adult with Smallpox rash

CDC/NIP/Barbara Rice

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Child with Smallpox rash

CDC/Cheryl Tryon

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Close-up Smallpox rash

CDC/James Hicks, 1973

Page 73: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Smallpox - Prevention of Smallpox - Prevention of Secondary InfectionSecondary Infection

Contagious All contacts are

quarantined for at least 17 days

Infectious until all scabs are healed over

Page 74: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Last child with Smallpox

CDC

Page 75: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Last adult with naturally occurring Smallpox, 1977

World Health Organization

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-1980--1980-

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SMALLPOXSMALLPOX

CONTAIN Decontamination NOT necessary IMMEDIATELY initiate airborne precautions, mask

patient, evacuate area and contact infection control. DO NOT DRAW BLOOD Limit movement to essential necessity House victims in pre-identified location

Identify/ Contain/Communicate/Triage/Treat/Receive/Dispose

Page 78: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

SMALLPOXSMALLPOX

PROPHYLAXISVaccine available and effective Immunize within 3 days of exposureAfter 3 days give VIG (vaccinia immune-

globins) as wellIsolate victims and contacts, separately (17-day

quarantine)

Identify/ Contain/Communicate/Triage/Treat/Receive/Dispose

Page 79: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Isolation PrecautionsIsolation Precautions

AnthraxStandard

PlagueDroplet

Smallpox Airborne (Respiratory)

Botulism Standard Tularemia Standard

Page 80: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Psychological IssuesPsychological Issues

Distress may be evident in:-ThinkingPhysicalEmotionalBehaviour

Page 81: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Bioterrorism Surveillance•Early, rapid recognition of unusual clinical syndromes or deaths & of increase above “expected levels” of common syndromes, diseases, or death

•Rapid etiologic diagnosis

•Rapid response

Eric K. Noji, M.D., M.P.H.

Page 82: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

•Key features–Real time data real time epidemiology

–Syndrome-based reporting

–Sentinel surveillance sites

–Pro-active (high profile potential target events, ongoing surveillance in sentinel sites)

–Reactive (monitoring and response)

–Aberration Detection

Eric K. Noji, M.D., M.P.H.

Bioterrorism Surveillance

Page 83: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

CDC Epidemiology and BioterrorismCDC Epidemiology and Bioterrorism

The detection and control of saboteurs are the responsibilities

of the FBI, but the recognition of epidemics caused by sabotage

is particularly an epidemiologic function…. Therefore, any plan of

defense against biological warfare sabotage requires trained

epidemiologists, alert to all possibilities and available for call

at a moment’s notice anywhere in the country”

Alexander LangmuirFounder of CDC EIS Program1952

Page 84: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Key to PlanningKey to Planning

Establish Chain of commandKnow Communications linesEstablish reporting and prompt data

collection methodsEducation of ED staffEducation of healthcare workersUtilize Local news media to reliably inform

population.

Page 85: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

RecommendationsRecommendations• It may not be prudent to await diagnostic

laboratory confirmation• It may be necessary to initiate a response based

upon the recognition of high-risk syndromes• Develop mechanisms to evaluate institutional

trends of high-risk syndromes• Develop laboratory protocols for notification of

infection control/hospital epidemiologist for “suspect” cultures or tests

Eric K. Noji, M.D., M.P.H.

Page 86: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Current ChallengesCurrent Challenges

Real-time transmission and analysisIdentification of localized clustersSustainability of surveillance systemDevelopment of response protocols

Eric K. Noji, M.D., M.P.H.

Page 87: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

Unanswered QuestionsUnanswered Questions

What is the threshold that initiates responseWhat is the sensitivity and specificity of

surveillance systemsUsefulness and feasibility of aggregate data

from hospital admissions Future: data electronically collected,

integrated, evaluated and shared in a “real time” fashion (?)

Eric K. Noji, M.D., M.P.H.

Page 88: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

NATIONAL BIOTERRORISM PREPAREDNESS AND RESPONSE INITIATIVENATIONAL BIOTERRORISM PREPAREDNESS AND RESPONSE INITIATIVE

CONTACT INFORMATION CONTACT INFORMATION Centers For Disease Control and Prevention

Cand Response Program (BPRP)Atlanta, Georgia 30033

770-488-7100

www.bt.cdc.gov

Page 89: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

THREAT IS REALPREPAREDNESS IS THE KEYPLANS INEFFECTIVE UNTIL KNOWN WHEN IS THE BEST TIME FOR

ACTION? WITH LUCK, WE’LL NEVER HAVE TO

INITIATE A RESPONSE PLAN“How lucky do you feel today??”

Page 90: and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho.

THE ENDTHE END

THE END