1. Bioterrorism Mass Casualty Response: Current Concepts and Controversies
European Masters in Disaster Medicine
Sandigliano, Italy
02 May 2005
Eric K. Noji, M.D., M.P.H., FACEP
Medical Epidemiologist
Centers for Disease Control & Prevention
Washington, D.C.

3. The Immediate Future – A Revolution in biotechnology, genomics and proteomics that will affect all human beings

6. “A bioterrorism attack anywhere in the world is inevitable in the 21st century.” Anthony Fauci, Director, NIAID
Clinical Infectious Diseases 2001;32:678

7. Smallpox Infected People Disperse
Flights to thirty eight US cities with infected passengers

8. … Life Has Changed for us all
I find this image and the next two genuinely terrifying. I hesitated using them here -- in part because they might be regarded as EXPLOITING the suffering of those who died or were left behind with horrible loss.
But it is important, I believe, NOT to forget that – for good reason – it is TERROR which lends its name to terrorism.

9. Conventional (Explosive) Biological / Radoilogic
CBRNE Agents
Conventional (Explosive)
Chemical
Biological / Radoilogic
Onset
Instant
Rapid
Often Delayed
Source
Obvious
Often covert
First Victim Encounter
Prehospital
Hospital
Containment
Easy
Relatively Easy
Difficult
Decon Helpful
Usually Not
Yes
Usually Not*

14. Infection: Invasion of a host by an agent, with subsequent establishment and multiplication of the agent. An infection may or may not lead to disease.
Disease
results only if and when, as a consequence of the invasion and growth of a pathogen, tissue function is impaired.

15. Thou shalt Protect Thyself

16. Protection Against BW Physical Personal protective gear Chemical
pre- & post-exposure antibiotics
Immunologic
passive (e.g. Botulinum antitoxin)
active (e.g. Anthrax & Vaccinia vaccines)

20. Thou shalt Decontaminate as Appropriate

21. Decontamination after Biological Attack
Materiel
often unnecessary
less relevant than for Chem attack
5.0% bleach more than adequate
0.1% bleach kills anthrax spores
Personnel
decon rarely needed
less relevant than for Chem attack
soap & water
use common sense

22. Diagnosis
Clinical
Epidemiological
Laboratory

23. Anthrax (Bacillus anthracis)
Inhalational, gastrointestinal, cutaneous
NOT communicable (except maybe cutaneous)
Vaccine not available for civilian use
20%-80% mortality

24. Anthrax: Inhalational
Inhalation of spores
Incubation: 1 to 43 days
Initial symptoms (2-5 d)
Fever, cough, myalgia, malaise
Terminal symptoms (1-2d )
High fever, dyspnea, cyanosis
Hemorrhagic mediastinitis/effusion
Rapid progression shock/death
Mortality rate ~ 100% w/o RX

25. Varying Presentations of NYC Cutaneous Lesions

26. Diagnosis
-Diagnosis difficult given diseases have been seen by few living clinicians
-Abnormal presentations of classical diseases may be present due to super infection
-Diagnosis critical for epidemiological monitoring
-Accurate data required for potential future prosecution of war crimes
-Psychogenic overlay may cloud the diagnostic process

28. Small Pox (Variola major virus)
Transmitted primarily by aerosol route, contaminated clothes & linens
Highly communicable
Vaccine can lessen the severity of disease if given within 4 days of exposure

29. Increasing Global Travel
Rapid access to large populations
Poor global security & awareness
...create the potential for simultaneous creation of large numbers of casualties

30. Epidemiological Pattern of Smallpox Weapon
New foci of
secondary infection
“Contaminated” zone
“Infected” zone
Zone of initial
explosion

32. Pneumonic Plague Caused by infection with Yersinia Pestis
Pneumonic form will occur after intentional aerosol delivery
Incubation period of 1-7 days

34. Obtaining Specimens CBC, ABG Nasal Swabs (culture, PCR)
Blood for Bacterial Culture, PCR
Serology
Sputum Bacterial Culture
Toxin Assays (blood, urine)
Throat Swab (viral culture, PCR, ELISA)
Environmental Samples?

35. Where to Send Specimens?
Local
Clinical
Lab
Laboratory
Channels
520th
TAML
USAMRIID
USAMRICD

37. Thou shalt Render Prompt Treatment

38. Biological Warfare Diseases Non-Specific Febrile Presentations

39. Smallpox: Current Vaccine
Made from live Vaccinia virus
ID inoculation with bifurcated needle (scarification)
Pustular lesion/induration surrounding central scab/ulcer 6-8 days post-vaccination
Low grade fever, axillary lymphadenopathy
Scar (permanent) demonstrates successful vaccination
Immunity not life-long
Vaccine is live vaccinia virus (not smallpox virus)
Intradermal inoculation
Unique vaccination method compared to other current vaccination techniques (scarification with a bifurcated needle)
Scar after vaccination was evidence of successful vaccination
Immunity is not life-long
Average immunity after vaccination 3-10 yrs.
WHO

43. Thou shalt Practice Good Infection Control

44. Isolation Precautions Biowarfare Diseases
Pneumonic Plague
Droplet Precautions
Smallpox
? Airborne Precautions
“Strict Quarantine”
Viral Hemorrhagic Fevers
Contact Precautions

45. What is the US Health Care System?
Roughly 6000 hospitals
615,000 physicians and surgeons
2.4 million registered nurses
240,000 pharmacists
Approximately $390 billion spent on healthcare in 2003
$15.5 billion spent on hospital construction (2001)

46. Current Issues
The US healthcare system functions at capacity on a daily basis
Expansion (surge) capability relies on federal programs that take time to deploy
Personnel engaged in healthcare are already functioning at maximum
Contagious patients may render existing facilities inoperable
No formal process to identify who is in charge (of what) when using multi-jurisdictional assets

47. WORSENING SITUATION IN US
Many hospitals on diversion during normal times (no inpatient beds, consultants)
Decreasing number of emergency depts, trauma centers, inpatient beds
Not economically viable for hospitals to maintain surge capacity,

55. Metropolitan Medical Response System MMRS
Enhancing existing local first responder, medical, public health and emergency planning to increase capabilities to manage the incident until Federal resources arrive (typically hours)

57. National Disaster Medical System
MAJOR COMPONENTS
Medical Response
Patient Evacuation
Definitive Medical Care

59. Strategic National Stockpile
Twelve push packages ready for deployment within 12 hours anywhere in the U.S.
Vendor Managed Inventory (VMI) – specific medical supplies needed to control and contain outbreaks of infectious diseases and other emergency incidents

62. SNS Contents Pharmaceuticals: Antibiotics
Mark I kits, diazepam, atropine, pralidoxime
IV Supplies:
catheters, syringes, fluids, heparin-locks, administration sets
Airway Supplies:
ventilators, ambu-bags, ET tubes, laryngoscopes, suction devices, oxygen masks, NG tubes
Other Emergency Medications:
for hypotension, anaphylaxis, sedation, pain management
Bandages and Dressings
Vaccine

63. Bad communication adds to crisis
Mixed messages from multiple “experts”
Late information “overcome by events”
Over-reassuring messages
No reality check on recommendations
Myths, rumors, doomsayers not countered
Poor performance by spokesperson/leader
Public power struggles and confusion

65. A Typical Day at CDC Autumn 2001

66. Public Awareness
Reliable, credible information to the public is key to keeping cooperation and minimizing panic

67. Tactical response to biological weapon exposure
Need to make life-saving decisions rapidly in the absence of data
Access to subject matter experts will be limited
No “textbook” experience to guide response
Need coherent, rapid process for addressing staff and civilian safety in midst of crisis

68. Top STRATEGIC Challenges to Hospital Preparedness
Surge Capacity
Healthcare Personnel
Relevant training
Sufficient numbers
Materiel
Pharmaceuticals
Decontamination equipment
Collaboration at local, state, and federal level
Must prepare for MCI at the same time as providing “routine” healthcare to the community!

69. Bottom Line
Early, rapid recognition of unusual clinical syndromes or deaths
Early rapid recognition of increase above “expected levels” of common syndromes, diseases, or death

70. CDC and Biodefense Alexander Langmuir Founder of CDC EIS Program 1952
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 Langmuir
Founder of CDC EIS Program
1952

71. Questions ?