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Erie County Department of Health

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Less for plague pneumonia. ASSESS THE PATIENT. Erie County Department of Health. Buffalo, New York ... NOT a true pneumonia. Critical toxin level=death. CXR/CT ... – PowerPoint PPT presentation

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Title: Erie County Department of Health


1
Preparing For Bioterrorism
COL (ret) William H. Dice MD Office of Public
Health Emergency Preparedness
Erie County Department of Health Buffalo, New York
2
Review Six Select Agents Anthrax Plague Tulare
mia Smallpox Viral Hemorrhagic Fevers Botulism
Erie County Department of Health Buffalo, New York
3
Identify Preparation Steps 1.Suspect 2.PPE 3.As
sess 4.Confirm diagnosis 5.Empiric
treatment 6.Prevent spread 7.Investigate 8.Noti
fy health department 9.Tell others
Erie County Department of Health Buffalo, New York
4
STEP 1
MAINTAIN A HIGH INDEX OF SUSPICION
Biological Warfare NOT a natural occurrence
Suspect
Erie County Department of Health Buffalo, New York
5
STEP 1
MAINTAIN A HIGH INDEX OF SUSPICION
Anthrax Plague Tularemia Smallpox Hemorr
hagic Fevers Botulinum Toxin
FLI Hemoptysis CAP Fever DIC Weakness
Suspect
Erie County Department of Health Buffalo, New York
6
STEP 2
USE PERSONAL PROTECTION
PPE
Erie County Department of Health Buffalo, New York
7
STEP 2
USE PERSONAL PROTECTION
Wear N95 Mask Use eye protection Wear gloves Wash
hands
PPE
Erie County Department of Health Buffalo, New York
8
STEP 3
ASSESS THE PATIENT
Anthrax Wide Mediastinum/Effusion Plague
Pneumonia/Adenopathy Tularemia Pneumonia Smallp
ox Fever/Vesicular rash VHF Bleeding Botulism
Weakness/Cranial n. palsy
Erie County Department of Health Buffalo, New York
9
ASSESS THE PATIENT
Anthrax
Bacillus anthracis Aerobic gram spore-forming
nonmotile rod
Erie County Department of Health Buffalo, New York
10
ASSESS THE PATIENT
Anthrax
US 1944 1994 224 cases reported US 1976-2001 0
Inhalational
US 2001 11 Inhalational Cases-5 fatal 11
Cutaneous Cases-0 fatal
Erie County Department of Health Buffalo, New York
11
ASSESS THE PATIENT
Anthrax
1979 Sverdlovsk Bioweapons Accident 250
cases 100 deaths Onset of illness 2-43 days
after release
Erie County Department of Health Buffalo, New York
12
ASSESS THE PATIENT
Anthrax
Transmission Inhalation of 1-5 micron
spores LD10 may be 100 spores
Incubation Period 1-7 days (60 days)
Erie County Department of Health Buffalo, New York
13
ASSESS THE PATIENT
Plague
Nonmotile bipolar staining gram - bacillus
Erie County Department of Health Buffalo, New York
14
ASSESS THE PATIENT
Plague
Readily available Mass produced High fatality
rate Potential human-human transmission Pandemi
cs 541 Europe 1346 Europe 1855 China
Erie County Department of Health Buffalo, New York
15
ASSESS THE PATIENT
Plague
Obtained illegally in 1995 by an
Ohio microbiologist
US 1947-1996 390 cases reported 84 bubonic 13
septicemic 2 pneumonic
Erie County Department of Health Buffalo, New York
16
ASSESS THE PATIENT
Plague
Transmission Rodent epizootic
Person-Person Contact w/ infected tissue
Incubation Period 1-7 days Less for plague
pneumonia
Erie County Department of Health Buffalo, New York
17
ASSESS THE PATIENT
Tularemia
Francisella tularensis
Aerobic nonmotile gram - coccobacillus
Erie County Department of Health Buffalo, New York
18
ASSESS THE PATIENT
Tularemia
One of the most infectious organisms known Used
as a bioweapon in WWII. The WHO (1969) estimates
that 50kg sprayed over 5million will cause
250,000 casualties with 19,000 deaths and cost
5.4billion/100,000 exposed.
Erie County Department of Health Buffalo, New York
19
ASSESS THE PATIENT
Tularemia
Transmission Arthropod bites Handling or
eating meat from rabbits, hares, voles,
muskrats, and beavers Inhaling contaminated
dust
Incubation Period 1-14 days
Erie County Department of Health Buffalo, New York
20
ASSESS THE PATIENT
Smallpox
Variola Major Variola Minor
Brick-shaped DNA orthopoxvirus
Erie County Department of Health Buffalo, New York
21
ASSESS THE PATIENT
Smallpox
Russia continues weapons development Smallpox
aerosol weapon tested in 1972 In 1997, a Russian
researcher published a report that he had
successfully inserted a gene for Ebola into the
Vaccinia genome.
Erie County Department of Health Buffalo, New York
22
ASSESS THE PATIENT
Smallpox
Transmission Face to face contain virus First 7-10 days after rash
Incubation Period 7-19 days 2-4 days from
illness to rash
Erie County Department of Health Buffalo, New York
23
ASSESS THE PATIENT
Viral Hemorrhagic Fevers
Illness with fever and bleeding disorder
Erie County Department of Health Buffalo, New York
24
ASSESS THE PATIENT
Viral Hemorrhagic Fevers
Filoviridae Ebola/Marburg Arenaviridae
Lassa Bunyaviridae Rift Valley Flavaviridae
Yellow Fever
The US weaponized Yellow Fever and Rift Valley
Fever
Erie County Department of Health Buffalo, New York
25
ASSESS THE PATIENT
Viral Hemorrhagic Fevers
Transmission rodents, mosquito or tick bites
close personal contact contaminated supplies
(Ebola and Lassa)
Incubation Period Ebola 2-21 d Lassa 5-16 d
Erie County Department of Health Buffalo, New York
26
ASSESS THE PATIENT
Botulism
Clostridium botulinum toxin
Erie County Department of Health Buffalo, New York
27
ASSESS THE PATIENT
Botulism
Weaponized and used Germany in WWII Aum
Shinrikyo in Tokyo and at US military bases Iraq
produced 19,000 liters. Aerosol release will
affect 10 of people within 0.5km
Erie County Department of Health Buffalo, New York
28
ASSESS THE PATIENT
Botulism
Transmission Inhalation Ingestion Inactivate
d by heat (85C for 5 min)
Incubation Period Food 2 hours (typical 12-72
h) Inhalation 12-80 h in monkeys
Erie County Department of Health Buffalo, New York
29
STEP 4
CONFIRM A DIAGNOSIS
Rule In/Out Or Refer
Laboratory Response Network
Confirm
Erie County Department of Health Buffalo, New York
30
CONFIRM A DIAGNOSIS
Anthrax
Diagnosis Painless depressed black
eschar Fever, pleural effusion Wide
mediastinum Laboratory RO 2 A
tests (morphology, motility, hemolysis)
Erie County Department of Health Buffalo, New York
31
CONFIRM A DIAGNOSIS
Anthrax
NOT a true pneumonia Critical toxin
leveldeath CXR/CT abnormal Seen on blood gram
stain Cultures negative after abx
Erie County Department of Health Buffalo, New York
32
CONFIRM A DIAGNOSIS
Plague
Diagnosis Buboes, Fever, Lung
infiltrates, Sepsis Gangrene Laboratory
Bipolar rod Pinpoint colony
Erie County Department of Health Buffalo, New York
33
CONFIRM A DIAGNOSIS
Plague
Naturally occurring pneumonic plague is rare
Erie County Department of Health Buffalo, New York
34
CONFIRM A DIAGNOSIS
Plague
Attack will require rodent control Hemoptysis and
rapidly fatal pneumonia suggests plague
Erie County Department of Health Buffalo, New York
35
CONFIRM A DIAGNOSIS
Tularemia
Diagnosis Atypical pneumonia Pleuritis Hilar
lymphadenopathy Laboratory Tiny poorly
staining gram (-) coccobacilli No
growth-MacConkey/EMB
Erie County Department of Health Buffalo, New York
36
CONFIRM A DIAGNOSIS
Tularemia
Tularemia is a rural disease Type A most common
in US. Type B most common in Europe Largest
outbreak in Sweden 1966-1967 Conjunctivitis 26
Skin ulcer 12 Pharyngitis 31 Oral
ulcers 9 Rash 32
Erie County Department of Health Buffalo, New York
37
CONFIRM A DIAGNOSIS
Smallpox
Diagnosis Skin Vesicles Fever, Headache, Body
ache, Prostration Laboratory Viral
culture PCR/EM
Erie County Department of Health Buffalo, New York
38
CONFIRM A DIAGNOSIS
Smallpox
Rash Centrifugal Including palms and
soles Smallpox is a disease of the
skin Hemorrhagic cases look like meningococcemia
Erie County Department of Health Buffalo, New York
39
CONFIRM A DIAGNOSIS
Viral Hemorrhagic Fevers
Diagnosis Febrile with petechiae, bleeding,
and shock Laboratory Viral Culture Serology P
CR at reference labs
Erie County Department of Health Buffalo, New York
40
CONFIRM A DIAGNOSIS
Viral Hemorrhagic Fevers
VHFs look alike clinically Jaundice
with yellow/rift valley fevers
Fever, severe illnesss and 2 of
Purpura,epistaxis,hematemesis, hemoptysis,bloody
stool AND no other likely DX
Erie County Department of Health Buffalo, New York
41
CONFIRM A DIAGNOSIS
Botulism
Erie County Department of Health Buffalo, New York
42
CONFIRM A DIAGNOSIS
Botulism
Diagnosis Acute afebrile, symmetric,
descending flaccid paralysis. Multiple cranial
nerve palsies Laboratory Collect
specimen before antitoxin
Erie County Department of Health Buffalo, New York
43
CONFIRM A DIAGNOSIS
Botulism
Bulbar Palsies diplopia dysarthria dysphagia
dysphonia
Triad Afebrile, clear sensorium, and symmetric
descending paralysis
Erie County Department of Health Buffalo, New York
44
BREAK
Parque Nacional Canaima Venezuela
45
STEP 5
BEGIN TREATMENT
Anthrax
Ciprofloxacin 400mg IV q12h Doxycycline 100mg IV
q12h 2nd drug Consider rifampin, vancomycin,
chloramphenicol, clindamycin, clarithromycin,
penicillin, ampicillin, and imipenem.
Empiric Treatment
Erie County Department of Health Buffalo, New York
46
STEP 5
BEGIN TREATMENT
Anthrax
Prophylaxis Cipro, doxycycline,
penicillin postinhalation for 60 days Anthrax
Vaccine Adsorbed (AVA)
Empiric Treatment
Erie County Department of Health Buffalo, New York
47
STEP 5
BEGIN TREATMENT
Plague
Streptomycin 1g IM bid Gentamicin 5mg/kg
IM/IV q8h Doxycycline 100mg IV
q12h Ciprofloxacin 400mg IV q12h Chloramphenico
l 25mg/kg IV q6h
Erie County Department of Health Buffalo, New York
48
STEP 5
BEGIN TREATMENT
Plague
Prophylaxis Doxycycline for contacts of
untreated pneumonic cases for 7 days
Erie County Department of Health Buffalo, New York
49
STEP 5
BEGIN TREATMENT
Tularemia
Streptomycin 1g IM q12h Gentamicin 5mg/kg IM/IV
qd Doxycycline 100mg IV q12h Chloramphenicol
15mg/kg IV q6h Ciprofloxacin 400 mg IV q12h
Not an FDA approved use
Erie County Department of Health Buffalo, New York
50
STEP 5
BEGIN TREATMENT
Tularemia
Prophylaxis Doxycycline or Cipro for 14
days after aerosol attack NONE for case contacts
Erie County Department of Health Buffalo, New York
51
STEP 5
BEGIN TREATMENT
Smallpox
Support Cidofovir Post exposure vaccination
Not an FDA approved use
Erie County Department of Health Buffalo, New York
52
STEP 5
BEGIN TREATMENT
Smallpox
Prophylaxis Vaccination within 4 days of exposure
Erie County Department of Health Buffalo, New York
53
STEP 5
BEGIN TREATMENT
Viral Hemorrhagic Fever
Support Ribavirin (Lassa) 30mg/kg IV once
then 16mg/kg q6h
Not an FDA approved use
Erie County Department of Health Buffalo, New York
54
STEP 5
BEGIN TREATMENT
Viral Hemorrhagic Fever
Prophylaxis Ribavirin -high risk Lassa
contacts Yellow Fever vaccine not effective
after exposure
Not an FDA approved use
Erie County Department of Health Buffalo, New York
55
STEP 5
BEGIN TREATMENT
Botulism
Support Immunization Antitoxin Equine
(anaphylaxis in 2) 1 vial per
patient 404-639-2206/2888
Aminoglycosides/clindamycin contraindicated
Erie County Department of Health Buffalo, New York
56
STEP 5
BEGIN TREATMENT
Botulism
Prophylaxis NONE
Erie County Department of Health Buffalo, New York
57
STEP 6
QUARANTINE OR ISOLATE
Anthrax
Communicability
Person-person is rare Skin lesions sterile w/i
24hrs of TX Spores active for decades
Standard isolation procedures Quarantine NOT
required
Prevent Spread
Erie County Department of Health Buffalo, New York
58
STEP 6
QUARANTINE OR ISOLATE
Plague
Communicability
Person-person possible Close contact (Isolation Droplet precautions Isolate for
48hrs Quarantine contacts for 7 days
Erie County Department of Health Buffalo, New York
59
STEP 6
QUARANTINE OR ISOLATE
Tularemia
Communicability
NO person to person transmission
Isolation NOT required Quarantine NOT required
Erie County Department of Health Buffalo, New York
60
STEP 6
QUARANTINE OR ISOLATE
Smallpox
Communicability Person to person (6-8
feet) Isolation Negative pressure Vaccinate
staff N-95, gloves, gown Quarantine Contacts
for 17 days
Erie County Department of Health Buffalo, New York
61
STEP 6
QUARANTINE OR ISOLATE
Viral Hemorrhagic Fevers
Communicability
Limited knowledge
Isolation negative pressure with airborne
precautions Quarantine contacts for 21 days
Rift Valley Kenya
Erie County Department of Health Buffalo, New York
62
STEP 6
QUARANTINE OR ISOLATE
Botulism
Communicability
No person to person transmission Not absorbed
through intact skin
Isolation Not required
Erie County Department of Health Buffalo, New York
63
STEP 7
NOTIFY DEPARTMENT OF HEALTH
Erie County Department of Health 716-898-3696 NYS
Department of Health 866-881-2809 NYS Wadsworth
Lab 518-474-2821 NYS Warning Point 518-457-2200
Notify
Erie County Department of Health Buffalo, New York
64
STEP 8
START EPIDIMIOLOGIC INVESTIGATION
Demographics Exposure Source Clinical
Findings Laboratory
Investigate
Erie County Department of Health Buffalo, New York
65
STEP 9
SPREAD THE WORD
www.bt.cdc.gov http//training.fema.gov www.usamri
id.army.mil www.afrri.usuhs.mil
Tell
Erie County Department of Health Buffalo, New York
66
Identify Preparation Steps 1.Suspect 2.PPE 3.As
sess 4.Confirm diagnosis 5.Empiric
treatment 6.Prevent spread 7.Investigate 8.Noti
fy health department 9.Tell others
Erie County Department of Health Buffalo, New York
67
The End
Erie County Department of Health Buffalo, New York
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