Presentation on theme: "and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho."— Presentation transcript:
and Presented by Dr. Roslyn Bascombe-Adams Leaders - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho Rios, Jamaica
Overview 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 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.
Is there a credible risk of BNC warfare? The world today… – Terrorists ( high profile events, crowds, critical infrastructure..) – Doomsday cults – Insurgents U.S.A. s current war policies Consider flight paths of large airlines Geneva convention/duty to respond to vessel in distress
Do we OWE it to ourselves to prepare? Fore-warned is Fore-armed! ??????????
Agents of Most Concern Agents of Most Concern BLISTER AGENTS NERVE AGENTS
Coping with Chemical Agents IDENTIFY COMMUNICATE SECURE DECONTAMINATE TRIAGE TREAT RECEIVE/DISPOSE
Identifying Chemical Agents Usually overt attack/incident Burns to skin and mucosa, usu. within 2 mins Cardio-pulmonary injury/failure Shock Neurological damage Trauma Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
1. 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 Agents Used before (Gulf war, Japan subway) Massive cholinergic neurological stimulation SLUDGE syndrome ( salivation, lacrimation [ excess tears ], urination,diarrhoea, gastric emptying [ vomiting ] ) Miosis ( pinpoint pupils ) Fasciculations Seizures Flaccid paralysis Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Coping with Chemical Agents - 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. Schematic of Communication Cascade if indicated Poison Control Chief of Staff CEO Duty Doctor ER Director CMO CDC Initiator Duty Nurse Triage Nurse/EMTs Charge Nurse Nurse Supervisor Clin. Coordin Prog. Manager Security Manager
Coping with Chemical Exposure -Securing- Scene safety done by Police and Fire Due concern is given to exposed population, rescuers, victims, property Working 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 Exposure -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 Agents -Decontamination- Fire service has Hazmat branch and 1 0 responsibility Emergency Staff may be needed in a 2 o response Police may be needed in a 2 0 response e.g. explosives present, social disruption For rescue safety purposes, decontamination takes priority over care-giving. Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Coping with Chemical Agents -Decontamination- Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose Impact zone Decon Zone Advanced Medical Post (AMP)
Coping with Chemical Exposure - Triaging - Assess need to activate MCM plan Get additional – Staff – Oxygen – Nebulizers – Antidote – Medications – Safety gear, (Level II protective gear) Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Coping with Chemical Agents -Triaging- Triage will follow standard MCM practices – RED immediate priority – Yellow urgent priority – Green non-urgent – Black dead Remember: triage to treat on site and then triage to transport Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Coping with Chemical Exposure - Treating - Treat as clinically indicated Oxygen Nebulization Atropine IV for SLUDGE, until bronchial secretions decreases. 3-5mg/5-10 minutes 2-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 exposure - 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 Agents Use 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 Agents Likely to be covert Delayed impact because of incubation period Health care workers in the forefront as initiators Public health surveillance has prominent role Early communication is key
Close Cooperation with clinicians, healthcare and first responder communities Emergency departments, urgent care centers Infection control units Physician networks, private offices Hospitals, HMOs Medical examiners Poison control Law enforcement, fire, other first responders Eric K. Noji, M.D., M.P.H.
Anthrax - 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 Path of airborne Anthrax MOSCO W Sverdlov sk
ANTHRAX WHAT TO DO? Identify Contain Communicate Triage Treat Receive/Dispose
Anthrax High index of suspicion needed Travel history or exposure to suspect source Infectious contacts (for cutaneous) Employment history Activities over the preceding 3-5 days
Cutaneous Anthrax, face CDC Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Anthrax GASTROINTESTIONAL ANTHRAX Generally follows ingestion of contaminated, under-cooked meat Acute inflammation of GI tract Nausea, vomiting, loss of appetite Later, abdo pain, hemoptysis, severe diarrhea Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Aerosol / Infectivity Relationship (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 Anthrax 1 – 60 day incubation period Fever, myalgias, cough, and fatigue Initial improvement Abrupt onset of respiratory distress, shock Nonspecific physical findings Pneumonia is rare CXR - 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, 1961 Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Hemorrhagic Meningitis from Inhalation Anthrax CDC, 1966
Anthrax If highly clinical suspect or confirmed case, open lines of communication If 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
ANTHRAX Considered highly infectious if spores are inhaled ( or more spores needed) Low re-infectivity after spores fall Hazmat precautions are initiated to prevent or minimize inhalation anthrax from suspect packages Identify/Communicate/Contain/Decontaminate/Triage/Treat/Receive/Dispose
Anthrax For 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
ANTHRAX Unlikely to have MCM-type situation Manage according to clinical indications Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
ANTHRAX PROPHYLAXIS 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
ANTHRAX For 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 lesions Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
ANTHRAX For Inhalation and Gastro-intestinal anthrax, 1.Ciprofloxcin 400 mg IV Q8-12H OR Doxycycline 100 mg IV Q12H PLUS 2. Rifampin 600 mg po bid 3. Clindamycin 600 mg IV bid (vancomycin, penicillin, chloramphenicol, imipenem,clarithromycin) Consider Steroids Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
BOTULISM Gram positive bacillus Produces potent neurotoxin which inhibits release of acethylcholine Characteristic flaccid paralysis Usually food-borne Can be aerosolized
BOTULISM IDENTIFY High index of suspicion Incubates 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
BOTULISM CONTAIN Not transmitted person to person Routine immunization not required Standard precautions to manage Identify/Contain/Communicate/Triage/Treat/Receive/Dispose
BOTULISM COMMUNICATION Open crisis channels Duty doctor +/- charge nurse TRIAGE As clinically indicated Identify/Contain/Communicate/Triage/Treat/Receive/Dispose
BOTULISM TREATMENT Botulism antitoxin available Toxin may be found in serum, stool samples, gastric secretions Routine blood tests of limited value May need ventilator support from 2-3 months Identify/Communicate/Triage/Treat/Receive/Dispose
PLAGUE Gram negative bacillus Usually transmitted by infected fleas Can be aerosolized/weaponized Inhaled version causes PNEUMONIC rather than bubonic plague Incubation 2-8 days by fleas but 1 – 3 days by aerosol
Plague Disease Complex Inhalational Systemic Toxicity Respiratory failure & circulatory collapse/Death Liver enzymes 6% late meningitis Fulminant Pneumonia Fever, URI syndrome Sudden onset Fever/rigors Tender bubo cm APTT ecchymosis DIC Stridor, cyanosis, productive cough, Hemoptysis, bilateral infiltrates Pharyngitis 2 -3 days days 24 hrs 9% Erythema
Plague Late complications of septicemia or pneumonic plague may include acral gangrene of digits nose, earlobes, penis Identify/Contain/Communicate//Triage/Treat/Receive/Dispose
Pneumonic Plague Prevention of Secondary Infection 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
PLAGUE CONTAIN Remove clothes, bag, shower thoroughly Person-to-person spread by large droplets Standard and Droplet precautions Contagious until hours of antibiotics No vaccines available Identify/ Contain/Communicate/Decontaminate/Triage/Treat/Receive/Dispose
PLAGUE TREATMENT Doxycycline 100 mg bid Ciprofloxicin 500 mg bid Initiate 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
SMALLPOX Acute viral illness High morbidity in non-immune persons Incubates 7-17 days (average 12)
SMALLPOX IDENTIFY Flu-like illness 2-4 day prodrome Skin lesions Prominent 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 Secondary 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
SMALLPOX 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
SMALLPOX PROPHYLAXIS Vaccine available and effective Immunize within 3 days of exposure After 3 days give VIG (vaccinia immune- globins) as well Isolate victims and contacts, separately (17-day quarantine) Identify/ Contain/Communicate/Triage/Treat/Receive/Dispose
Psychological Issues Distress may be evident in:- Thinking Physical Emotional Behaviour
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 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 moments notice anywhere in the country Alexander Langmuir Founder of CDC EIS Program 1952
Key to Planning Establish Chain of command Know Communications lines Establish reporting and prompt data collection methods Education of ED staff Education of healthcare workers Utilize Local news media to reliably inform population.
Recommendations 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 Challenges Real-time transmission and analysis Identification of localized clusters Sustainability of surveillance system Development of response protocols Eric K. Noji, M.D., M.P.H.
Unanswered Questions What is the threshold that initiates response What is the sensitivity and specificity of surveillance systems Usefulness 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 INITIATIVE CONTACT INFORMATION NATIONAL BIOTERRORISM PREPAREDNESS AND RESPONSE INITIATIVE CONTACT INFORMATION Centers For Disease Control and Prevention Cand Response Program (BPRP) Atlanta, Georgia
THREAT IS REAL PREPAREDNESS IS THE KEY PLANS INEFFECTIVE UNTIL KNOWN WHEN IS THE BEST TIME FOR ACTION? WITH LUCK, WELL NEVER HAVE TO INITIATE A RESPONSE PLAN How lucky do you feel today??