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Association of Occupational and Environmental Clinics Worker Preparedness and Response to Bioterrorism Edward W. Cetaruk, M.D. Toxicology Associates – PowerPoint PPT presentation

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Title: Association%20of%20Occupational%20and%20Environmental%20Clinics

Association of Occupational and Environmental
Worker Preparedness and Response to
  • Edward W. Cetaruk, M.D.
  • Toxicology Associates
  • University of Colorado Health Sciences Center
  • Denver, Colorado, USA

History of Biological Warfare
  • Oldest of the NBC triad of agents
  • Used for gt 2,000 years
  • Sieges of middle ages
  • Smallpox blankets given to Native Americans
  • Germany in World War I
  • Japan in World War II
  • Modern Bioterrorism

Anthrax LettersUnited States
Weaponized Biowarfare Agents
  • Anthrax
  • Botulinum Toxin A
  • Brucellosis
  • Glanders
  • Marburg Virus
  • Plague
  • Q Fever
  • Salmonella
  • Smallpox
  • Staph Enterotoxin B
  • Monkey Pox
  • Ricin
  • Tularemia
  • VEE
  • VHFs

Biological Agents of Highest ConcernCategory A
  • Variola major (Smallpox)
  • Bacillus anthracis (Anthrax)
  • Yersinia pestis (Plague)
  • Francisella tularensis (Tularemia)
  • Botulinum toxin (Botulism)
  • Filoviruses and Arenaviruses (Viral hemorrhagic
  • ALL suspected or confirmed cases should be
    reported to health authorities immediately

Incubation Periods of Selected Biological Agents
Anthrax 1-5 Days Plague 2-3 Days Q Fever
10-40 Days Tularemia 2-10 Days Smallpox
7-17 Days Viral encephalitides V(2-6d) EW
(7-14 d) VHFs 4-21 Days Botulinum toxin 1-5
Days Staph. enterotoxin B 1-6 Hours
Infective Aerosol Doses of Selected Biological
Anthrax 8,000 (or fewer) spores Plague
100-500 organisms Q Fever 1-10
organisms Tularemia 10-50 organisms Smallpox
10-100 organisms Viral encephalitides 10-100
organisms VHFs 1-10 organisms Botulinum toxin
0.001 ug/kg
Aerosol Size and Infectivity
Infection Severity
Particle Size (Micron, Mass Median Diameter)
The ideal aerosol contains a homogeneous
population of 2 or 3 micron particulates that
contain one or more viable organisms
Less Severe More Severe
18-20 15-18 7-12 4-6 (bronchioles) 1-5
Maximum human respiratory infection is a particle
that falls within the 1 to 5 micron size
Bioterrorism Educational Needs of the Worker
  • Awareness
  • Fundamental understanding of biowarfare agents
  • Recognition and handling of suspicious mail or
    dissemination devices
  • PPE and workplace safety
  • Recognition of bioterrorist attack
  • Post exposure management

BioterrorismWho are First Responders?
  • Primary Care Personnel
  • Hospital ER Staff
  • Public Health Professionals
  • Emergency Response Personnel
  • Laboratory Personnel
  • Law Enforcement
  • Public
  • Military

First Responders
  • Often dealing with unknown agent(s)
  • May be exposed to infectious agent
  • May be exposed to infectious patients
  • May be targeted with secondary devices
  • May be first to notice the epidemiological
    pattern of a bioweapons attack

Emergency Plan
  • All Hazards Approach
  • Identify areas with risk of exposure
  • Develop controls to minimize risk
  • Engineering Controls
  • Administrative Controls
  • Housekeeping Controls
  • PPE for workers
  • Develop response and recovery plan
  • Training and Exercises

Emergency PlanExposure to Biological Agent
  • Policies and Procedures for handling suspicious
    mail or packages
  • Plan for facility response
  • Plan for involving appropriate authorities
  • Medical Surveillance
  • Training and Exercises

Handling of Suspicious Mail
  • Do not shake, empty contents
  • Do not carry, show others, or allow others to
    examine it
  • Do not sniff, touch, look closely at it, or any
    contents that may have spilled
  • Leave on stable surface, alert others, leave
    area, close doors, shut off ventilation
  • Wash hands with soap and water
  • Notify law enforcement
  • Create list of persons with potential contact

Personal Protective Equipment
  • Level A
  • SCBA, Encapsulation
  • Level of protection for entering contaminated,
    unsecured scene
  • Level B
  • Level C
  • Level D

Personal Protective EquipmentRespirators
  • Powered Air-Purifying Respirator (PAPR)
  • HEPA filter face masks (N95, N100)
  • Respirators must be in compliance with
  • OSHA respiratory standard
  • (29 CFR 1910.134)
  • Respirators must be fit tested

Powered Air Purifying Respirator(PAPR)
  • Respirators should be used in accordance with a
    respiratory-protection program that complies with
    the OSHA respiratory-protection standard (29 CFR

Personal Protective EquipmentRespirators
  • The respirator is properly positioned over your
    nose and mouth at all times
  • The top strap or head harness assembly is
    positioned high on the back of the head
  • The lower strap is worn at the back of the neck
    below the ears
  • The straps are snug enough to keep the
    respirator from moving but not overly tight
  • Nothing (beards, head coverings, etc.) passes
    between the skin of the face and the respirators
    sealing edge

PPEDermal Protection
  • Disposable
  • Reusable
  • Overgarments, Booties, Hoods, Gloves
  • All PPE should be decontaminated prior to leaving
    potentially contaminated area
  • PPE should be removed and discarded prior to
    removing face mask

Section 3Anthrax as a Biological Weapon
  • Objectives
  • To understand the microbiology and epidemiology
    of anthrax
  • To understand the pathophysiology of the
    different anthrax clinical syndromes
  • To be able to recognize cutaneous anthrax
  • To be able to recognize an intentional
    anthrax release
  • To be able to treat patients with anthrax

AnthraxMicrobiology Epidemiology
  • Bacterium
  • Spores may survive gt 100 yrs
  • Worldwide soil distribution
  • Common disease of herbivores
  • Herbivores in USA vaccinated
  • Man infected via animal products
  • Woolsorters Disease

AnthraxWorldwide Occurrence
Source WHO World Anthrax Data Site
  • Spore enters skin, GI tract, or lung
  • Germinates in macrophage
  • Transported to regional lymph nodes
  • Local production of toxins
  • Swelling and Tissue Death
  • Toxemia

Anthrax Clinical Syndromes
  • Cutaneous
  • Gastrointestinal
  • Inhalational

Multiple forms can be seen as the result of a BW
  • Abdominal pain, usually accompanied by bloody
    vomiting or diarrhea, followed by fever and signs
    of sever infection
  • GI anthrax is sometimes seen as mouth and throat
    ulcerations with tender neck glands and fever
  • Develops after ingestion of contaminated, poorly
    cooked meat.
  • Incubation period 17 days
  • Case-fatality 2590 (role of early antibiotic
    treatment is undefined)

  • Begins as a papule, progresses through a
    vesicular stage to a depressed black necrotic
    ulcer (eschar)
  • Edema, redness, and/or necrosis without
    ulceration may occur
  • Form most commonly encountered in naturally
    occurring cases
  • Incubation period 112 days
  • Case-fatality
  • Without antibiotic treatment 20
  • With antibiotic treatment 1

Cutaneous Anthrax
Hospital Day 5
Hospital Day 12
2 months after discharge
JAMA. 2002287869-874
Inhalational Anthrax Clinical Presentation
  • Incubation Period 1-6 days
  • A brief prodrome resembling a viral-like
    illness, characterized by muscle aches, fatigue,
    fever, with or without respiratory symptoms,
    nausea, vomiting, abdominal pain
  • Early Symptoms malaise, fever, fatigue,
    non-productive cough, chest discomfort
  • Confusion, neck stiffness, and headache suggest
    meningitis (seen in 50 of patients)

Inhalational Anthrax Clinical Presentation
  • After initial onset of illness, symptoms may
    remain mild or even improve slightly before
  • Terminal Phase dyspnea, stridor, cyanosis,
    shock, chest wall edema, meningitis, widened
    mediastinum with effusion with overall
    toxic/septic clinical picture

Presenting Symptoms
Emerg Infect Dis vol.7, no. 6, 2001
Anthrax Diagnosis
  • Clinical picture of sudden onset of respiratory
    distress with mediastinal widening on x-ray
  • A small number of patients may present with GI or
    cutaneous anthrax
  • Gram stain of blood and blood cultures - but
    these may be late findings in the course of the
  • ELISA, FA, PCR and immunohistology testing may
    confirm diagnosis but samples must go to
    reference laboratory

Anthrax Treatment
  • Post-exposure
  • Oral prophylaxis
  • Ciprofloxacin (500 mg PO q12 h) X 60 days and
    until 3 doses of vaccine
  • Doxycycline (100 mg PO q12 h) X 60 days and until
    3 doses of vaccine
  • Vaccination
  • Acute Treatment
  • Usually futile in severe mediastinitis patients
    who inhaled or ingested spores
  • Ciprofloxacin - 400 mg IV q 8 to 12 hr
  • Doxycycline - 100 mg IV q 12 hr
  • Vaccination

Anthrax Vaccine
  • FDA approved 1970
  • Cell Free filtrate (NO organisms, dead or alive)
  • Adverse effects 1-3
  • Bioport Corporation

Laboratory Workers
  • Increased number of highly pathogenic bacterial
    and viral samples
  • Increased need for universal precautions
  • Increased need for security, including
    maintaining chain of custody for forensic samples
  • Increased need for decontamination procedures
  • Laboratory Response Network (LRN)

Laboratory WorkersDecontamination and
  • Effective sporicidal solutions
  • Commercially-available bleach diluted to 0.5
    Sodium hypochlorite (1 part household bleach to 9
    parts water)
  • Rinse off concentrated bleach to avoid caustic
  • Approved sporicidal agents