BIOTERRORISM

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BIOTERRORISM

• June 15, 2006
• Christina M. Cabott D.O.

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Introduction

• Bioterrorist event
• Release of biological agent into civilian
  population
• Purpose
• Creating fear
• Illness
• Death
• Disruption of social and economic infrastructure

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Introduction

• Biological agents
• Infectious agents
• Contagious
• Noncontagious
• Biologically produced toxins
• Act as chemical agents within human body

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Agents of Concern

• Agent selection
• 1. Potential for public health impact
• 2. Delivery potential
• Estimation of ease for development and
  dissemination
• Potential for person-to-person transmission of
  infection
• 3. Public perception (fear) of the agent
• 4. Special requirements for public health
  preparedness

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Agents of Concern

• Ranking category
• Class A agents most severe potential for
  widespread illness and death
• Variola major (small pox)
• Bacillus anthracis (anthrax)
• Yersinia pestis (plague)
• Class B agents less potential
• Class C agents future threats

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Class A Agents

• Variola major (small pox)
• Incubation 12-14 days
• SS
• Initially fever, severe myalgias, prostration
• Within 2 days papular rash on face spreading to
  extremities ? rash on palms and soles ? trunk
• Lesions progress at same rate
• Vesicular ? pustular ? scabs

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Class A Agents

• Bacillus anthracis (Cutaneous anthrax)
• Incubation usually lt 1 day, up to 2 weeks
• SS
• Macule or papule enlarging into eschar
• Surrounding vesicles and edema
• Sepsis possible

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Class A Agents

• Bacillus anthracis (GI anthrax)
• Incubation usually 1-7 days
• SS
• Abdominal pain
• Vomiting
• GI bleeding leading to sepsis
• Mesenteric adenopathy on CT

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Class A Agents

• Bacillus anthracis (Oropharyngeal anthrax)
• Incubation usually 1-7 days
• SS
• Sore throat
• Ulcers on base of tongue
• Marked unilateral neck swelling

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Class A Agents

• Bacillus anthracis (Inhalational anthrax)
• Incubation usually lt 1 week
• SS
• 1st stage fever, dyspnea, cough, headache,
  vomiting, abdominal pain, chest pain
• 2nd stage dyspnea, diaphoresis, shock
• Hemorrhagic mediastinitis with widened
  mediastinum on CXR

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Class A Agents

• Yersinia pestis (Bubonic plague)
• Incubation 2-8 days
• SS
• Fever, chills, painful swollen lymph nodes
• Nodes progress to bubo (possibly suppurative)

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Class A Agents

• Yersinia pestis (Pneumonic plague)
• Incubation 2-3 days
• SS
• Fever, chills, cough, dyspnea, nausea, vomiting,
  abdominal pain
• Clinical condition consistent with gram-negative
  sepsis

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Class A Agents

• Yersinia pestis (Primary septicemic plague)
• Incubation 2-8 days
• SS
• After bubo formation, clinical condition
  consistent with gram-negative sepsis, DIC

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Class A Agents

• Clostridium botulinum (Food-born botulism)
• Incubation 1-5 days
• SS
• GI symptoms
• Followed by symmetric cranial neuropathies,
  blurred vision
• Progresses to descending paralysis

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Class A Agents

• Clostridium botulinum (Inhalational botulism)
• Incubation 12-72 hours
• SS
• Symmetric cranial nerve palsies
• Progresses to descending paralysis

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Class A Agents

• Francisella tularensis (Tularemia)
• Incubation 2-5 days
• SS
• Abrupt nonspecific febrile illness
• Progressing to pleuropneumonitis
• May have mucocutaneous lesions

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Class A Agents

• Filoviruses and arenaviruses (Ebola virus)
• Viral hemorrhagic fevers
• Incubation 2 days 3 weeks, depending on the
  virus
• SS
• Initial nonspecific febrile illness, sometimes
  with rash
• Progresses to hematemesis, diarrhea, shock

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Class B Agents

• Coxiella burnetii (Q fever)
• Incubation 2-3 weeks
• SS
• Fever, myalgias, headache
• 30 develop pneumonia

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Class B Agents

• Brucella spp (Brucellosis)
• Incubation 2-4 weeks
• SS
• Fever, myalgias, back pain
• Possible CNS infections, endocarditis

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Class B Agents

• Burkholderia mallei (Glanders)
• Incubation 10-14 days
• SS
• Suppurative ulcers
• Pneumonia
• Pulmonic abscesses
• Sepsis

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Class B Agents

• Alpha viruses (VEE, EEE, WEE)
• Encephalitis
• Incubation variable
• SS
• Fever
• Headache
• Aseptic meningitis
• Encephalitis
• Focal paralysis
• Seizures

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Class B Agents

• Rickettsia prowazekii (Typhus fever)
• Incubation 7-14 days
• SS
• Fever
• Headache
• Rash

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Class B Agents

• Chlamydia psittaci (Psitticosis)
• Incubation 6-19 days
• SS
• Fever
• Headache
• Dry cough
• Pneumonia
• Endocarditis

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Class B Agents

• Toxins
• Ricin, Staphlococcus, Enterotoxin B
• Food safety threats
• Salmonella, Eschericia coli O157H7
• Water safety threats
• Vibrio cholera, Cryptosporidium parvum

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Class C Agents

• Emerging threats
• Nipah virus
• Hanta virus

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Recognition of Bioterrorist Event

• Patient presents with signs, symptoms, or
  immediately available diagnostic results that
  obviously indicate a suspect disease process.

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Recognition of Bioterrorist Event

• 2. Patient presents with protean symptoms, but
  an astute clinician establishes enough criteria
  (suspicious historical information, signs,
  symptoms, short turn-around lab results, public
  health corroborative information, etc.) to
  designate the patient as a presumptive case until
  diagnostic confirmation can be accomplished.

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Recognition of Bioterrorist Event

• 3. Patient presents, is evaluated and admitted
  or released, but not suspected as being a victim
  of bioterrorism. Diagnostic test results (blood
  cultures, immunoassays, etc.) subsequently
  establish a diagnosis, potentially even post
  mortem.

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Recognition of Bioterrorist Event

• 4. Multiple patients present over a defined
  period with similar symptoms or historical
  characteristics, raising the suspicions of a
  practitioner and causing that individual to
  report the concern. Further investigation with
  diagnostic testing and/or public health
  epidemiological investigation of the cohort
  establishes the cause.

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Recognition of Bioterrorist Event

• 5. Public health surveillance systems establish
  unusual patterns of signs, symptoms, or disease
  in the community and correlate with further
  investigation to establish the etiology.

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Recognition of Bioterrorist Event

• Emergency physician should know
• Basic pathological principles for each agent
• Modes of dissemination and transmission
• Disease signs and symptoms
• Recommended diagnostic testing
• Recommended therapy
• Immunizations, medicines, or prophylaxis
• Infectious control practices

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Recognition of Bioterrorist Event

• Pictorial resources
• Confirmatory tests
• Respond to notification of potential disease by
  another health or medical professional
• Querying the source for methodology of testing
  that produced the concern

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Recognition of Bioterrorist Event

• Exposure to an unidentified substance
• Source substance and where obtained
• Coordination with outside agencies, such as law
  enforcement and public health
• Patient exposure risk stratification

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Design and Implementation of Community
Surveillance Systems

• Clinical duties are minimally affected
• Does not consume valuable clinician or support
  staff time and attention
• Financial investment is not carried by the
  hospital or professional staff

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Design and Implementation of Community
Surveillance Systems

• Patient privacy and hospital proprietary issues
  are addressed appropriately
• Participation in the system provides direct
  benefit to the acute care medical community
• - All pertinent epidemiologic information is
  disseminated in real time to the practitioners

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Initial Response to a Potential Bioterrorist
Threat

• Within hospital environment
• Infection control procedures
• Notification of hospital departments
• Administration
• Infectious disease
• Infection control
• Laboratory services
• Security
• Environmental services

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Initial Response to a Potential Bioterrorist
Threat

• Within hospital environment
• Activation of Emergency Operations Plan (EOP)
• Preplanned surge capacity configuration
• Security dept aid in protection of facility and
  staff
• Media relations
• Outside of hospital environment
• Notification of jurisdictional public health
  department

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Initial Response to a Potential Bioterrorist
Threat

• Information that needs to be conveyed to public
  health department
• 1. Diagnosed or suspected agent of concern
• 2. Whether it is a presumed or definitive
  diagnosis and how many diagnosis were made
• 3. Patient demographics (including occupation)
• 4. Recent history of travel or participation in
  special events (i.e. mass gatherings,
  high-profile events, or at- risk gatherings)

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Initial Response to a Potential Bioterrorist
Threat

• Information that needs to be conveyed to public
  health department
• 5. Patient condition
• 6. Initial testing performed and further
  diagnostic testing being conducted
• 7. Treatment being provided
• 8. Public health assistance required (including
  testing)
• 9. Preferred method of contacting hospital or
  treating physicians for follow-up

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Initial Response to a Potential Bioterrorist
Threat
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Initial Response to a Potential Bioterrorist
Threat

• Protective equipment
• Gowns, gloves, respiratory masks
• Patient isolation
• Patient decontamination
• Removal of clothing
• Soap and warm water
• NO bleach

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Integration with Local Department of Health

• Development of community wide patient evaluation
  and treatment protocol
• Screening
• Testing
• Treatment methodologies
• Patient and public education

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Integration with Local Department of Health

• Clear and concise definition for the suspicious
  agent
• Reporting requirements (surveillance) for
  suspected or diagnosed cases
• Type of information
• Method of reporting (e.g. phone, fax, Internet)
• Contact methods (e.g. 24 hr access for technical
  advice)

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Treatment, Prophylaxis, and Immunizations

• Agent Variola major
• Vaccination Vaccinia vaccination
• Not recommended for general public use
• Contraindicated in immunocompromised pts and pts
  with eczema
• Useful in preventing disease if given within 4
  days of exposure

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Treatment, Prophylaxis, and Immunizations

• Agent Variola major
• Prophylaxis Vaccinia immunoglobin
• Within 2-3 days of exposure
• Limited supplies available
• Consider giving it to those with
  contraindications to the vaccine
• Treatment
• Mainly supportive

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Treatment, Prophylaxis, and Immunizations

• Agent Bacillus anthracis
• Vaccination Anthrax vaccination
• 6 part series at 0,2, and 4 week, then 6,12, and
  18 months
• Annual boosters required
• Not available to the public
• Animal models efficatious in inhalational
  anthrax

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Treatment, Prophylaxis, and Immunizations

• Agent Bacillus anthracis
• Prophylaxis
• Cipro or doxy for 60 days
• Amoxicilin if strain not resistant to treatment
• Treatment
• Cipro or doxy (amoxicillin if strain not
  resistant) in combo with 2 others, including
  clindamycin, rifampin, imipenem, aminoglycoside,
  chloramphenicol, vancomycin, streptomycin, and
  some macrolides

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Treatment, Prophylaxis, and Immunizations

• Agent Yersinia pestis
• Vaccination none
• Prophylaxis
• Cipro or doxy for 7 days
• Alt chloramphenicol
• Treatment
• Streptomycin or gentamycin
• Alt doxy, cipro, chloramphenicol

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Treatment, Prophylaxis, and Immunizations

• Agent Clostridium botulinum
• Vaccination
• Not available to public
• Pentavalent toxoid of C botulinum toxin types A-E
• 3-part series, with yearly booster
• Prophylaxis none

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Treatment, Prophylaxis, and Immunizations

• Agent Clostridium botulinum
• Treatment
• Antitoxin from local public health agency
• Antitoxin may preserve remaining neurologic
  function, BUT does not reverse paralysis
• May require prolonged, assisted mechanical
  ventilation and supportive care

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Treatment, Prophylaxis, and Immunizations

• Agent Francisella tularensis
• Vaccination
• Live, attenuated vaccine under FDA investigation
• Prophylaxis
• Cipro or doxy for 14 days

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Treatment, Prophylaxis, and Immunizations

• Agent Francisella tularensis
• Treatment
• Streptomycin or gentamycin
• Alt doxy, cipro, chloramphenicol

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Treatment, Prophylaxis, and Immunizations

• Agent Filoviruses and arenaviruses (e.g. Ebola
  virus)
• Vaccination none
• Prophylaxis none
• Treatment
• Supportive therapy
• Ribavirin may have applicability in arenaviruses

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Treatment for Bioterrorism

• General Emergency Operation Plans
• Need to have enough staff to handle large surge
  in general patient volume
• Specialty requirements
• Patient with unusual medical conditions
• Patients who may be contagious
• Contamination risks to staff and other patients

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Treatment for Bioterrorism

• Disease containment
• Isolation
• Designation of staff to care for infected vs.
  noninfected patients
• Proper personal protective equipment

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Treatment for Bioterrorism

• Management of personnel
• Need more personnel to care for more patients
• Staff reluctance to care for potentially
  infectious patients

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Treatment for Bioterrorism

• Logistics
• Limited supply of drugs and medical supplies
• Sharing of critical supplies, staff, and
  equipment among local hospitals
• National Pharmaceutical Stockpile

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Treatment for Bioterrorism

• Patient Management
• Addressing requirements of each patient encounter
• Preprinted instructions
• Category of risk stratification
• Why patient placed in that category
• How disease transmitted
• Measures to prevent spread
• Early signs and symptoms of disease
• Appropriate steps if symptoms occur

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Treatment for Bioterrorism

• Patient Management
• Appropriate follow-up
• Proper record keeping
• Organization of charts

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Treatment for Bioterrorism

• Vaccinations
• Not to be given in a pre-event setting to general
  public
• Recommended therapies
• Usually not for pregnant or lactating women
• Usually not approved for children
• Should be given if risk of infection and its
  consequences exceeds risks of the medications or
  vaccines

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Treatment for Bioterrorism

• Fatality Management
• Bodies are considered evidence
• Processed through coroner or medical examiner

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Sources of Expert Information

• http//jama.ama-assn.org
• http//www.bt.cdc.gov
• http//chemdef.apgea.army.mil/textbook/contents.as
  p
• http//www.apic.org
• Local poison control center
• CDCs emergency response center
• 1-770-488-7100