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Preparing Our Communities

• Welcome!

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Faculty Disclosure

• For Continuing Medical Education (CME) purposes
  as required by the American Medical Association
  (AMA) and other continuing education credit
  authorizing organizations
• In order to assure the highest quality of CME
  programming, the AMA requires that faculty
  disclose any information relating to a conflict
  of interest or potential conflict of interest
  prior to the start of an educational activity.
• The teaching faculty for the BDLS course offered
  today have no relationships / affiliations
  relating to a possible conflict of interest to
  disclose. Nor will there be any discussion of
  off label usage during this course.

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Biological Events

• Chapter 5

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Objectives

• Describe the difference between biological events
  and bioterrorism (BT)
• Discuss public health BT surveillance
• Identify the CDC BT Category A agents
• Identify emerging infectious diseases
• Compare and contrast BT and other CBRNE WMD
  utilizing the DISASTER paradigm

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Biological Events

• Biological events Natural vs. Intentional

Outbreak of monkey pox in pet prairie
dogs Avian Flu pandemic Natural occurrence of
anthrax Bubonic plague outbreak

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Bioterrorism Release Types Overt or Covert
Covert or Overt ?
Covert or Overt ?
(1763)Captain Simeon Ecuyer had sent
smallpox-infected blankets and handkerchiefs to
the Indians surrounding the fort (as a supposed
peace offering)-- but actually an early example
of biological warfare -- which started an
epidemic among the Indians.
Letter sent to the New York Post and NBC
News Containing white powder
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Potential Methods of Detection
Public Health Surveillance

• Increased number of patients
• Increased unexplained deaths
• Unusual patient age distribution
• Unusual seasonality
• Unusual manifestation of disease
• Animal die-off
• Notifiable disease reporting by physicians
  other providers
• Automated reporting of laboratory results
• Number and type of 911 calls
• Number and type of EMS runs
• Syndromic surveillance

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CDC Categories BT Agents

• Divided into Categories A, B,C based on
• Quantity of agent available
• Ability to disseminate the agent
• Person-to-person transmission
• Severity of disease
• Public response, panic, etc..
• Overall risk to national security

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Category A Agents

• Anthrax
• Smallpox
• Plague
• Botulinum toxin
• Tularemia
• Viral hemorrhagic fevers

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Category B Agents(examples)

• Infectious Agents
• Brucellosis
• Glanders

• Why are these Category B Agents
• Less quantity available than Category A
• Harder to disseminate
• Less person to person transmission- if any
• Slightly less severity of disease
• Less known to public - therefore less likely to
  cause panic
• Slightly less risk to National Security

• Bio-toxins
• Ricin toxin from Ricinus communis (castor beans)
• Staphylococcal enterotoxin B

• Water safety threats
• Vibrio cholerae
• Food safety threats
• Salmonella species
• Escherichia coli O157H7
• Shigella

• Viral encephalitis
• Venezuelan Equine Encephalitis

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Category C

• Emerging infectious diseases as bioterrorism
  agents
• Nipah virus
• Hantavirus
• Emerging infectious disease that posses a
  significant public health threat
• Avian Flu
• SARS

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Category A Anthrax

• Endemic in animals worldwide with occasional
  human cases
• Handling infected animal products (especially
  cattle, sheep, horses, mules and goats)
• Spores used for bioattack
• Aerosolized directly or sent in mail/packages
• Three forms
• Cutaneous, Inhalation, GI

Anthrax in CSFUS index case
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Anthrax Clinical Features

• Inhalation
• Incubation 2-43 days (may be longer)
• Prodrome
• Fevers, malaise, dry cough, chest pain, dyspnea,
  myalgia
• Abrupt onset of fulminant illness
• Sudden high fever, respiratory distress, shock
• Meningitis in 50
• Actual pneumonia uncommon

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Widened mediastinum pleural effusions
Normal Chest X-Ray
Inhalational anthraxUS index case
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Anthrax Clinical Features

• Cutaneous
• Incubation 1 to 7days (up to 12 days)
• Erythematous itchy papule ? ulcer ?
  characteristic black eschar with surrounding
  erythema and edema
• Regional adenopathy and systemic symptoms (e.g.,
  fever, malaise)
• Most lesions completely resolve

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Anthrax Clinical Features

• Gastrointestinal
• Incubation period 1-7 days
• Not likely after a bioattack
• Presents as febrile illness with bloody diarrhea
• Eating undercooked infected meat

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Anthrax Diagnosis

• Blood cultures
• Usually positive in lt 24h
• Gram stain pleural fluid or CSF
• Sputum gram stain/culture is usually NOT positive
• Inhalational disease
• Very suggestive if fever and widened mediastinum
• Cutaneous disease
• Culture fluid from under eschar
• Nasal swabs are a poor test

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Anthrax Treatment

• Ciprofloxacin 400 mg IV q12h
• 10-15 mg/kg for children
• Other fluoroquinolones probably also effective
• OR
• Doxycycline 100 mg IV q12h
• 2.2 mg/kg for children
• PLUS
• 1 or 2 additional antibiotics
• Clindamycin, rifampin, vancomycin, penicillin,
  chloramphenicol, imipenem, or clarithromycin

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Prophylaxis and Infection Control

• Prophylaxis
• Ciprofloxacin 500 mg PO BID(Peds10-15 mg/kg)
• or
• Doxycycline 100 mg PO BID (Peds2.2 mg/kg)
• Continue for 60 days (? 100 days)
• Vaccine available for DOD forces
• Infection Control
• Standard barrier precautions are needed
• Not transmitted person-to-person
• Only immunize / prophylaxis exposed at BT attack

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Anthrax Vaccination Schedule
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0
4 weeks
2 weeks
6 months
12 months
18 months

• 6 shots over 18 months, then annual booster
• Dosing schedule is 0.5 mL subcutaneously at each
  visit
• Then yearly boosters

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Botulism

• Clostridium botulinum

A Toxin Producing Obligate, Anaerobic, Spore
Forming, Gram Pos.
Bacillus
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Botulism - General

• Caused by a toxin produced by Clostridium
  botulinum
• Sporadic cases and outbreaks caused by tainted
  foods
• For bioattack toxin could be delivered as an
  aerosol or used to contaminate food / water

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Botulism - Clinical Features

• 12 to 36 hour incubation
• Range 2 h to 8 days
• Clinical recognition is key to diagnosis
• Bulbar palsies Must be present!
• Ptosis, blurred vision, dry mouth, dysarthria,
  trouble swallowing
• Afebrile,AAO x 3, difficulty speaking
• Descending skeletal muscle paralysis
• Death Respiratory muscle paralysis

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17 Year-Old with Mild Botulism
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Botulism - Treatment

• Supportive care
• Respiratory failure
• Prolonged Ventilator support
• Antitoxin
• State health department obtained
• Prevents further damage
• Does not alter current damage

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Botulism Infection Control

• Prophylaxis
• No proven prophylaxis at this time
• Investigational Vaccine
• Isolation
• Standard precautions (not P-to-P)
• Need to contact public health authority
  immediately Others may be exposed to
  contaminated food source or agent

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Plague
Yersinia pestis

• Yersinia pestis

Source www.cdc.gov
Gram Neg., Anaerobic, Rod Shaped Bac. Safety
Pin Bipolar on Wright Staining
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Plague - General

• Endemic in animals throughout the world
• Prairie dogs in the Southwestern US
• High potential as a BT agent
• Endemic form
• Spread to humans via a flea vector
• Results in bubonic form of the disease
• Bioattack
• Most likely aerosolized
• Results in pneumonic plague
• Release of infected fleas

Buboes
Source www.cdc.gov
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Plague Clinical Features

• Following Aerosolized Bioattack
• 1- 6 day incubation
• Abrupt onset
• High fever, chills, and malaise
• Cough with bloody sputum
• Sepsis
• Severe rapidly progressive pneumonia
• Untreated 100 mortality

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Plague - Diagnosis

• CXR with patchy infiltrates
• Culture of blood and sputum
• Need to inform the laboratory if you suspect
  plague special techniques
• May show characteristic safety-pin bipolar
  staining
• Sudden Gm(neg) pneumonia

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Plague pneumonia
Normal Chest X-Ray
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Plague - Treatment

• Preferred Start within first 24 hours for 10
  days
• Streptomycin 1 g IM q12h
• 15 mg/kg/dose for children
• Avoid in pregnant women
• Gentamicin 5 mg /kg IM or IV qd
• Or 2 mg/kg load the 1.7 mg/kg q8h
• For children use 2.5 mg/kg q8h
• Alternative
• Doxycycline 100 mg IV q12h
• 2.2 mg/kg/dose q12h for children
• Ciprofloxacin 400 mg IV q12h
• Other fluoroquinolones probably effective
• For children 15 mg/kg/dose q12h

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Plague - Infection Control

• Prophylaxis Treat for 7 days
• Doxycycline 100 mg PO bid
• 2.2 mg/kg for children
• Ciprofloxacin 500 mg PO bid
• 20 mg/kg for children
• other fluoroquinolones probably effective
• Isolation
• Droplet precautions (Yes, P-to-P)

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Smallpox

Source www.cdc.gov
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Smallpox - General

• One of the deadliest disease
• Mortality rate of 30
• US stopped vaccinating in 1972
• Declared eradicated by WHO
• In 1980, however...
• Bioattack
• Aerosolized virus or by exposure to purposefully
  infected terrorists

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Smallpox - Clinical Features

• Incubation period
• 7-17 day (average 12d), Weaponized 3-5 d
• Severe prodrome Key difference!
• 2-3 day of fever, severe myalgias, prostration,
  occ. n/v, delerium
• 10 with light facial erythematous rash
• Distinctive rash
• Initially on face and extremities
• Including palms and soles
• Spreads to trunk

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Small Pox - Clinical Features

• Rash
• Macules ? papules ? vesicles ? pustules
• Unlike chicken pox, lesions dont appear in
  crops
• All lesions in an area are in the same stage of
  development
• Lesions are firm, deep, frequently umbilicated
• Rash scabs over in 1-2 weeks

Chickenpox
Smallpox
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Source www.cdc.gov
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Smallpox
The main diagnostic tool for smallpox
Source www.cdc.gov
is the history and physical!
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Smallpox - Treatment

• Vaccination
• In the early stages of disease
• Supportive care
• Penicillinase-resistant antibiotics (for
  secondary infection)
• Daily eye rinsing
• Adequate hydration and nutrition
• FDA has not approved specific therapy
• Topical idoxuridine for corneal lesions (Dendrid)
• Cidofovir ?

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Smallpox - Infection Control

• Prophylaxis
• Vaccine is effective if given within 3 days of
  exposure
• Isolation
• Airborne and contact precautions
• Febrile illness after potential exposure should
  prompt isolation before rash starts
• Immediate contact your hospital epidemiologist
  and the public health authorities

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Tularemia

• Francisella tularensis

Source www.cdc.gov
Gram Neg. Coccobacillus
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Tularemia - General

• Endemic in North America and Eurasia
• Sporadic human cases spread by ticks or biting
  flies
• Occasionally from direct contact with infected
  animals (ulceroglandular)
• Bioattack
• Aerosolized bacteria
• Typhoidal tularemia ( / - ) pneumonia

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Tularemia - Clinical Features

• Bioattack
• 3-5 day incubation (range 1-14 days)
• Acute febrile illness with prostration
• 80 will have radiographic evidence of pneumonia
  
• May have associated conjunctivitis or skin ulcer
  regional adenopathy

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Tularemia - Diagnosis

• Culture of blood and sputum
• May take weeks to isolate and ID
• Gram negative coccobacillus
• Confirmation may require reference laboratory
• Potential hazard to laboratory personnel
• Laboratory must be notified if tularemia is
  suspected

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Tularemia - Treatment

• Preferred Treatment time varies with Abx
• Streptomycin 1 g IM q12h
• 15 mg/kg for children
• Gentamicin 5 mg / kg IM or IB q day
• for children use 2.5 mg/kg q8h
• Alternative
• Doxycycline 100 mg IV q12h
• 2.2 mg/kg for children
• Ciprofloxacin 400 mg IV q12h
• Children 15 mg/kg
• Other fluoroquinolones probably effective

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Tularemia - Infection Control

• Prophylaxis Treat for 14 days
• Doxycycline 100 mg PO bid
• 2.2 mg/kg for children
• Ciprofloxacin 500 mg PO bid
• 15-20 mg/kg for children
• Tetracycline
• Isolation
• Standard precautions (Not P-to-P)

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Viral Hemorrhagic Fevers
Source www.cdc.gov
Ebola virus
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VHF - General

• Naturally occurring disease
• Transmitted to humans by contact with infected
  animals or arthropod vectors.
• Sporadic outbreaks in Africa, parts of Asia and
  Europe (Outside of Africa, likely BT event)
• VHF viruses as bioterrorism agents
• Weaponized by several countries
• Aerosolization
• Case fatality rates
• Omsk hemorrhagic fever 0.5
• Ebola 90

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VHF - Clinical Features

• Incubation 2 - 21days
• Depends on virus
• Initial presentation
• Nonspecific prodrome (fever, myalgias, headache,
  abdominal pain, prostration)
• Exam may show only flushing of face and chest,
  conjunctival injection, and petechiae
• Disease progresses to generalized mucous membrane
  hemorrhage and shock occurs

Marburg Disease
Bolivian Hemorrhagic Fever
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VHF - Diagnosis

• Ancillary testing
• Thrombocytopenia, leukopenia, AST elevation
  common
• Definitive diagnosis requires detection of
  antigens or antibodies
• Testing done at CDC
• Do not wait to confirm the diagnosis before
  notifying the local public health authorities

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VHF - Treatment

• Supportive care
• Ribavirin may be useful
• Best early in the course of illness
• Adults and children 30 mg/kg IV load (max 2
  g)
• then 16 mg/kg (max 1g) q6h x 4 days
• then 8 mg/kg (max 500 mg) IV q8h for 6 days
• Oral dosing regimen is available

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VHF - Infection Control

• Prophylaxis
• None at this time
• Vaccine in primates being tested
• Isolation Key!
• Blood and bodily fluids extremely infectious
• Liquid-impervious protective coverings, including
  leg and shoe coverings
• Double gloves, Face shields or goggles
• N-95 or better respirators
• Negative pressure room

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Emerging Infectious Diseases

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Pandemic
A Global Epidemic!
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Past flu pandemics
1918 Spanish Flu
1957 Asian Flu
1968 Hong Kong Flu
A(H1N1)
A(H2N2)
A(H3N2)
20-40 m deaths 675,000 US deaths
1-4 m deaths 70,000 US deaths
1-4 m deaths 34,000 US deaths
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Put another way
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Pandemic Influenzawww.cdc.gov
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Pandemic Influenza
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Pandemic Influenza Healthcare Workforce

• Who is going to show up for work?
• The reports, articles and plans are alarming!
• Will you?

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Containment

• Limit travel
• Isolate ill and quarantine exposed
• Trace contacts
• Curfews cancel public gatherings
• Prophylaxis treatment
• Neuramidase inhibitors ?
• Vaccine ?

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• D Detection
• I Incident Command
• S Safety Security
• A Assess Hazards
• S Support
• T Triage Treatment
• E Evacuation
• R Recovery

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• Detection

There may not be a scene May be hard to
detect Long Incubation period Symptoms manifest
slowly Non-specific symptoms
Beware of multiple people with similar Complaints,
particularly in the healthy population
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• D Detection
• I Incident Command
• S Safety Security
• A Assess Hazards
• S Support
• T Triage Treatment
• E Evacuation
• R Recovery

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Incident Command

• Absence of a scene if covert
• Lead role of law enforcement
• Unified command of law enforcement and public
  health
• Special public health emergency powers

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Security

• Hospital ingress and egress
• Must be able to secure hospital
• Most bioattacks likely covert
• Patients will come in through ER
• ER becomes the scene

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Suspicious Package

• Do not open suspicious packages
• Secure area
• Shut off ventilation if possible
• Alert appropriate authorities

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Assessing Hazards

• Protective isolation quarantine
• Epidemiologic assessment
• Environmental assessment
• Laboratory diagnosis of ill persons
• Role of immunization, prophylaxis and treatment
• Little role for decontamination

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Personal Protective Equipment

• Degree of protection
• Controversial
• CDC guidelines
• Very conservative
• N-95 respirators, gloves, fluid-impervious gowns
• Better than nothing

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Support

• Initially, local management issue!
• Local hospital capacity
• Local healthcare providers
• Is your local community ready?

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SupportLocal Hospital Capacity
Coordination Augmentation

• Pre-event planning essential for surge
• Surge facilities for medical care expansion
• Expect being overrun with worried well
• Involvement of local pharmacies

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SupportStrategic National Stockpile

• Pre-positioned material managed by CDC and DHS
• Medications, antidotes, vaccines, PPE,
  equipment,et al.
• 12 hour Push Packages
• Vendor managed inventory
• Local coordination of receipt critical

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Triage

• Three types of patients
• (1). Ill and need definitive treatment
• (2). Exposed but not ill may need prophylaxis
  and quarantine
• (3). Not exposed need reassurance
• Difficult to distinguish between groups 2 3!

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Evacuation

• Dedicated treatment facilities
• Isolation of patients
• Surge capacity implications
• Hospital becomes a scene

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Recovery

• Law enforcement
• Evidence, apprehension, prosecution,...
• Public health
• Stop spread, identify source, treatment
  options,...
• Mental health
• Wide-spread panic, worried-well, responders,...
• Environmental health
• Viability of weaponized release, nature
  effects, soiled materials,...

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Summary

• Now you can
• Describe the difference between biological events
  and bioterrorism (BT)
• Discuss public health BT surveillance
• Identify the CDC BT Category A agents
• Identify emerging infectious diseases
• Compare and contrast BT and other CBRNE WMD
  utilizing the DISASTER paradigm

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Questions?
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