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NBC Agents of Terrorism. and . Disaster Preparedness. Presented by Dr. Roslyn Bascombe-Adams “Leaders” - International Course for Managers on Health, Disasters and Development February 18 th 2003, Ocho Rios, Jamaica. Overview. Why Consider NBC-warfare ?

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  1. NBC Agents of Terrorism and Disaster Preparedness Presented by Dr. Roslyn Bascombe-Adams “Leaders” - International Course for Managers on Health, Disasters and Development February 18th 2003, Ocho Rios, Jamaica

  2. 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” Bio-terrorism Agents. • Considerations for contingency planning.

  3. 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. FEAR

  4. 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

  5. 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

  6. Do we OWE it to ourselves to prepare?Fore-warned is Fore-armed! ??????????

  7. Chemical Agents • Blister agents • Mustard gas, phosgene oxime • Nerve Agents • Sarin, Ricin, Tabun, GF, VX, • Pulmonary Agents • Phosgene, chlorine • Pesticides • Organophosphates

  8. Agents of Most Concern • BLISTER AGENTS • NERVE AGENTS

  9. Coping with Chemical Agents • IDENTIFY • COMMUNICATE • SECURE • DECONTAMINATE • TRIAGE • TREAT • RECEIVE/DISPOSE

  10. 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

  11. 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

  12. 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

  13. 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

  14. E.g. Schematic of Communication Cascade if indicatedPoison Control Chief of StaffCEO Duty DoctorER Director CMO CDC Initiator Duty Nurse Triage Nurse/EMT’s Charge Nurse Nurse Supervisor Clin. CoordinProg. Manager Security Manager

  15. 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

  16. 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

  17. Coping with Chemical Agents-Decontamination- • Fire 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

  18. Coping with Chemical Agents-Decontamination- Impactzone Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose Decon Zone Advanced Medical Post (AMP)

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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.

  26. 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

  27. 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)

  28. 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 MOSCOW Sverdlovsk

  29. ANTHRAX WHAT TO DO? • Identify • Contain • Communicate • Triage • Treat • Receive/Dispose

  30. 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

  31. CDC

  32. CDC Cutaneous Anthrax, face Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

  33. CDC Cutaneous Anthrax Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

  34. Cutaneous Anthrax Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

  35. Cutaneous AnthraxDifferential Diagnosis • Spider bite • Ecthyma gangrenosum • Ulceroglandular tularemia • Plague • Staphlococcus cellulitis • Streptococcal cellulitis

  36. 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

  37. Anthrax Spores

  38. Aerosol / Infectivity Relationship Particle Size (Micron, Mass Median Diameter) Infection Severity 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 (alveoli) Maximum human respiratory infection is a particle that falls within the 1 to 5 micron size

  39. 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

  40. Inhalation Anthrax widened mediastinum 22 hours before death CDC/Dr. P.S. Brachman, 1961 Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

  41. Hemorrhagic Meningitis from Inhalation Anthrax CDC, 1966

  42. Inhalational AnthraxDifferential Diagnosis • Mycoplasmal pneumonia • Legionnaires Disease • Psittacosis • Tularemia • Q fever • Viral Pneumonia • Histoplasmosis (fibrous mediastinitis) • Coccidioidomycosis

  43. 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

  44. 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

  45. 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

  46. ANTHRAX • Unlikely to have MCM-type situation • Manage according to clinical indications Identify/Communicate/Secure/Decontaminate/Triage/Treat/Receive/Dispose

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