and and
Presented by Dr. Roslyn Bascombe-Adams
“Leaders” - International Course for Managers on Health,
Disasters and Development
February 18th 2003, Ocho Rios, Jamaica
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.
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.
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
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
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!
??????????
Chemical AgentsChemical Agents
Blister agents– Mustard gas, phosgene oxime
Nerve Agents– Sarin, Ricin, Tabun, GF, VX,
Pulmonary Agents– Phosgene, chlorine
Pesticides– Organophosphates
Agents of Most ConcernAgents of Most Concern
BLISTER AGENTS
NERVE AGENTS
Coping with Chemical AgentsCoping with Chemical AgentsIDENTIFYCOMMUNICATESECUREDECONTAMINATETRIAGETREATRECEIVE/DISPOSE
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
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
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
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
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
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
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
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
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)
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
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
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
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
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
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
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.
Potential Biological agentsPotential Biological agents
CATEGORY A AGENTS (CDC)Bacillus anthracis – AnthraxClostridium botulinum – BotulismYersinia pestis – PlagueVariola major – SmallpoxFrancisella tularensis – tularemiaViral Hemorrhagic fevers
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)
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
ANTHRAXANTHRAX
WHAT TO DO?IdentifyContainCommunicateTriageTreatReceive/Dispose
AnthraxAnthrax
High index of suspicion neededTravel history or exposure to suspect sourceInfectious contacts (for cutaneous)Employment historyActivities over the preceding 3-5 days
Cutaneous Anthrax, face CDC
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Cutaneous Anthrax CDC
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Cutaneous AnthraxCutaneous Anthrax
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Cutaneous AnthraxCutaneous AnthraxDifferential DiagnosisDifferential Diagnosis
Spider biteEcthyma gangrenosumUlceroglandular tularemiaPlagueStaphlococcus cellulitisStreptococcal cellulitis
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
Anthrax SporesAnthrax Spores
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
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
Inhalation Anthrax widened mediastinum 22 hours before death
CDC/Dr. P.S. Brachman, 1961Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Hemorrhagic Meningitis from Inhalation Anthrax
CDC, 1966
Inhalational AnthraxInhalational AnthraxDifferential DiagnosisDifferential Diagnosis
Mycoplasmal pneumoniaLegionnaires DiseasePsittacosisTularemiaQ feverViral PneumoniaHistoplasmosis (fibrous mediastinitis)Coccidioidomycosis
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
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
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
ANTHRAXANTHRAX
Unlikely to have MCM-type situation
Manage according to clinical indications
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
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
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
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
BOTULISMBOTULISM
Gram positive bacillusProduces potent neurotoxin which inhibits
release of acethylcholineCharacteristic flaccid paralysisUsually food-borneCan be aerosolized
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
BOTULISMBOTULISM
CONTAINNot transmitted person to personRoutine immunization not requiredStandard precautions to manage
Identify/Contain/Communicate/Triage/Treat/Receive/Dispose
BOTULISMBOTULISM
COMMUNICATIONOpen crisis channelsDuty doctor +/- charge nurse
TRIAGEAs clinically indicated
Identify/Contain/Communicate/Triage/Treat/Receive/Dispose
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
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
PLAGUEPLAGUEIDENTIFY Fever, cough, chest pain Haemopytsis Muco-purulent sputum Bronchopneumonia on X-ray
Identify/Contain/Communicate/Triage/Treat/Receive/Dispose
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
PlaguePlague
Late complications of septicemia orpneumonic plague may include acral gangrene of digitsnose, earlobes,penis
Identify/Contain/Communicate//Triage/Treat/Receive/Dispose
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
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
PLAGUEPLAGUE
COMMUNICATEActivate crisis linesInvolve infection control practitioner ASAP
Identify/ Contain/Communicate/Triage/Treat/Receive/Dispose
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
SMALLPOXSMALLPOX
Acute viral illnessHigh morbidity in non-immune personsIncubates 7-17 days (average 12)
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
Adult with Smallpox rash
CDC/NIP/Barbara Rice
Child with Smallpox rash
CDC/Cheryl Tryon
Close-up Smallpox rash
CDC/James Hicks, 1973
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
Last child with Smallpox
CDC
Last adult with naturally occurring Smallpox, 1977
World Health Organization
-1980--1980-
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
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
Isolation PrecautionsIsolation Precautions
AnthraxStandard
PlagueDroplet
Smallpox Airborne (Respiratory)
Botulism Standard Tularemia Standard
Psychological IssuesPsychological Issues
Distress may be evident in:-ThinkingPhysicalEmotionalBehaviour
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.
•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
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
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.
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.
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.
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.
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
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??”
THE ENDTHE END
THE END