Preparedness for Bioterrorism: A role for CT primary care providers

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Preparedness for Bioterrorism A role for CT
primary care providers

• Amanda Durante, PhD
• Yale Center for Public Health Preparedness
• September 21, 2006

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By the end of this session the learner should be
able to

• List organisms that are considered Class A
  biological weapon agents.
• Describe basic epidemiologic and clinical
  characteristics of Class A agents.
• Access information on the prevention, diagnosis
  and treatment of Class A agents.
• Describe disease patterns that may suggest a
  bioterrorism outbreak.
• Describe CT-specific reporting requirements when
  a clinician suspects a disease that could cause a
  public health emergency.
• Describe ways CT primary care clinicians can get
  involved in disaster planning in CT.

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Role of Primary Care Providers

• Be prepared to diagnose and treat BT diseases
• Keep alert to unusual disease patterns
• Use reportable disease system to alert public
  health officials of a potential problem
• Get involved in disaster planning process

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Category A bioterrorism agents

• Anthrax (Bacillus anthracis)
• Smallpox (variola virus)
• Plague (Yersinia pestis)
• Tularemia (Francisella tularensis)
• Botulism (botulinum toxin)
• Viral Hemorrhagic Fever

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CDC Category A Agents

• Easily disseminated and/or transmitted from
  person-to-person
• Cause high mortality and have the potential for
  major public health impact
• Might cause panic or social disruption
• Require special action for public health
  preparedness

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Useful resource on BT agents for primary care
providers

• Weinstein RS, Alibek K. Biological and Chemical
  Terrorism A Guide for Healthcare Providers and
  First Responders. Thieme, New York 2003
• CDC BT pages - http//www.bt.cdc.gov/bioterrorism
• Epidemiology, diagnosis, treatment, prophylaxis,
  infection control

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Anthrax
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Anthrax clinical description

• An illness with acute onset characterized by
  several distinct clinical forms, including the
  following
• Cutaneous a skin lesion evolving during a period
  of 2-6 days from a papule, through a vesicular
  stage, to a depressed black eschar
• Inhalation a brief prodrome resembling a viral
  respiratory illness, followed by development of
  hypoxia and dyspnea, with radiographic evidence
  of mediastinal widening
• Intestinal severe abdominal distress followed by
  fever and signs of septicemia
• Oropharyngeal mucosal lesion in the oral cavity
  or oropharynx, cervical adenopathy and edema, and
  fever

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Etiologic agent

• Bacillus anthracis
• Encapsulated, aerobic, gram-positive, spore
  forming, rod-shaped bacterium
• Zoonotic disease in herbivors
• Spores resist adverse environmental conditions
  and disinfectant

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Occurrence in the 21st Century

• Naturally occurring cases exposure to infected
  animals or spore contaminated animal products
• Intentional - Inhalational and cutaneous disease
  as are result of exposure to B. anthracis spores
  through U.S. mail

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Modes of transmission

• Skin direct skin contact with spores
• Respiratory tract inhalation of aerosolized
  spores
• GI consumption of undercooked meat or dairy
  from infected animals

NO person-to-person transmission of inhalational
or GI anthrax
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Anthrax Cutaneous
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• Anthrax Cutaneous

Vesicle developmentDay 2
Day 6
Day 4
Day 10
Eschar formation
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Anthrax Inhalational
?Mediastinal widening JAMA 199928117351745
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Mediastinal Widening and Pleural Effusion on
Chest X-Ray in Inhalational Anthrax
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Smallpox
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Clinical Case Definition

• Classical presentation
• An illness with acute onset of fever 101º F
• followed by a rash characterized by firm, deep
  seated vesicles or pustules in the same stage of
  development
• without other apparent cause
• Clinically consistent cases
• presentations of smallpox that do not meet this
  classical clinical case definition
• a) hemorrhagic type, b) flat type, and c) variola
  sine eruptione.

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Occurrence

• Ancient scourge many millions killed
• Global eradication in 1980
• Bioweapon potential
• Prior use in French-Indian War
• Produced by USSR
• It is believed that there are unaccounted for
  stocks

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Etiologic agent

• Variola Virus
• No animal or environment reservoir or vectors

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Modes of transmission

• Generally direct and fairly prolonged
  face-to-face contact
• Can be spread by direct contact with body fluids
  or contaminated objects
• Rarely spread in the air of enclosed settings
  such as buildings, buses, trains

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Period of communicabililty

• Sometimes contagious with onset of fever
• Most contagious during first 7 10 days of rash
• Contagious until last scab falls off

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• Lesion Progression
• Maculopapular
• Deep vesicles
• Pustules
• Scabs

Courtesy of World Health Organization
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Courtesy of National Archives
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Courtesy of National Archives
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Evaluating Patients for Smallpox CDC Algorithm
http//www.bt.cdc.gov/agent/smallpox/diagnosis/
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Plague
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Clinical description

• A disease characterized by fever and leukocytosis
  that presents in one or more of the following
  principal clinical forms
• Regional lymphadenitis (bubonic plague)
• Septicemia without an evident bubo (septicemic
  plague)
• Plague pneumonia, resulting from hematogenous
  spread in bubonic or septicemic cases (secondary
  plague pneumonia ) or inhalation of infectious
  droplets (primary plague pneumonia)
• Pharyngitis and cervical lymphadenitis resulting
  from exposure to larger infectious droplets or
  ingestion of infected tissues (pharyngeal plague)
  

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Etiologic agent - Yersinia Pestis

• Bacterium gram negative rod
• Epizootic
• Normally circulates between small mammals via
  fleas without human involvement.
• During rodent plague epidemics, rodents die and
  fleas seek out other hosts including humans

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Plague occurrence

• 3 Pandemics
• Justinian - 6th century Africa/Asia
• Black Death 14th century Europe
• Worldwide 19th/20th century
• Cases naturally occurring cases in the US
• Potential for use as bioweapon
• WWII
• Former USSR production

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(No Transcript)
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Transmission of Bubonic Septicemic Plague

• Organism entry
• Contact of broken skin with contaminated
  materials
• Bite of infected flea
• Organism exit
• No spread from person-to-person under normal
  conditions

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Transmission of pneumonic plague

• Organism entry into lungs
• Breathing in Y. pestis
• Direct contact with a human or animal case of
  pneumonic plague
• Aerosolized for bioterrorism purposes
• Spread as a result of untreated bubonic or
  septicemic plague
• Organism exit from lungs
• Respiratory droplets

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Bubo ruptured inguinal lymph node
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Femoral bubo
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Axillary bubo
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Primary Pneumonic Plague
Inglesby, et al. JAMA. 20002832281-2290
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Botulism

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Occurrence

• U.S. incidence 100 cases annually
• Use as bioweapon
• Japanese in WWII (Unit 731)
• Former US and USSR bioweapon programs
• Iraqi missiles and bombs armed with it
• Japanese cult in early 1990s

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Etiologic agent

• Neurotoxin produced by Clostridium botulinum
• Most lethal substance known

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Clinical description Foodborne botulism

• Ingestion of toxin results in an illness of
  variable severity.
• Common symptoms are diplopia, blurred vision, and
  bulbar weakness. Symmetric paralysis may progress
  rapidly.

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Clinical description Infant botulism

• Constipation, poor feeding, and failure to
  thrive that may be followed by progressive
  weakness, impaired respiration, and death

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Clinical description Wound botulism

• An illness resulting from toxin produced by
  Clostridium botulinum that has infected a wound.
• Common symptoms are diplopia, blurred vision, and
  bulbar weakness. Symmetric paralysis may progress
  rapidly.

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Other botulism

• Clinical description - See Foodborne Botulism
• Case classification
• Confirmed a clinically compatible case that is
  laboratory confirmed in a patient aged greater
  than or equal to 1 year who has no history of
  ingestion of suspect food and has no wounds

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Modes of transmission

• No person-to-person transmission
• Exposure types
• Foodborne - Ingestion of toxin
• Infant Ingestion of C. botulinum
• Wound Infection with C. botulinum
• Inhalation of aerosolized toxin
• As BT agent may be aerosolized or added to food
  or water

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Tularemia
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Clinical description

• An illness characterized by several distinct
  forms, including the following
• Ulceroglandular  cutaneous ulcer with regional
  lymphadenopathy
• Glandular  regional lymphadenopathy with no
  ulcer
• Oculoglandular  conjunctivitis with preauricular
  lymphadenopathy
• Oropharyngeal  stomatitis or pharyngitis or
  tonsillitis and cervical lymphadenopathy
• Intestinal  intestinal pain, vomiting, and
  diarrhea
• Pneumonic  primary pleuropulmonary disease
• Typhoidal  febrile illness without early
  localizing signs and symptoms

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Etiologic agent Fracisella tulerensis

• Bacterium gram negative coccobacillius
• Reservoirs
• small mammals
• Can be recovered from contaminated water, soil,
  straw, animal carcasses
• Highly infectious
• Inhalation or inoculation of 10 organisms can
  cause disease

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Occurrence

• US - About 200 human cases reported per year
• Mostly in south-central and western states
• Bioweapon potential
• Less deadly but incapacitating
• Former US and USSR weaponized production
• WW II

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Modes of transmission

• Contact with infected body fluids
• Environmental exposures
• Arthropod bites (ticks deer flies)
• Handling infected animal tissue
• Contact or ingestion of contaminated food, water
  or soil
• Inhalation of aerosolized bacteria
• BT attack
• Lawn mowers

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If aerosolized tularemia was released into in
densely populated area

• Abrupt onset of a large number of acute,
  non-specific febrile illness (38º-40º C)
  beginning 3 5 days later
• Pleuropneumonitis developing in a significant
  proportion of cases during ensuing days and
  weeks.
• May also cause affect
• Eyes ocular tularemia
• Broken skin ulceroglandular or glandular
  disease
• Oropharyngeal disease with cervical
  lymphadeninitis

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Clinical Features Ulceroglandular form

• Painful maculopapule, pustule, ulcer

CDC/Emory University/Dr. Sellers. PHIL1344
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Viral hemorrhagic fever
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VHF

• Group of illness caused by several distinct
  families of viruses
• 4 families
• Arenaviruses, filoviruses, bunyaviruses,
  flaviviruses

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Clinical features - VHF

• Severe multisystem syndrome
• Overall vascular system damage
• Bodys ability to regulate itself is impaired
• Often accompanied by hemorrhagic (in itself not
  usually life threatening)

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Ebola Marburg Viruses - clinical course

• Sudden onset of flu-like illness
• May progress to nausea, vomiting, diarrhea,
  abdominal pain, photophobia, maculopapular rash,
  DIC, internal and external hemorrhage, multiorgan
  failure with jaundice and renal insufficiency

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Ebola and Marburg Etiologic agents

• Flioviridae family viruses
• Among the most virulent viruses (25-90 case
  fatality depending on strain)
• Zoonotic
• Humans are incidental hosts

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Atlanta, Georgia Electron Micrograph Ebola
virus causing African Hemorrhagic Fever.
(Courtesy of the National Archives, 82-424)
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Marburg Ebola Occurrence

• Naturally occurring sporadic outbreaks in Africa
• Cases have occurred in West as a result of
  exposure to animal reservoirs
• BT potential
• Russian biowarfare program
• Iraq is believe to have tried

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Ebola and Marburg - transmission

• Direct contact with infected tissue and body
  fluids or contaminated objects
• Probably aerosol inhalation

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Role of Clinicians

• Be prepared to diagnose and treat BT diseases
• Keep alert to unusual disease patterns
• Use reportable disease system to alert public
  health officials of a potential problem
• Get involved in disaster planning process

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Clusters of patients with the same disease or
syndrome

• Especially when
• there is more cases than would be expected
• cases are geographically or temporally clustered
• the illness is unexplained
• there are multiple atypical presentations of the
  disease
• the mortality or morbidity is higher than expected

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Even a single case may be a signal

• Caused by an uncommon agent
• Unusual for region, age group or season
• Fulminant disease in otherwise healthy patient
• Atypical presentation

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Other clues

• Similar genetic type of agent from distinct
  sources
• Unusual, atypical, genetically engineered, or
  antiquated strain
• Atypical aerosol, food, or water transmission
• Concurrent animal disease

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Role of Clinicians

• Be prepared to diagnose and treat BT diseases
• Keep alert to unusual disease patterns
• Use CT reportable disease system to alert public
  health officials of a potential problem
• Get involved in disaster planning

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CT Reportable Disease surveillance

• Clinicians required to report any of a list of
  diseases upon recognition or strong suspicion
• List available at
• http//www.dph.state.ct.us/BCH/infectiousdise/pdf/
  Vol26No1_FNLCLR.pdf

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Category 1 diseases/conditions - 2006
Reportable immediately by telephone to local
Director of Health and CT DPH Epidemiology
Program (860 507 7722)
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Reporting provides access to

• Local and CT Department of Health resources
• Epidemiologic investigation
• Clinical consultation
• Laboratory testing
• Risk communication
• Link to other relevant agencies

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Surveillance case definitions

• US Case Definitions for Infectious Conditions
  Under Public Health Surveillance
• http//www.cdc.gov/epo/dphsi/casedef/index.htm

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Role of Clinicians

• Be prepared to diagnose and treat BT diseases
• Keep alert to unusual disease patterns
• Use CT reportable disease system to alert public
  health officials of potential problem
• Get involved in disaster planning process

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National Incident Management System

• Standard approach to incident management and
  response developed by the DHS in March 2004
• uniform set of procedure that all emergency
  responders use to conduct response operations
• Participate in opportunities for training
• In-house
• TRAINConnecticut - https//ct.train.org/DesktopShe
  ll.aspx

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Disaster planning

• Insure that Charter Oak Health Center is involved
  in the on-going disaster planning process
• Attend Capitol Region Emergency Planning
  Committee meetings

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Acknowledgements

• Centers for Disease Control and Prevention
• Bioterrorism Basics for Primary Care
  Practitioners. Center for Biosecurity. University
  of Saint Louis.