Bioterrorism Agents – Plague Lesson 6 Public Health Management.

Bioterrorism Agents – PlagueBioterrorism Agents – PlagueLesson 6Lesson 6

Public Health ManagementPublic Health Management

ObjectivesObjectives

• Purposes of epidemiological Purposes of epidemiological investigationsinvestigations

• Case definitionsCase definitions• Sentinel events indicating Sentinel events indicating

bioterrorismbioterrorism• Public health responsePublic health response

– Natural PlagueNatural Plague– Bio-terrorist PlagueBio-terrorist Plague

• Contact management and Contact management and prophylaxisprophylaxis

Principal Purposes of Principal Purposes of Epidemiologic InvestigationsEpidemiologic Investigations

• Characterize cases and confirm outbreakCharacterize cases and confirm outbreak

• IdentifyIdentify– Causative agentCausative agent– SourceSource– Mode of TransmissionMode of Transmission

• IdentifyIdentify– CasesCases– Case ContactsCase Contacts

• Person, place, timePerson, place, time

• Risk factorsRisk factors

• Control and Prevention strategiesControl and Prevention strategies

• Monitor and evaluate responseMonitor and evaluate response

Principal Purposes of Principal Purposes of Epidemiologic InvestigationsEpidemiologic Investigations

Plague Case DefinitionsPlague Case DefinitionsSuspect and ProbableSuspect and Probable

• Suspect CaseSuspect Case– Clinically compatibleClinically compatible– Clinical specimens – features of Clinical specimens – features of Y. pestisY. pestis

• Probable CaseProbable Case– Clinically compatibleClinically compatible– Presumptive laboratory resultsPresumptive laboratory results

• Positive DFAPositive DFA• PCR evidence of PCR evidence of Y. pestisY. pestis• Single elevated serum antibody titer to F1 antigenSingle elevated serum antibody titer to F1 antigen

Plague Case DefinitionsPlague Case DefinitionsConfirmedConfirmed

• Confirmed CaseConfirmed Case– Confirmatory isolation of Confirmatory isolation of Y. pestisY. pestis 4-fold change in antibody titer to F1 4-fold change in antibody titer to F1

antigenantigen– IHC staining can be considered when IHC staining can be considered when

isolation or serology not possibleisolation or serology not possible

Early CasesEarly Cases

• Lab confirmation importantLab confirmation important– First cases in geographic areaFirst cases in geographic area– Treatment and isolationTreatment and isolation– Post- or pre-exposure prophylaxisPost- or pre-exposure prophylaxis– Other controlsOther controls

• Call public health Call public health

immediatelyimmediately

Natural Disease vs BioterrorismNatural Disease vs Bioterrorism

• Announced, credible threatAnnounced, credible threat

• Observed threat eventObserved threat event

• DetectionDetection

• Animal cases in unusual settingsAnimal cases in unusual settings

• Human cases without link to endemic areaHuman cases without link to endemic area

Natural Disease vs BioterrorismNatural Disease vs BioterrorismNatural PlagueNatural Plague

• Recent endemic exposureRecent endemic exposure

• Handling of sick cat, flea bites in endemic Handling of sick cat, flea bites in endemic areaarea

• Recent travel to endemic areaRecent travel to endemic area

• Sporadic, infrequent casesSporadic, infrequent cases

• Bubonic most common Bubonic most common

presentationpresentation

Natural Disease vs BioterrorismNatural Disease vs BioterrorismBioterrorist PlagueBioterrorist Plague

• No known endemic No known endemic exposureexposure

• Point source in urban, Point source in urban, crowded settingcrowded setting

• Severe respiratory illnessSevere respiratory illness• Cluster of severe and fatal Cluster of severe and fatal

pneumoniapneumonia• Plague cases that don’t Plague cases that don’t

respond to recommended respond to recommended antibiotic treatmentantibiotic treatment

Control and ContainmentControl and ContainmentInitial StagesInitial Stages

• Sampling of environmentSampling of environment

• Definition of dispersionDefinition of dispersion

• Confirmation of Confirmation of Y. pestisY. pestis

• Deploy SNSDeploy SNS

• Epidemiologic InvestigationEpidemiologic Investigation

• Animal controlAnimal control

• CommunicationsCommunications

• Coordination of activitiesCoordination of activities

• Active surveillanceActive surveillance

• Assisted surveillanceAssisted surveillance

• Clinician Information RequestsClinician Information Requests– Number of plague patientsNumber of plague patients– Number of plague rule-outsNumber of plague rule-outs– Chart review for unrecognized illnessChart review for unrecognized illness

Control and ContainmentControl and ContainmentInitial StagesInitial Stages

Chart ReviewsChart Reviews

• ER discharges, admits, ER discharges, admits, transferstransfers

• Non-lab confirmed fevers, Non-lab confirmed fevers, pneumoniaspneumonias

• Prioritize hospitalized patientsPrioritize hospitalized patients• Follow-up on those transferred Follow-up on those transferred

outout• Critical for determining extent Critical for determining extent

and source of outbreakand source of outbreak

Symptomatic Patient EvaluationSymptomatic Patient Evaluation

• Seek care: febrile Seek care: febrile respiratory, other plague respiratory, other plague compatible syndromescompatible syndromes

• Referral and triage Referral and triage hospitalshospitals

• Isolation and respiratory Isolation and respiratory droplet precautiondroplet precaution

• All fevers 38.5All fevers 38.5C or higher C or higher or cough presumptive or cough presumptive pneumonic plaguepneumonic plague

Contact ManagementContact Management

Contact – Within 6-7 Contact – Within 6-7 feet, or 2 meters, of feet, or 2 meters, of patient in prior 7 dayspatient in prior 7 days

• Evaluate contacts with Evaluate contacts with fever or coughfever or cough

• 7 days prophylaxis and 7 days prophylaxis and symptom monitoringsymptom monitoring

Contact ManagementContact ManagementProphylaxis GroupsProphylaxis Groups

• Exposed to Exposed to Y. pestisY. pestis release release• Household members of respiratory plagueHousehold members of respiratory plague• HCWs with direct patient contactHCWs with direct patient contact• First respondersFirst responders• Patient transportersPatient transporters• Co-workers, friends, Co-workers, friends,

others with close others with close contact to contact to symptomatic respiratorysymptomatic respiratory

Contact ManagementContact ManagementAntibiotics and MonitoringAntibiotics and Monitoring

• Doxycycline is first choiceDoxycycline is first choice• Alternatives: Tetracyclines, sulfonamides, Alternatives: Tetracyclines, sulfonamides,

chloramphenicolchloramphenicol• IND for gentamicin,IND for gentamicin,

ciprofloxacinciprofloxacin• Temperature twice dailyTemperature twice daily• Unrestricted unless fever or Unrestricted unless fever or cough developscough develops

Contact ManagementContact Management

• Prophylaxis refusal – Prophylaxis refusal – monitor x 7 daysmonitor x 7 days

• Special populations Special populations managementmanagement

• No vaccine with No vaccine with proven efficacyproven efficacy

Other Management IssuesOther Management Issues

• Mass prophylaxis clinicsMass prophylaxis clinics

• Monitor news announcementsMonitor news announcements

• Environmental samplingEnvironmental sampling

Environmental AssessmentEnvironmental Assessment

• Goals of AssessmentGoals of Assessment– Infected animalsInfected animals– Infectious fleasInfectious fleas– Contaminated surfaces, soils, Contaminated surfaces, soils,

water supplieswater supplies

• Plague bacteria survive Plague bacteria survive poorly externallypoorly externally

• Short-term risk for humansShort-term risk for humans

Environmental TestingEnvironmental Testing

• Plague in animals, new regionsPlague in animals, new regions

• Need for vector or rodent controlNeed for vector or rodent control

• Control and prevention measuresControl and prevention measures

• Need for follow-up surveillanceNeed for follow-up surveillance

• Effectiveness of Effectiveness of

control measurescontrol measures

Review Questions – PlagueReview Questions – PlagueLesson 6Lesson 6

Public Health ManagementPublic Health Management

Plague Review QuestionPlague Review QuestionLesson 6, Question 1Lesson 6, Question 1

• Mass casualty situationMass casualty situation

• Bioterrorist attack with plagueBioterrorist attack with plague

• Public health wants you to interview Public health wants you to interview patients for movement in past weekpatients for movement in past week

Why are they doing this to you now?Why are they doing this to you now?



A.A. Look like they’re doing somethingLook like they’re doing something

B.B. Determine source of exposureDetermine source of exposure

C.C. B and DB and D

D.D. Prophylaxis recommendation Prophylaxis recommendation developmentdevelopment



C.C. B and DB and D– Determine source of exposureDetermine source of exposure– Prophylaxis recommendationsProphylaxis recommendations


• You’re on hospital emergency response You’re on hospital emergency response teamteam

• Categorizing plague cases at your hospitalCategorizing plague cases at your hospital

A confirmed case would NOT include…A confirmed case would NOT include…



A.A. Confirmed isolation of Confirmed isolation of Y. pestisY. pestis

B.B. IHC staining of IHC staining of Y. pestisY. pestis

C.C. Stained organisms of Stained organisms of Y. pestisY. pestis

D.D. Fourfold or greater increase in antibody Fourfold or greater increase in antibody titer to F1 antigentiter to F1 antigen



C. Stained organisms of C. Stained organisms of Y. pestisY. pestis


• You’re a public health workerYou’re a public health worker

• State epidemiologists asks you to State epidemiologists asks you to determine if plague case is natural or determine if plague case is natural or bioterroristbioterrorist

Which would best describe naturally Which would best describe naturally occurring plague?occurring plague?



A.A. History of sporadic cases in areaHistory of sporadic cases in area

B.B. 1 patient only1 patient only

C.C. Patient has history of rodent exposurePatient has history of rodent exposure

D.D. All of the aboveAll of the above



D.D. All of the aboveAll of the above– History of sporadic casesHistory of sporadic cases– Only 1 caseOnly 1 case– History of rodent exposureHistory of rodent exposure


• Plague bioterror eventPlague bioterror event

• Identifying close contactsIdentifying close contacts

• Considering antibiotic prophylaxisConsidering antibiotic prophylaxis

Which of the following fall is not considered Which of the following fall is not considered a close contact?a close contact?



A.A. Friends in another cityFriends in another city

B.B. Patient transportersPatient transporters

C.C. Household members of respiratoryHousehold members of respiratory

D.D. Co-workers within 6 feetCo-workers within 6 feet



A.A. Friends in another cityFriends in another city

Review QuestionReview QuestionLesson 6, Question 5Lesson 6, Question 5

• Plague bioterror eventPlague bioterror event

• Large number of casualtiesLarge number of casualties

• You’re on local emergency response teamYou’re on local emergency response team

What activity would you expect from What activity would you expect from response leaders?response leaders?



A.A. Quarantine entire cityQuarantine entire city

B.B. Drop individual investigationsDrop individual investigations

C.C. Symptomatic patients stay homeSymptomatic patients stay home

D.D. Establishment of treatment centersEstablishment of treatment centers



D. Establishment of treatment centersD. Establishment of treatment centers

6) You work at a public health department in New Mexico. Your local hospital has a positive test in their lab for a single case of suspect pneumonic plague. The patient has a documented exposure to an ill animal. How will you manage this patient?

B. Look for all close contacts to the patient and begin on prophylaxis.

C. Stop the referral testing at the public health lab. We know it’s plague because there was an ill animal.

A. I won’t do anything. The patient is being treated.

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Plague: Lesson 6- Public Health Issues

Plague: Lesson 6- Public Health Issues

Module: Plague

BT Agents

BT Agents Home

Module Introduction-

Module Objectives

Target Audience

Continuing Education Credit

Lessons-

1) General Overview

2) Clinical Presentation

3) Differential Diagnosis

4) Laboratory Issues

5) Medical Management

6) Public Health Issues

7) Veterinarian Issues

8) Module Self-Assessment

Additional Resources

6-21. Question

A. The best answer is B. It is important that all close contacts to a pneumonic plague case receive prophylaxis.

B. Correct. It is important that all close contacts to a pneumonic plague case receive prophylaxis.

C. The best answer is B. Even naturally-occurring cases of plague should be laboratory confirmed. It is also important that all close contacts to a pneumonic plague case receive prophylaxis.


• You work in public health in New MexicoYou work in public health in New Mexico

• Local hospital with suspect plagueLocal hospital with suspect plague

• Documented exposure to ill animalDocumented exposure to ill animal

How will you manage this patient?How will you manage this patient?



A.A. Nothing. Patient is being treated.Nothing. Patient is being treated.

B.B. Manage all close contactsManage all close contacts

C.C. Stop referral testing. There was a sick Stop referral testing. There was a sick animal. We know it’s plague.animal. We know it’s plague.



B. Manage all close contactsB. Manage all close contacts

Bioterrorism Agents – Plague Lesson 6 Public Health Management.

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