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

3. 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.

4. 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.

5. Disaster 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

6. 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

7. Do we OWE it to ourselves to prepare? Fore-warned is Fore-armed! ??????????

8. Chemical Agents Blister agents – Mustard gas, phosgene oxime Nerve Agents – Sarin, Ricin, Tabun, GF, VX, Pulmonary Agents – Phosgene, chlorine Pesticides – Organophosphates

9. Agents of Most Concern Agents of Most Concern BLISTER AGENTS NERVE AGENTS

10. Coping with Chemical Agents IDENTIFY COMMUNICATE SECURE DECONTAMINATE TRIAGE TREAT RECEIVE/DISPOSE

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Coping with Chemical Agents -Decontamination- Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose Impact zone Decon Zone Advanced Medical Post (AMP)

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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.

27. Potential Biological agents CATEGORY A AGENTS (CDC) Bacillus anthracis – Anthrax Clostridium botulinum – Botulism Yersinia pestis – Plague Variola major – Smallpox Francisella tularensis – tularemia Viral Hemorrhagic fevers

28. Anthrax Gram positive bacillus May 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)

29. 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

30. ANTHRAX WHAT TO DO? Identify Contain Communicate Triage Treat Receive/Dispose

31. 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

34. Cutaneous Anthrax, face CDC Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

35. Cutaneous Anthrax CDC Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

39. Cutaneous Anthrax Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

40. Cutaneous Anthrax Differential Diagnosis Spider bite Ecthyma gangrenosum Ulceroglandular tularemia Plague Staphlococcus cellulitis Streptococcal cellulitis

41. 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

42. Anthrax Spores

43. 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

44. 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

45. Inhalation Anthrax widened mediastinum 22 hours before death CDC/Dr. P.S. Brachman, 1961 Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

46. Hemorrhagic Meningitis from Inhalation Anthrax CDC, 1966

47. Inhalational Anthrax Differential Diagnosis Mycoplasmal pneumonia Legionnaires Disease Psittacosis Tularemia Q fever Viral Pneumonia Histoplasmosis (fibrous mediastinitis) Coccidioidomycosis

48. 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

49. ANTHRAX Considered highly infectious if spores are inhaled (2500-5000 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

50. 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

51. ANTHRAX Unlikely to have MCM-type situation Manage according to clinical indications Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

52. 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

53. 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

54. 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

55. BOTULISM Gram positive bacillus Produces potent neurotoxin which inhibits release of acethylcholine Characteristic flaccid paralysis Usually food-borne Can be aerosolized

56. BOTULISM IDENTIFY 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

57. BOTULISM CONTAIN Not transmitted person to person Routine immunization not required Standard precautions to manage Identify/Contain/Communicate/Triage/Treat/Receive/Dispose

58. BOTULISM COMMUNICATION Open crisis channels Duty doctor +/- charge nurse TRIAGE As clinically indicated Identify/Contain/Communicate/Triage/Treat/Receive/Dispose

59. 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

60. 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

61. PLAGUE IDENTIFY Fever, cough, chest pain Haemopytsis Muco-purulent sputum Bronchopneumonia on X-ray Identify/Contain/Communicate/Triage/Treat/R eceive/Dispose

62. 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 1 - 10 cm APTT ecchymosis DIC Stridor, cyanosis, productive cough, Hemoptysis, bilateral infiltrates Pharyngitis 2 -3 days 2 - 10 days 24 hrs 9% Erythema

63. Plague Late complications of septicemia or pneumonic plague may include acral gangrene of digits nose, earlobes, penis Identify/Contain/Communicate//Triage/Treat/Receive/Dispose

64. 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

65. PLAGUE CONTAIN Remove clothes, bag, shower thoroughly Person-to-person spread by large droplets Standard and Droplet precautions Contagious until 48 - 72 hours of antibiotics No vaccines available Identify/ Contain/Communicate/Decontaminate/Triage/Treat/Receive/Dispose

66. PLAGUE COMMUNICATE Activate crisis lines Involve infection control practitioner ASAP Identify/ Contain/Communicate/Triage/Treat/Receive/Dispose

67. 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

68. SMALLPOX Acute viral illness High morbidity in non-immune persons Incubates 7-17 days (average 12)

69. 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

71. Adult with Smallpox rash CDC/NIP/Barbara Rice

72. Child with Smallpox rash CDC/Cheryl Tryon

73. Close-up Smallpox rash CDC/James Hicks, 1973

74. Smallpox - Prevention of Secondary Infection Contagious All contacts are quarantined for at least 17 days Infectious until all scabs are healed over

75. Last child with Smallpox CDC

76. Last adult with naturally occurring Smallpox, 1977 World Health Organization

77. -1980-

78. 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

79. 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

80. Isolation Precautions Anthrax Standard Plague Droplet SmallpoxAirborne (Respiratory) BotulismStandard TularemiaStandard

81. Psychological Issues Distress may be evident in:- Thinking Physical Emotional Behaviour

82. 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.

83. 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

84. 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

85. 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.

86. 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.

87. 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.

88. 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.

89. 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 30033 770-488-7100 www.bt.cdc.gov

90. 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??

91. THE END