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.

The Immediate Future 2003 – 2010 A Revolution in biotechnology, genomics and proteomics that will affect all human beings

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

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

… 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.

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*

                                                                         

                                                                   

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.

Thou shalt Protect Thyself

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

Thou shalt Decontaminate as Appropriate

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

Diagnosis Clinical Epidemiological Laboratory

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

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

Varying Presentations of NYC Cutaneous Lesions

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

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

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

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

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

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?

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

Thou shalt Render Prompt Treatment

Biological Warfare Diseases Non-Specific Febrile Presentations

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

Thou shalt Practice Good Infection Control

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

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)

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

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,

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 48-72 hours)

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

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

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

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

A Typical Day at CDC Autumn 2001

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

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

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!

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

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

Questions ?