Download Bio-terrorism Agents and the Mass Casualty Response Plan

and
Presented by Dr. Roslyn Bascombe-Adams
“Leaders” - International Course for Managers on Health,
Disasters and Development
February 18th 2003, Ocho Rios, Jamaica
Overview

Why Consider NBC-warfare?
 What are Potential Chemical Agents?
 Guide to managing Chemical Agents .
 What are likely Bio-terrorism Agents?
 Guide to managing “common” Bioterrorism Agents.
 Considerations for contingency planning.
Definition of Biological Terrorism
The use or threatened use of biological
or biologically-related toxins against
civilians, with the objective of causing
illness, death or
Eric K. Noji, M.D., M.P.H.
Disaster Risks
NATURAL







Hurricanes/Cyclones
Tidal waves/Tsunamis
Landslides
Floods
Earthquakes
Fires
Volcanic eruptions
TECHNOLOGICAL







Vehicle/Aircraft accidents
Explosions/Bombing
Fires
Oil spills
Chemical exposure
Germ warfare
Nuclear explosions
Is there a credible risk of
BNC warfare?

The world today…
– Terrorists (high profile events, crowds, critical infrastructure..)
– Doomsday cults
– Insurgents
U.S.A. ‘s current war policies
 Consider flight paths of large airlines
 Geneva convention/duty to respond to vessel in
distress

??????????
Do we OWE it to ourselves to
prepare?
Fore-warned
is
Fore-armed!
Chemical Agents

Blister agents
– Mustard gas, phosgene oxime

Nerve Agents
– Sarin, Ricin, Tabun, GF, VX,

Pulmonary Agents
– Phosgene, chlorine

Pesticides
– Organophosphates
Agents of Most Concern

BLISTER AGENTS

NERVE AGENTS
Coping with Chemical Agents

IDENTIFY
 COMMUNICATE
 SECURE
 DECONTAMINATE
 TRIAGE
 TREAT
 RECEIVE/DISPOSE
Identifying Chemical Agents

Usually overt attack/incident
 Burns to skin and mucosa, usu. within 2 mins
 Cardio-pulmonary injury/failure
 Shock
 Neurological damage
 Trauma
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
1. Blister Agents

Used before (WW2)
 Burns to skin & mucus membranes (within 2 mins)
 Tracheo-bronchial damage
(SOB, wheezing, pulmonary edema)

More morbidity
 Supportive care
 Mortality 20-30%
 Death usually secondary to immune suppression seen 5-7
days post-exposure
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
2. Nerve Agents

Used before (Gulf war, Japan subway)
 Massive cholinergic neurological stimulation
 “SLUDGE” syndrome (salivation, lacrimation [excess tears],
urination,diarrhoea, gastric emptying [vomiting])
 Miosis (pinpoint pupils)
 Fasciculations
 Seizures
 Flaccid paralysis
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Coping with Chemical Agents
- Communication FIRST LINE KEY PLAYERS
– AIRPORT CONTROLLER
– PORT & MARINE OPERATER
– 911 DISPATCHER
– EMT
– DUTY NURSE
– PHYSICIAN
– MILITARY
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
E.g. Schematic of Communication Cascade
if indicated
Poison Control
Chief of Staff
Duty Doctor ER Director CMO
Initiator
Duty Nurse Triage Nurse/EMT’s
Charge Nurse
CEO
CDC
Nurse Supervisor
Clin. Coordin
Prog. Manager
Security Manager
Coping with Chemical Exposure
-Securing
Scene safety done by Police and Fire
 Due concern is given to exposed population,
rescuers, victims, property
 Working Areas must be recognized and respected
–
–
–
–
Strictly restricted area
Restricted area
Reserved area
Media area
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Coping with Chemical Exposure
-Securing
If MCM activated
– Hospital security :
 Cordons ER
 Controls lower parking lot
 Discourages non-essential pedestrian flow
– Police needed for traffic & crowd control
– Military
Coping with Chemical Agents
-DecontaminationFire service has Hazmat branch and 10 responsibility
 Emergency Staff may be needed in a 2o response
 Police may be needed in a 20 response e.g.
explosives present, social disruption
 For rescue safety purposes, decontamination takes
priority over care-giving.

Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Coping with Chemical Agents
-DecontaminationImpact zone
Decon
Zone
Advanced Medical Post (AMP)
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Coping with Chemical Exposure
- Triaging 
Assess need to activate MCM plan
 Get additional
–
–
–
–
–
–
Staff
Oxygen
Nebulizers
Antidote
Medications
Safety gear, (Level II protective gear)
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Coping with Chemical Agents
-Triaging
Triage will follow standard MCM practices
–
–
–
–
RED immediate priority
Yellow urgent priority
Green non-urgent
Black dead
Remember: triage to treat on site and then triage to
transport
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Coping with Chemical Exposure
- Treating Treat as clinically indicated
 Oxygen
 Nebulization
 Atropine IV for “SLUDGE”, until bronchial
secretions decreases. 3-5mg/5-10 minutes
 2-PAM (pralidixime) 1-3 mg IV for flaccid
paralysis (may repeat in 3 hrs)
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Coping with Chemical exposure
- Receiving/Disposition 
This will depend on number and severity of
victims
 Dispose as clinically indicated
– Ward
– ICU
– “Other” Holding Areas/Clinics
– Discharge
– Morgue/Make-shift morgue
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Biological Agents

Use before
–
–
–
–
–
–
–
–
Sieges of middle ages
Smallpox blankets given to Native Americans
Germany in WW I
Japan in WW II
1984 Salmonella poisoning, Oregon
1995 Iraq used anthrax/botulism toxin weapons
1995 Aum Shinrikyo tried anthrax and failed
1997 – 1999 Multiple Anthrax hoaxes
Biological Agents

Likely to be covert
 Delayed impact because of incubation period
 Health care workers in the forefront as initiators
 Public health surveillance has prominent role
 Early communication is key
Close Cooperation with
clinicians, healthcare and first
responder communities

Emergency departments, urgent care centers
 Infection control units
 Physician networks, private offices
 Hospitals, HMOs
 Medical examiners
 Poison control
 Law enforcement, fire, other first responders
Eric K. Noji, M.D., M.P.H.
Potential Biological agents
CATEGORY A AGENTS (CDC)
 Bacillus anthracis – Anthrax
 Clostridium botulinum – Botulism
 Yersinia pestis – Plague
 Variola major – Smallpox
 Francisella tularensis – tularemia
 Viral Hemorrhagic fevers
Anthrax

Gram positive bacillus
 May be
– Inhalational ( incub. 2-60 days, average 5)
 80-90% mortality (treated)
– Cutaneous (incub. 1-7 days)
 20% mortality (untreated)
– Gastro-intestinal (incub.1-7 days)
 50% mortality(untreated)
Anthrax - Soviet Incident
An accident at a Soviet
military compound in
Sverdlovsk
(microbiology facility) in
1979 resulted in an
estimated 68 deaths
downwind, of ~ 79
infected
Biological
Warfare
research,
production and
storage facility
Path of
airborne
Anthrax
MOSCO
W
Sverdlov
sk
ANTHRAX
WHAT TO DO?
 Identify
 Contain
 Communicate
 Triage
 Treat
 Receive/Dispose
Anthrax

High index of suspicion needed
 Travel history or exposure to suspect source
 Infectious contacts (for cutaneous)
 Employment history
 Activities over the preceding 3-5 days
Cutaneous Anthrax, face
CDC
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Cutaneous Anthrax
CDC
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Cutaneous Anthrax
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Cutaneous Anthrax
Differential Diagnosis

Spider bite
 Ecthyma gangrenosum

Ulceroglandular tularemia
 Plague
 Staphlococcus cellulitis
 Streptococcal cellulitis
Anthrax
GASTROINTESTIONAL ANTHRAX
 Generally follows ingestion of contaminated ,
under-cooked meat
 Acute inflammation of GI tract
 Nausea, vomiting, loss of appetite
 Later, abdo pain, hemoptysis, severe diarrhea
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Anthrax Spores
Aerosol / Infectivity Relationship
Particle Size Infection
(Micron, Mass
Severity
The ideal aerosol
contains a
homogeneous
population
of 2 or 3 micron
particulates that
contain one or more
viable organisms
Maximum human
respiratory infection
is
a particle that falls
within the 1 to 5
micron size
Median
Diameter)
18-20
Less
Severe
15-18
7-12
4-6
(bronchioles)
1-5
(alveoli)
More
Severe
Inhalational Anthrax
 1 – 60 day incubation period
 Fever, myalgias, cough, and fatigue
 Initial improvement
 Abrupt onset of respiratory distress,
shock
 Nonspecific physical findings
 Pneumonia is rare
 CXR - may show widened
mediastinum +/-bloody pleural
effusion
 50 % of cases have associated
hemorrhagic meningitis
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Inhalation Anthrax widened mediastinum 22 hours before
death
CDC/Dr. P.S. Brachman, 1961
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
Hemorrhagic Meningitis from Inhalation
Anthrax
CDC, 1966
Inhalational Anthrax
Differential Diagnosis

Mycoplasmal pneumonia
 Legionnaires Disease
 Psittacosis
 Tularemia
 Q fever
 Viral Pneumonia
 Histoplasmosis (fibrous mediastinitis)
 Coccidioidomycosis
Anthrax

If highly clinical suspect or confirmed case, open
lines of communication
 If suspect package/letter
– Contain physically
– Do not shake/empty contents
– If spills occurred, cover immediately. Never try to
clean up a spill!
– Wash hands with soap and water
– Close windows/doors/ shut down A/C and leave room
– List all contacts for future reference and follow-up.
Identify/Communicate/Contain/Decontaminate/Triage/Treat/Receive/Dispose
ANTHRAX

Considered highly infectious if spores are inhaled
(2500-5000 or more spores needed)
 Low re-infectivity after spores fall
 Hazmat precautions are initiated to prevent or
minimize inhalation anthrax from suspect
packages
Identify/Communicate/Contain/Decontaminate/Triage/Treat/Receive/Dispose
Anthrax

For suspect/confirmed patient(s) or persons
exposed to suspicious powder
– Remove all clothing and accessories ASAP and bag in
plastic
– Shower with soap and water ASAP

For suspect package/room
– Hazmat team will secure area, remove object, seal
room, initiate testing source
Identify/Communicate/Contain/Decontaminate/Triage/Treat/Receive/Dispose
ANTHRAX

Unlikely to have MCM-type situation

Manage according to clinical indications
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
ANTHRAX
PROPHYLAXIS
Started on clinical suspicion OR exposure to confirmed
powder OR beginning of suspect symptoms following
possible exposure
 Immunization (at 0, 2, 4 weeks) plus meds x 1 mth
 Ciprofloxicin (caution in children, elderly & pregnancy)
 Doxycycline
 ?Amoxicillin
 Nasal swabs useful only with highly credible exposure &
no discrete environmental source to test.
Identify/Communicate/Contain/Decontaminate/Triage/Treat/Receive/Dispose
ANTHRAX
For Cutaneous Anthrax, as with post-exposure
prophylaxis:
Cipro 500 mg po bid x 60 days
Or
Doxy 100 mg po bid x 60 days
Except there are
1. Signs of systemic involvement
2. Extensive edema
3. Head lesions
4. Neck lesions
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
ANTHRAX
For Inhalation and Gastro-intestinal anthrax,
1. Ciprofloxcin 400 mg IV Q8-12H
OR
Doxycycline 100 mg IV Q12H
PLUS
2. Rifampin 600 mg po bid
3. Clindamycin 600 mg IV bid
(vancomycin, penicillin, chloramphenicol,
imipenem,clarithromycin)
Consider Steroids
Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose
BOTULISM

Gram positive bacillus
 Produces potent neurotoxin which inhibits
release of acethylcholine
 Characteristic flaccid paralysis
 Usually food-borne
 Can be aerosolized
BOTULISM
IDENTIFY
 High index of suspicion
 Incubates 12-36 hrs after ingestion, 24 –72 hrs after
inhalation
 Fully alert, responsive patient
 Symmetrical cranial neuropathies
 Descending weakness
 No sensory deficit
 Respiratory dysfunction
Identify/Contain/Communicate/Triage/Treat/Receive/Dispose
BOTULISM
CONTAIN
 Not transmitted person to person
 Routine immunization not required
 Standard precautions to manage
Identify/Contain/Communicate/Triage/Treat/Receive/Dispose
BOTULISM
COMMUNICATION
 Open crisis channels
 Duty doctor +/- charge nurse
TRIAGE
 As clinically indicated
Identify/Contain/Communicate/Triage/Treat/Receive/Dispose
BOTULISM
TREATMENT
 Botulism antitoxin available
 Toxin may be found in serum, stool samples,
gastric secretions
 Routine blood tests of limited value
 May need ventilator support from 2-3 months
Identify/Communicate/Triage/Treat/Receive/Dispose
PLAGUE

Gram negative bacillus
 Usually transmitted by infected fleas
 Can be aerosolized/weaponized
 Inhaled version causes PNEUMONIC
rather than bubonic plague
 Incubation 2-8 days by fleas but 1 – 3 days
by aerosol
PLAGUE
IDENTIFY
 Fever, cough, chest pain
 Haemopytsis
 Muco-purulent sputum
 Bronchopneumonia on X-ray
Identify/Contain/Communicate/Triage/Treat/R
eceive/Dispose
Plague Disease Complex
Inhalational
2 -3
days
Pharyngitis
Sudden
onset
Fever/rigors
9%
Erythema
Tender bubo
1 - 10 cm
2 - 10 days
Fever,
URI
syndrome
24 hrs
Fulminant
Pneumonia
Stridor, cyanosis,
productive cough,
Hemoptysis,
bilateral infiltrates
Systemic
Toxicity
Liver
enzymes
6% late
meningitis
APTT
ecchymosis
DIC
Respiratory failure
& circulatory collapse/Death
Plague

Late complications
of septicemia or
pneumonic plague
may include acral
gangrene of digits
nose, earlobes,
penis
Identify/Contain/Communicate//Triage/Treat/Receive/Dispose
Pneumonic Plague
Prevention of Secondary
Infection

Secondary
transmission is
possible and
likely
• Standard,
contact,
and aerosol
precautions for at
least 48 hrs until
sputum cultures are
negative or
pneumonic plague is
excluded
Identify/ Contain/Communicate/Decontaminate/Triage/Treat/Receive/Dispose
PLAGUE
CONTAIN
 Remove clothes, bag, shower thoroughly
 Person-to-person spread by large droplets
 Standard and Droplet precautions
 Contagious until 48 - 72 hours of antibiotics
 No vaccines available
Identify/ Contain/Communicate/Decontaminate/Triage/Treat/Receive/Dispose
PLAGUE
COMMUNICATE
 Activate crisis lines
 Involve infection control practitioner ASAP
Identify/ Contain/Communicate/Triage/Treat/Receive/Dispose
PLAGUE
TREATMENT
 Doxycycline 100 mg bid
 Ciprofloxicin 500 mg bid
 Initiate post-exposure prophylaxis ASAP to
seven days following last exposure or until
exclusion
 Blood, sputum, tracheal aspirate cultures
Identify/ Contain/Communicate/Triage/Treat/Receive/Dispose
SMALLPOX

Acute viral illness
 High morbidity in non-immune persons
 Incubates 7-17 days (average 12)
SMALLPOX
IDENTIFY
 Flu-like illness 2-4 day prodrome
 Skin lesions
 Prominent on face (in contrast to truncal
distribution of chickenpox)
 Synchronous onset rash
Identify/ Contain/Communicate/Triage/Treat/Receive/Dispose
Adult with Smallpox rash
CDC/NIP/Barbara Rice
Child with Smallpox rash
CDC/Cheryl Tryon
Close-up Smallpox rash
CDC/James Hicks, 1973
Smallpox - Prevention of
Secondary Infection

Contagious
 All contacts are
quarantined for at least 17
days
 Infectious until all scabs
are healed over
Last child with Smallpox
CDC
Last adult with naturally occurring Smallpox, 1977
World Health Organization
-1980-
SMALLPOX
CONTAIN
 Decontamination NOT necessary
 IMMEDIATELY initiate airborne precautions, mask
patient, evacuate area and contact infection control.
 DO NOT DRAW BLOOD
 Limit movement to essential necessity
 House victims in pre-identified location
Identify/ Contain/Communicate/Triage/Treat/Receive/Dispose
SMALLPOX
PROPHYLAXIS
 Vaccine available and effective
 Immunize within 3 days of exposure
 After 3 days give VIG (vaccinia immuneglobins) as well
 Isolate victims and contacts, separately (17-day
quarantine)
Identify/ Contain/Communicate/Triage/Treat/Receive/Dispose
Isolation Precautions





Anthrax
Standard
Plague
Droplet
Smallpox Airborne
(Respiratory)
Botulism Standard
Tularemia Standard
Psychological Issues
Distress may be evident in: Thinking
 Physical
 Emotional
 Behaviour
Bioterrorism Surveillance
•Early, rapid recognition of unusual clinical
syndromes or deaths & of increase above
“expected levels” of common syndromes,
diseases, or death
•Rapid etiologic diagnosis
•Rapid response
Eric K. Noji, M.D., M.P.H.
Bioterrorism Surveillance
•Key features
–Real time data  real time epidemiology
–Syndrome-based reporting
–Sentinel surveillance sites
–Pro-active (high profile potential target events, ongoing
surveillance in sentinel sites)
–Reactive (monitoring and response)
–Aberration Detection
Eric K. Noji, M.D., M.P.H.
CDC Epidemiology and Bioterrorism
The detection and control of saboteurs are the responsibilities
of the FBI, but the recognition of epidemics caused by
sabotage
is particularly an epidemiologic function…. Therefore, any plan
of
defense against biological warfare sabotage requires trained
epidemiologists, alert to all possibilities and available for call
at a moment’s notice anywhere in the country”
Alexander Langmuir
Founder of CDC EIS Program
1952
Key to Planning

Establish Chain of command
 Know Communications lines
 Establish reporting and prompt data
collection methods
 Education of ED staff
 Education of healthcare workers
 Utilize Local news media to reliably inform
population.
Recommendations
•
It may not be prudent to await diagnostic
laboratory confirmation
•
It may be necessary to initiate a response based
upon the recognition of high-risk syndromes
• Develop mechanisms to evaluate institutional
trends of high-risk syndromes
• Develop laboratory protocols for notification of
infection control/hospital epidemiologist for
“suspect” cultures or tests
Eric K. Noji, M.D., M.P.H.
Current Challenges
 Real-time transmission
and analysis
 Identification of localized clusters
 Sustainability of surveillance system
 Development of response protocols
Eric K. Noji, M.D., M.P.H.
Unanswered Questions

What is the threshold that initiates response
 What is the sensitivity and specificity of
surveillance systems
 Usefulness and feasibility of aggregate data
from hospital admissions
 Future: data electronically collected,
integrated, evaluated and shared in a “real
time” fashion (?)
Eric K. Noji, M.D., M.P.H.
NATIONAL BIOTERRORISM PREPAREDNESS AND RESPONSE INITIATIVE
CONTACT INFORMATION
Centers For Disease Control and Prevention
Cand Response Program (BPRP)
Atlanta, Georgia 30033
770-488-7100
www.bt.cdc.gov

THREAT IS REAL

PREPAREDNESS IS THE KEY

PLANS INEFFECTIVE UNTIL KNOWN

WHEN IS THE BEST TIME FOR
ACTION?

WITH LUCK, WE’LL NEVER HAVE TO
INITIATE A RESPONSE PLAN

“How lucky do you feel today??”
THE END
THE END