Bioterrorism: Roles of State Level Public Health

Bioterrorism vs. Other Disasters  Natural Disasters: Public Health (Health and Medical ) is supportive  Bioterrorism: Public Health Leads with Law Enforcement

Role of Texas Department of Health in Bioterrorism  Epidemic Detection and Investigation  Communication with local, state, & federal health partners  Activation and implementation of the State Emergency Response Plan

Epidemic Detection and Investigation  Early detection, recognition and

reporting

of disease cases  Rapid

laboratory

identification of responsible organism  Coordinated

response

to control the outbreak and prevent transmission

Rapid Laboratory Diagnosis  Rapid identification saves lives.

 Appropriate modern technology  Appropriate staffing with 24/7 back-up

Coordinated Response to Control and Prevent  Recommend medical treatment protocols and outbreak control to local physicians and hospitals, including quarantine measures where appropriate  Divert needed antibiotics currently available in the state to areas of the epidemic  Request additional pharmaceuticals through the CDC

External Communications  Communicate with local, state and federal health partners using Health Alert Network.

 Notify federal, state and local elected officials of the outbreak including TDH investigative and control activities.

 Inform the general public.

Health Alert Network (HAN)  Connecting health partners to TDH and CDC for rapid communication of crucial epidemic and treatment information.

 Information is sent to alert local authorities via FAX, email, and pager  Local authorities can communicate back to TDH, CDC, or their local or regional “hub” by the same means

Leadership Role in State Emergency Response Plan 

TDH participates in the State Emergency Operations Center



TDH is the lead agency in implementation of the Health and Medical Services Annex H of the State Emergency Management Plan

State Emergency Management  State health department response is integrated within the State Emergency Response  At the first suggestion of an epidemiologically unusual event, EM and law enforcement are informed  Resources of state are coordinated and made available and links to federal assets opened.

Public Health Leads in Bioterrorism 

State Health Dept assists local health agency

.

 Initial detection of illness or identification of microbial threat are core public health functions  Epidemiologic determination of possible exposure means, locations.

Public Health Leads in Bioterrorism  Takes or recommends appropriate control measures and monitors impact  Provides medical/health information for medical care  Provides public information regarding scope of outbreak and actions for public

Public Health Leads in Bioterrorism  Coordinates federal health assets including National Pharmaceutical Stockpile  Advises on cleanup and disposition of the deceased

Public Health in Response Planning  Response is a local responsibility  State and federal assets are to

Assist

 Coordinate with law enforcement through emergency management  Epidemiologic investigation in tandem with criminal investigation

Emergency Response

Hierarchy  Institution Response  Local Response  County Response  State Response  National Response

Resources  APIC Bioterrorism Readiness Plan: A Template for Healthcare Facilities  Disaster Preparedness Planning and Response in Texas Hospitals  Texas Department of Health  Centers for Disease Control and Prevention (CDC)

Hospital’s Role  Integrate different emergency planning efforts to assure a coordinated response  Identify and prepare for their role in an emergency response to a biological event

Recognition  A rapid increase in the number of previously healthy persons with similar symptoms seeking medical treatment  Cluster of previously healthy persons with similar symptoms who live, work, or recreate in the a common geographical area  Unusual clinical presentation

Hospital Preparedness and Response  Mitigation  Preparedness  Response  Recovery

Federal Response  Department of Health and Human Services (HHS)  Office of Emergency Preparedness (OEP)  Federal Emergency Management Agency (FEMA)  Department of Justice (DoJ)  Department of Defense (DoD)

Federal Response  Centers for Disease Control and Prevention (CDC)  Food and Drug Administration (FDA)  National Institutes of Health (NIH)  Federal Bureau of Investigation (FBI)

Federal Response  FBI is the lead federal agency for coordinating the federal response to a terrorist incident or threat  FEMA is lead agency in consequence management  CDC has established the Strategic Pharmaceutical Stockpile (NPS)

Texas Department of Health Role (TDH)  TDH is the lead state agency for the public health response to a bioterrorist incident or threat  Primary objective is to determine the etiology and source of the outbreak and identify the most effective and efficient interventions to protect public safety

Local Health Department Role  Lead role in early detection and identification of a bioterrorist event  County plans  ICP's need to participate in the planning process along with safety officers and epidemiologists for local response

Role of Infection Control Practitioner  Significant !

 Rapid identification of an outbreak of community-acquired infection  Notification of local health department  Day-to-day surveillance activities

Surveillance  Critical Care Units  Emergency Room  Ambulatory Clinics  Develop syndrome monitoring system for departments most likely to be first affected by a bioterrorism event

IC Considerations  Epidemiology, Diagnosis and Treatment  Hospital Emergency Management Plan  Local Health Department response  Prepared to take a leadership role in the hospital’s response to the outbreak  Trained professional should be available in the event the ICP is unavailable

References and Further Assistance  Local Public Health Service/State Health Department  Centers for Disease Control  Local FBI Representatives

Web Sites  CDC Bioterrorism www.bt.cdc.gov

 Association for Infection Control Professionals and Epidemiologists (APIC) www.apic.org/bioterror/  For management of Biologic Casualties www.usarmiid.army.mil/education/bluebook.ht

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Scenario  From Aug 29-Sept 1, five 18 yr old females & two males were seen in Hospital A’s emergency dept with diarrhea & abdominal cramping; stool specimens are taken. Three were admitted.

Scenario  Hospital A’s Micro Lab Supv. calls ICP on Sept 1 to report two stool specimens from Aug.30 are positive for E. coli 0157:H7; one is negative & four are pending.

 ICP notifies the treating physician and confers with the local health dept. epidemiologist.

Scenario  Hospital B is contacted by local health dept. and reports no cases.  Sept. 2 ICP-A interviews 3 hospitalized pts. discovering all are college freshman and informs local health dept.  County Medical Director calls college Health Services MD and regional/state/national health dept.

Scenario  College Health Services MD confirms three cases treated at infirmary among freshman within last 24 hrs.

 County Environmental Health Director is notified by County Medical Director.

 Sept 3 Hospital-A admits another 19 yr old college freshman with bloody diarrhea.

Scenario  Sept 4 County Medical Director calls meeting to coordinate information among:  College Health Services MD  Hospital (A & B) ICPs  County Environmental Health Director  Local/regional/state TDH epidemiologists  CDC representative

Scenario  Outbreak investigation is initiated.

 Flyers are distributed on campus requesting all students to report GI illnesses to 1-800-SICK  E.coli 0157 questionnaire is completed for each suspected or confirmed case.

 Local media is briefed via the college health services representative.

Scenario  CDC reps reviewed all admissions/ED visits for case definition from 8/15-9/15 at hospitals A & B  cases were limited to an on-campus event freshman “Howdy Week” picnic on Aug 27  Total of 27 students had food-borne illnesses; 10 were confirmed as E. coli 0157:H7  All responded to treatment.

Mental Health Issues and Interventions in Terrorism

What is Terrorism?

 The unlawful use of force or violence against persons or property

Terrorism  Terrorism is a unique cause of a crisis used to create a condition of fear and uncertainty, demoralization, and helplessness as a coercive force

Terrorism Overview  Used to support political, religious, or ideological goals   The threat of the crime can be as devastating as the commission of the act  Kill one,frighten thousands Recent Terrorism – 1993 World Trade Center – – 1995 OKC Federal Building 911 World Trade Center

Mental Health Facts  10-35% suffer significant posttraumatic stress after a disaster  Over 50% of disaster workers in the 9/11 WTC can be expected to develop post traumatic stress  The “worried well” – Tokyo Sarin incident – 12 dead – 900 hospitalized – Up to 9000 worried – A 10:1 ratio of the “Worried Well”

Mental Health Facts  Mental Health Aspects of a mass casualty event may well be the most widespread, long lasting, and expensive consequences – Warwick, 2001

Initial Crisis Intervention Phase 1-Assembly  Set up a command center and respite center in a safe location schools/ballrooms/churches  Involve hospital risk management,Medical Director of Infection Control and public relations to communicate with media

Initial Crisis Intervention Phase 1-Assembly  Have mental health professionals, EMS workers/Disaster relief team, Clergy, Social workers present as appropriate  Non-threatening fact finding information(who,what,where,when,how)  Acknowledge the significant impact of the event

Initial Crisis Intervention Phase 1-Assembly   Communication Methods Phase 1-”Assembly” – – – – – – Mass Media-TV,radio Mouth to mouth Internet Emergency Service Vehicles Handbills “Town” Meeting

Initial Crisis Intervention Phase 2 - the Facts  Who should communicate?

– Most appropriate – Most credible – Most prepared • Explain facts known • What is known, what is not known-control rumors, informs, reduce anxiety, and return sense of control

Initial Crisis Intervention Phase 2 – the Facts  Facts – What is known about disease and health effects – Precautions to be taken – Treatments that are available – What is being done to prevent spread of disease – Discuss expected outcomes as known to date

Initial Crisis Intervention Phase 3  Discuss common signs and symptoms of Stress Management  Discuss typical reactions to terrorism  Discuss signs and symptoms of: – – grief stress - anger - survivor guilt – responsibility guilt

Initial Crisis Intervention Phase 4 Discuss Management Techniques  Personal coping strategies  Self Care strategies  Community Resources  Organizational Resources  Hand out sheets with names and numbers of resources

Therapeutic Conversation as an Initial Crisis Intervention  Thoughts – – – – What were their thoughts at the time?

Help to facilitate an understanding of their experience How can I help you cope? Comfort?

What do you think will help?

 Reactions – – Support and encourage feelings without probing Emphasis that reactions are a result of the event and not personal weakness

Therapeutic Conversation as an Initial Crisis Intervention  Encouragement – Effective coping and self care-identify immediate needs – Education-handouts of common mental health reactions to similar events – Use of existing resources (social, religious, physical) – – Referrals-agencies in your community Achieving closure

What is a disaster?

 Severe/large magnitude  Immediate, coordinated response by government or private sector

Types of Disasters  Natural – Earthquake, floods  Human source – Explosions, fires  Health-related – Accident, catastrophic illness  Social – Hostage, riots

Psychological Impact  Human made disasters are more pathogenic than natural disasters  Terrorism may be the worst-due to the unpredictable, unrestrained nature

Risk Factors  Death  Home destruction/loss  Property Loss  Injury to family/friends  Children involved/hurt/killed  Intentional Cause  Other stressors in life

Risk Factors  Worry about safety of loved one  Familiarity of victims  Other major trauma in past year  Level of personal preparedness  Amount of social support  Access to Resources  Self-Expectations

Phases of Disaster  Threat/Warning  Impact of actual disaster  Heroic  Afterward-honeymoon period  Disillusionment  Reconstruction

Phases of Disaster  The phases of recovery do not always follow a logical or linear order

Disaster Psychology   Survivors often reject disaster assistance People may not see themselves as needing help   Stress and grief normal responses Design the relief efforts for the community needs  Interventions must be appropriate to the phase of the disaster

Types of Terrorism Weapons  Chemical agents such as nerve gas   Blistering agents Blood agents such as cyanide  Chemical agents such as tear gas      Easy to use and make More stable than biological Easier to control Not contagious Inexpensive

Types of Terrorism Weapons  Biological Weapons – Viruses such as Smallpox, Ebola, – Encephalitis – Bacterial such as anthrax, botulism, plague – Fungi – Toxins of microbes-ricin, aflatoxin, – botulinum, Staph enterotoxin B

Biological Weapons  Cheap, easily hidden  Weaponized by aerosol, food, water, blood, vectors  Can be very toxic  Short window for intervention  Demoralizing effects

Biological Weapons  Incubation period may allow for widespread distribution  Many unfamiliar to physicians  High psychological impact

Fear of Biological Weapons  Fear of illness and death  Vaccination/Treatment issues  Fear of death and/or disfigurement  Fear of contagion  Emerging diseases-increased level of outbreaks and media coverage of same

Why is Terrorism so Psychologically Damaging?

 Unknown type of event  Agents cannot be seen/identified  Lack of protection/fear of contamination or contagion  Lack of warning  Suddenness of events  Serious threat to life

Why is Terrorism so Psychologically Damaging?

 Wide scope of destruction/causalities  Intentional  Gruesome situations  High emotional impact/uncertainty  Lack of personal control  Possible long term health problems  Disruption of social systems

Attitude and Reality  Impossible to defend against  Disastrous outcome  High death rate /casualty  Terror!

 But defense may be possible, can limit casualties, mortality can be minimized  BE PREPARED, NOT SCARED

Preparation  Proactive – Plan and train – Post-incident management and care

Vaccines

Vaccines for common BT events  Smallpox vaccine for smallpox  Program to vaccinate front line health care workers and public health officials – ACIP-unwise to expand program due to unanticipated health and safety concerns such as myo/pericariditis and unknown long-term sequelae

Smallpox Vaccine  Indicated for people investigating monkey pox/smallpox cases-(pre-vaccination is preferred)  HCW caring for patients up to 14 days post exposure  Contacts of patients-3 hrs/6.5 feet  Lab workers/cultures

Smallpox Vaccine  Vaccine manufacturer-Wyeth Labs Dry-vax  Made from vaccinia or cowpox virus in calf lymph  Antibody level less than 5 years  Waning immunity after 10 years

Smallpox Vaccine:

Complications of vaccination

 – – – Mild Inadvertent inoculation to other sites such as face, eyelid, nose, mouth, genitalia, rectum Erythematous/urticarial rash Stevens-Johnson's syndrome

Smallpox Vaccine:

Complications of vaccination

 Moderate-severe – Eczema vaccinatum – Generalized vaccinia – Progressive vaccinia

Smallpox Vaccine:

Complications of vaccination

 Severe – Post vaccinial encephalitis – Vaccinial keratitis

Smallpox Vaccine:

Complications of vaccination

 Rates – 42.1 cases/million auto inoculation – Generalized vaccinia 9.0

– Eczema vaccinatum 3.0

– Progressive vaccinia 3.0

– Post vaccinial encephalitis 2.0

Smallpox Vaccine  Contraindications – History /presence of eczema in person/family member – Other chronic or acute skin conditions – Immunosuppression – Pregnancy/breastfeeding – Less than 1 year old – Vaccine component allergy

Smallpox Vaccine Administration Post Event   Persons exposed to initial release of virus Any person who had face-to-face contact or household contact, with a confirmed or suspected smallpox patient at any time until scabs have separated  Lab personnel who process such specimens and persons exposed to infectious medical waste

Anthrax Vaccine (AVA)  Vaccination – 3 subcutaneous injections at 0, 2, 4 weeks – 3 booster vaccinations at 6, 12, 18 months – Annual booster thereafter  Contraindications-any previous anaphylactic reaction from AVA or any of the vaccine componenets

Anthrax Vaccine (AVA)  Immune response – 83% after first dose – 95% after 3 doses – In one clinical trial of millworkers it was 92.5% effective based on person time of occupational exposure

Anthrax Vaccine (AVA)  Adverse Reactions – Frequent local/mild reactions-severe induration greater than 120 mm, edema, pain, pruritis in 3% – – Other mild reactions in 20% Systemic reactions such as fever, chills, body aches, nausea in 0.06 % – 1544 reports of adverse events in 1,859,000 doses 5% were serious – Death - no causation confirmed in 2 deaths

Anthrax Vaccine(AVA)  Other Serious Adverse Effects(<10%) – Cellulitis – Pneumonia – Guillain-Barre – Seizures – Cardiomyopathy – Sysytemic Lupus

APIC http://www.apic.org/ http://www.apic.org/elearn/BTReadi2.pdf

TDH http://www.tdh.state.tx.us/bioterrorism/ IDSA http://www.idsociety.org

http://www.idsociety.org/BT/ToC.htm

CDC http://www.cdc.gov/ http://www.bt.cdc.gov/agent/smallpox/response-plan/index.asp

http://www.bt.cdc.gov/ http://www.bt.cdc.gov/agent/agentlist-category.asp

State of California http://www.dhs.ca.gov

http://www.dhs.ca.gov/lnc/download/btr/btr.pdf

US Army Medical Research Institute http://www.usamriid.army.mil

http://www.usamriid.army.mil/education/bluebook.html

Johns Hopkins University http://www.jhu.edu/ http://www.hopkins-biodefense.org/ St. Louis University School of Public Health http://www.slu.edu/ http://www.slu.edu/colleges/sph/slusph/Default.htm