1. Bioterrorism Agents – Plague Lesson 6 Public Health Management

2. Objectives Purposes of epidemiological investigationsPurposes of epidemiological investigations Case definitionsCase definitions Sentinel events indicating bioterrorismSentinel events indicating bioterrorism Public health responsePublic health response –Natural Plague –Bio-terrorist Plague Contact management and prophylaxisContact management and prophylaxis

3. Principal Purposes of Epidemiologic Investigations Characterize cases and confirm outbreakCharacterize cases and confirm outbreak IdentifyIdentify –Causative agent –Source –Mode of Transmission IdentifyIdentify –Cases –Case Contacts

4. 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 Epidemiologic Investigations

5. Plague Case Definitions Suspect and Probable Suspect CaseSuspect Case –Clinically compatible –Clinical specimens – features of Y. pestis Probable CaseProbable Case – Clinically compatible –Presumptive laboratory results Positive DFAPositive DFA PCR evidence of Y. pestisPCR evidence of Y. pestis Single elevated serum antibody titer to F1 antigenSingle elevated serum antibody titer to F1 antigen

6. Plague Case Definitions Confirmed Confirmed CaseConfirmed Case –Confirmatory isolation of Y. pestis –  4-fold change in antibody titer to F1 antigen –IHC staining can be considered when isolation or serology not possible

7. Early Cases Lab confirmation importantLab confirmation important –First cases in geographic area –Treatment and isolation –Post- or pre-exposure prophylaxis –Other controls Call public healthCall public health immediately immediately

8. Natural 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

9. Natural Disease vs Bioterrorism Natural Plague Recent endemic exposureRecent endemic exposure Handling of sick cat, flea bites in endemic areaHandling of sick cat, flea bites in endemic area Recent travel to endemic areaRecent travel to endemic area Sporadic, infrequent casesSporadic, infrequent cases Bubonic most commonBubonic most commonpresentation

10. Natural Disease vs Bioterrorism Bioterrorist Plague No known endemic exposureNo known endemic exposure Point source in urban, crowded settingPoint source in urban, crowded setting Severe respiratory illnessSevere respiratory illness Cluster of severe and fatal pneumoniaCluster of severe and fatal pneumonia Plague cases that don’t respond to recommended antibiotic treatmentPlague cases that don’t respond to recommended antibiotic treatment

11. Control and Containment Initial Stages Sampling of environmentSampling of environment Definition of dispersionDefinition of dispersion Confirmation of Y. pestisConfirmation of Y. pestis Deploy SNSDeploy SNS Epidemiologic InvestigationEpidemiologic Investigation Animal controlAnimal control CommunicationsCommunications

12. Coordination of activitiesCoordination of activities Active surveillanceActive surveillance Assisted surveillanceAssisted surveillance Clinician Information RequestsClinician Information Requests –Number of plague patients –Number of plague rule-outs –Chart review for unrecognized illness Control and Containment Initial Stages

13. Chart Reviews ER discharges, admits, transfersER discharges, admits, transfers Non-lab confirmed fevers, pneumoniasNon-lab confirmed fevers, pneumonias Prioritize hospitalized patientsPrioritize hospitalized patients Follow-up on those transferred outFollow-up on those transferred out Critical for determining extent and source of outbreakCritical for determining extent and source of outbreak

14. Symptomatic Patient Evaluation Seek care: febrile respiratory, other plague compatible syndromesSeek care: febrile respiratory, other plague compatible syndromes Referral and triage hospitalsReferral and triage hospitals Isolation and respiratory droplet precautionIsolation and respiratory droplet precaution All fevers 38.5  C or higher or cough presumptive pneumonic plagueAll fevers 38.5  C or higher or cough presumptive pneumonic plague

15. Contact Management Contact – Within 6-7 feet, or 2 meters, of patient in prior 7 days Evaluate contacts with fever or coughEvaluate contacts with fever or cough 7 days prophylaxis and symptom monitoring7 days prophylaxis and symptom monitoring

16. Contact Management Prophylaxis Groups Exposed to Y. pestis releaseExposed to Y. pestis 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 contact to symptomatic respiratory

17. Contact Management Antibiotics and Monitoring Doxycycline is first choiceDoxycycline is first choice Alternatives: Tetracyclines, sulfonamides, chloramphenicolAlternatives: Tetracyclines, sulfonamides, chloramphenicol IND for gentamicin,IND for gentamicin,ciprofloxacin Temperature twice dailyTemperature twice daily Unrestricted unless fever orUnrestricted unless fever or cough develops

18. Contact Management Prophylaxis refusal – monitor x 7 daysProphylaxis refusal – monitor x 7 days Special populations managementSpecial populations management No vaccine with proven efficacyNo vaccine with proven efficacy

19. Other Management Issues Mass prophylaxis clinicsMass prophylaxis clinics Monitor news announcementsMonitor news announcements Environmental samplingEnvironmental sampling

20. Environmental Assessment Goals of AssessmentGoals of Assessment –Infected animals –Infectious fleas –Contaminated surfaces, soils, water supplies Plague bacteria survive poorly externallyPlague bacteria survive poorly externally Short-term risk for humansShort-term risk for humans

21. Environmental 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 ofEffectiveness of control measures

22. Review Questions – Plague Lesson 6 Public Health Management

23. Plague Review Question Lesson 6, Question 1 Mass casualty situationMass casualty situation Bioterrorist attack with plagueBioterrorist attack with plague Public health wants you to interview patients for movement in past weekPublic health wants you to interview patients for movement in past week Why are they doing this to you now?

24. Plague Review Question Lesson 6, Question 1 Why are they doing this to you now? A.Look like they’re doing something B.Determine source of exposure C.B and D D.Prophylaxis recommendation development

25. Plague Review Question Lesson 6, Question 1 Why are they doing this to you now? C.B and D –Determine source of exposure –Prophylaxis recommendations

26. Plague Review Question Lesson 6, Question 2 You’re on hospital emergency response teamYou’re on hospital emergency response team Categorizing plague cases at your hospitalCategorizing plague cases at your hospital A confirmed case would NOT include…

27. Plague Review Question Lesson 6, Question 2 A confirmed case would NOT include… A.Confirmed isolation of Y. pestis B.IHC staining of Y. pestis C.Stained organisms of Y. pestis D.Fourfold or greater increase in antibody titer to F1 antigen

28. Plague Review Question Lesson 6, Question 2 A confirmed case would NOT include… C. Stained organisms of Y. pestis

29. Plague Review Question Lesson 6, Question 3 You’re a public health workerYou’re a public health worker State epidemiologists asks you to determine if plague case is natural or bioterroristState epidemiologists asks you to determine if plague case is natural or bioterrorist Which would best describe naturally occurring plague?

30. Plague Review Question Lesson 6, Question 3 Which would best describe naturally occurring plague? A.History of sporadic cases in area B.1 patient only C.Patient has history of rodent exposure D.All of the above

31. Plague Review Question Lesson 6, Question 3 Which would best describe naturally occurring plague? D.All of the above –History of sporadic cases –Only 1 case –History of rodent exposure

32. Plague Review Question Lesson 6, Question 4 Plague bioterror eventPlague bioterror event Identifying close contactsIdentifying close contacts Considering antibiotic prophylaxisConsidering antibiotic prophylaxis Which of the following fall is not considered a close contact?

33. Plague Review Question Lesson 6, Question 4 Which of the following fall is not considered a close contact? A.Friends in another city B.Patient transporters C.Household members of respiratory D.Co-workers within 6 feet

34. Plague Review Question Lesson 6, Question 4 Which of the following fall is not considered a close contact? A.Friends in another city

35. Review Question Lesson 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 response leaders?

36. Plague Review Question Lesson 6, Question 5 What activity would you expect from response leaders? A.Quarantine entire city B.Drop individual investigations C.Symptomatic patients stay home D.Establishment of treatment centers

37. Plague Review Question Lesson 6, Question 5 What activity would you expect from response leaders? D. Establishment of treatment centers

38. 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. Next Back 21 of _ 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 OverviewGeneral Overview 2) Clinical PresentationClinical Presentation 3) Differential DiagnosisDifferential Diagnosis 4) Laboratory IssuesLaboratory Issues 5) Medical ManagementMedical Management 6) Public Health Issues 7) Veterinarian IssuesVeterinarian Issues 8) Module Self-Assessment Additional ResourcesModule Self-AssessmentAdditional 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.

39. Plague Review Question Lesson 6, Question 6 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?

40. Plague Review Question Lesson 6, Question 6 How will you manage this patient? A.Nothing. Patient is being treated. B.Manage all close contacts C.Stop referral testing. There was a sick animal. We know it’s plague.

41. Plague Review Question Lesson 6, Question 6 How will you manage this patient? B. Manage all close contacts