Bio-terrorism Agents and the Mass Casualty Response Plan
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Transcript 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