Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce

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Preparing for and Responding to Bioterrorism
Information for the Public Health Workforce
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Acknowledgements
This presentation, and the accompanying
instructors manual, were prepared by Jennifer
Brennan Braden, MD, MPH, at the Northwest Center
for Public Health Practice in Seattle, WA, for
the purpose of educating public health employees
in the general aspects of bioterrorism
preparedness and response. Instructors are
encouraged to freely use all or portions of the
material for its intended purpose. The
following people and organizations provided
information and/or support in the development of
this curriculum. A complete list of resources
can be found in the accompanying instructors
guide.
Patrick OCarroll, MD, MPH Project Coordinator
Centers for Disease Control and Prevention
Judith Yarrow Design and Editing Health Policy
and Analysis University of WA Washington State
Department of Health
Jeff Duchin, MD Jane Koehler, DVM,
MPH Communicable Disease Control, Epidemiology
and Immunization Section Public Health - Seattle
and King County Ed Walker, MD University of
WA Department of Psychiatry
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Diseases of Bioterrorist Potential Plague and
Botulism
CDC, AFIP
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Diseases of Bioterrorist Potential Learning
Objectives

• Describe the epidemiology, mode of transmission,
  and presenting symptoms of disease caused by the
  CDC-defined Category A agents
• Identify the infection control and prophylactic
  measures to implement in the event of a suspected
  or confirmed Category A case or outbreak

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PlagueHistory Significance

• 14th Century Black Death responsible for
  gt20million deaths in Europe
• Used as a BW agent by Japan in WW II
• Studied by Soviet and, to a smaller extent, U.S.
  BW programs
• 1995 Larry Wayne Harris arrested for illicit
  procurement of culture via mail

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PlagueEpidemiology

• Caused by Yersinia pestis
• About 10-15 cases/year U.S.
• Mainly SW states
• Human plague occurs from bite of an infected flea
  (bubonic)
• Only pneumonic form of plague is spread
  person-to-person
• Last case of person-to-person transmission in
  U.S. occurred in 1924

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Yersinia Pestis

• Gram negative, non-motile, non-spore-forming
  bacillus
• Resistant to freezing temperature and drying,
  killed by heat and sunlight

Source Centers for Disease Control and
Prevention, Division of Vector-Borne Infectious
Diseases, Fort Collins, CO
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Plague Case Definition

• Characterized by fever, chills, headache,
  malaise, prostration, leukocytosis that
  manifests in one or more of the following
  clinical forms
• Regional lymphadenitis (bubonic)
• Septicemia w/o evident bubo (septicemic)
• Plague pneumonia
• Pharyngitis cervical lymphadenitis (pharyngeal)

MMWR 199746(RR-10)
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PlagueCase Definition, cont.

• Laboratory criteria for diagnosis
• Presumptive
• Elevated serum antibody titers to Y. pestis F1
  antigen (w/o documented 4-fold change) in a
  patient with no history of plague vaccination OR
• Detection of F1 antigen in a clinical specimen by
  fluorescent assay
• Confirmatory
• Isolation of Y. pestis from a clinical specimen
  OR
• 4-fold or greater change in serum antibody titer
  to Y. pestis F1 antigen

MMWR 199746(RR-10)
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Plague Case Classification

• Suspected Clinically compatible case w/o
  presumptive or confirmatory lab results
• Probable Clinically compatible case with
  presumptive lab results
• Confirmed Clinically compatible case with
  confirmatory lab results

MMWR 199746(RR-10)
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PlagueClinical Forms

• Bubonic plague
• Most common naturally-occurring form
• Mortality 60 untreated, lt5 treated
• Primary or secondary septicemic plague
• Pneumonic plague
• Most likely BT presentation
• From aerosol or septicemic spread to lungs
• Survival unlikely if treatment not initiated w/in
  24 hours of the onset of symptoms

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Pneumonic PlagueClinical Presentation

• Incubation 1-6 days (usually 2-4 days)
• Acute onset of fever with cough, dyspnea, and
  chest pain
• Hemoptysis characteristic watery or purulent
  sputum also possible
• Prominent GI symptoms may be present, including
  nausea, vomiting, diarrhea, and abdominal pain

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Pneumonic PlagueClinical Presentation

• Other symptoms include headache, chills, malaise,
  myalgias
• Rarely, cervical bubo present
• Rapid progression to respiratory failure shock

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Bubonic Plague

• Incubation 2-8 days
• Sudden onset nonspecific symptoms fever, chills,
  malaise, muscle aches, headache
• Regional lymphadenitis (buboes)
• Swollen, very painful lymph nodes
• Typically inguinal, femoral, axillary, or
  cervical
• Erythema overlying skin
• May have surrounding edema
• Concurrent with or shortly after onset of other
  symptoms

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Septicemic Bubonic Plague
Source CDC NVBID
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PlagueInfection Control

• Person-to-person transmission via respiratory
  droplets
• Standard respiratory droplet precautions
• Treatment 10 days antibiotics
• Case isolation for at least the first 48 hrs of
  antibiotic treatment
• Bubonic plague - standard precautions

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PlagueInfection Control

• Antibiotic prophylaxis for close contacts
• Duration 7 days or duration of risk of exposure
  7 days
• Close contacts refusing prophylaxis
• Observe 7 days after last exposure and treat if
  fever or cough develop
• Bubonic contacts
• Observe 7d and treat if symptoms develop

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Plague Summary of Key Points

• The most likely presentation in a BT attack is
  pneumonic plague.
• Unlike other forms of plague, pneumonic plague is
  transmitted person to person, and thus
  respiratory droplet precautions are indicated in
  suspected cases until 48 hours after the
  initiation of antibiotic therapy.

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Case Reports

• Plague

Plague Pneumonia - CA. MMWR 198433(34)
Pneumonic Plague -- Arizona, 1992. MMWR 41(40)

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Clostridium Botulinum

• C. botulinum spores found in soil worldwide
• Toxin causative agent of botulism
• Types A-G A,BE most commonly associated with
  human disease
• Most potent toxin known (lethal dose 1ng/kg)
• Inactivated by chlorine (20min) and sunlight
  (1-3hrs) destroyed by heat (5min at 85?C)
• Absorbed into circulation via mucosal surface or
  wound, not intact skin
• Interferes with nerve transmission ? paralysis

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Clostridium BotulinumEpidemiology

• Approximately 100 reported cases botulism/year
  in the U.S.
• Infant most common (72)
• Food-borne not common
• Incubation (food-borne) 12-72hrs (range 2hr-8d)
• Dose dependent
• Could be less following a BT attack
• No person-to-person transmission
• Death 60 untreated lt5 treated

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Botulism Bioterrorism

• Weaponized by former U.S. and Soviet offensive BW
  programs
• Iran, Iraq, N. Korea, Syria believed to have
  developed/be developing toxin as a weapon
• Aerosol use or food supply sabotage most likely

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BotulismClinical Forms

• Food-borne
• Toxin produced anaerobically in improperly
  processed or canned, low-acid foods contaminated
  by spores
• Wound
• Toxin produced by organisms contaminating wound
• Infant
• Toxin produced by organisms in intestinal tract
• Inhalation botulism
• No natural occurrence, developed as BW weapon

3 accidental cases in veterinary personnel, W.
Germany, 1962
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Botulism Case Definition

• Ingestion of botulinum toxin results in an
  illness of variable severity. Common symptoms
  are diplopia, blurred vision and bulbar weakness.
  Symmetric paralysis may progress rapidly.
• Laboratory criteria for diagnosis
• Detection of botulinum toxin in serum, stool or
  patients food (food-borne) or other clinical
  specimen (botulism, other) OR
• Isolation of Clostridium botulinum from stool
  (food-borne) or other clinical specimen

Assay available at CDC some state public
health labs
MMWR 199746(RR-10)
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Botulism Case Classification

• Botulism, Food-borne
• Probable Clinically compatible with an
  epidemiologic link
• Confirmed Clinically compatible case that is
  laboratory confirmed or that occurs among persons
  who ate the same food as persons who have
  laboratory-confirmed botulism
• Botulism, Other
• Confirmed Clinically compatible case that is
  laboratory confirmed in a patient ? 1 yr who has
  no history of ingestion of suspect food and has
  no wounds

age parameter may not apply in BT
MMWR 199746(RR-10)
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BotulismTreatment

• Ventilatory assistance and supportive care
• Standard precautions
• Botulinum antitoxin
• Most effective if given early does not reverse
  effect of toxin already bound to nerve receptor
• Trivalent equine product against types A,B, and E
  currently available from CDC
• Heptavalent (A-G) antitoxin - investigational
• Monovalent human anti-serum for infant botulism
  -investigational

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BotulismProphylaxis

• Pre-exposure
• Prophylaxis for at-risk lab workers and military
  with investigational vaccine
• No pre-exposure prophylaxis recommended for
  general public
• Post-exposure close monitoring of those exposed
  treat with antitoxin at first signs of illness

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Botulism Summary of Key Points

• An outbreak of botulism occurring with a common
  geographic factor, but with no common food
  exposure, would suggest a deliberate aerosol
  exposure.
• Inhalational botulism does not occur naturally,
  and any potential cases suggest a deliberate
  source of infection.

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Botulism Summary of Key Points

• Gastrointestinal symptoms may not occur with
  inhalational botulism or with food-borne botulism
  (e.g., resulting from deliberate contamination of
  the food supply).
• Botulinum antitoxin must be administered as soon
  as possible for optimum results.

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BotulismCase Reports


MMWR Morb Mortal Wkly Rep 199948(21)



MMWR Morb Mortal Wkly Rep 199544(48)
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Resources

• Centers for Disease Control Prevention
• Bioterrorism Web page
• CDC Office of Health and Safety Information
  System (personal protective equipment)
• USAMRIID -- includes link to on-line version of
  Medical Management of Biological Casualties
  Handbook
• Johns Hopkins Center for Civilian Biodefense
  Studies

http//www.bt.cdc.gov/
http//www.cdc.gov/od/ohs/
http//www.usamriid.army.mil/
http//www.hopkins-biodefense.org
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Resources

• Office of the Surgeon General Medical Nuclear,
  Biological and Chemical Information
• St. Louis University Center for the Study of
  Bioterrorism and Emerging Infections
• Public Health - Seattle King County

http//www.nbc-med.org
http//bioterrorism.slu.edu
http//www.metrokc.gov/health
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Resources

• Washington State Department of Health
• Communicable Disease Epidemiology
• [phone] OR
• [phone] (24 hour emergency)
• Association for Professionals in Infection
  Control
• MMWR Rec Rep. Case definitions under public
  health surveillance.

http//www.doh.wa.gov
http//www.apic.org/bioterror
199746(RR-10)1-55