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Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce

Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce. Acknowledgements. This presentation, and the accompanying instructor’s manual, were prepared by Jennifer Brennan Braden, MD, MPH, at the

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Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce

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  1. Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce

  2. Acknowledgements This presentation, and the accompanying instructor’s manual, were prepared by Jennifer Brennan Braden, MD, MPH, at the Northwest Center for Public Health Practice in Seattle, WA, for the purpose of educating public health employees in the general aspects of bioterrorism preparedness and response. Instructors are encouraged to freely use all or portions of the material for its intended purpose. The following people and organizations provided information and/or support in the development of this curriculum. A complete list of resources can be found in the accompanying instructor’s guide. Patrick O’Carroll, MD, MPH Project Coordinator Centers for Disease Control and Prevention Judith Yarrow Design and Editing Health Policy and Analysis; University of WA Washington State Department of Health Jeff Duchin, MD Jane Koehler, DVM, MPH Communicable Disease Control, Epidemiology and Immunization Section Public Health - Seattle and King County Ed Walker, MD; University of WA Department of Psychiatry

  3. Diseases of Bioterrorist Potential: Plague and Botulism CDC, AFIP

  4. Diseases of Bioterrorist PotentialLearning Objectives • Describe the epidemiology, mode of transmission, and presenting symptoms of disease caused by the CDC-defined Category A agents • Identify the infection control and prophylactic measures to implement in the event of a suspected or confirmed Category A case or outbreak

  5. PlagueHistory & Significance • 14th Century: “Black Death” responsible for >20million deaths in Europe • Used as a BW agent by Japan in WW II • Studied by Soviet and, to a smaller extent, U.S. BW programs • 1995: Larry Wayne Harris arrested for illicit procurement of culture via mail

  6. PlagueEpidemiology • Caused by Yersinia pestis • About 10-15 cases/year U.S. • Mainly SW states • Human plague occurs from bite of an infected flea (bubonic) • Only pneumonic form of plague is spread person-to-person • Last case of person-to-person transmission in U.S. occurred in 1924

  7. Yersinia Pestis • Gram negative, non-motile, non-spore-forming bacillus • Resistant to freezing temperature and drying, killed by heat and sunlight Source: Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases, Fort Collins, CO

  8. Plague Case Definition • Characterized by fever, chills, headache, malaise, prostration, & leukocytosis that manifests in one or more of the following clinical forms: • Regional lymphadenitis (bubonic) • Septicemia w/o evident bubo (septicemic) • Plague pneumonia • Pharyngitis & cervical lymphadenitis (pharyngeal) MMWR 1997;46(RR-10)

  9. PlagueCase Definition, cont. • Laboratory criteria for diagnosis: • Presumptive • Elevated serum antibody titers to Y. pestis F1 antigen (w/o documented 4-fold change) in a patient with no history of plague vaccination OR • Detection of F1 antigen in a clinical specimen by fluorescent assay • Confirmatory • Isolation of Y. pestis from a clinical specimen OR • 4-fold or greater change in serum antibody titer to Y. pestis F1 antigen MMWR 1997;46(RR-10)

  10. Plague: Case Classification • Suspected: Clinically compatible case w/o presumptive or confirmatory lab results • Probable: Clinically compatible case with presumptive lab results • Confirmed: Clinically compatible case with confirmatory lab results MMWR 1997;46(RR-10)

  11. PlagueClinical Forms • Bubonic plague • Most common naturally-occurring form • Mortality 60% untreated, <5% treated • Primary or secondary septicemic plague • Pneumonic plague • Most likely BT presentation • From aerosol or septicemic spread to lungs • Survival unlikely if treatment not initiated w/in 24 hours of the onset of symptoms

  12. Pneumonic PlagueClinical Presentation • Incubation: 1-6 days (usually 2-4 days) • Acute onset of fever with cough, dyspnea, and chest pain • Hemoptysis characteristic; watery or purulent sputum also possible • Prominent GI symptoms may be present, including nausea, vomiting, diarrhea, and abdominal pain

  13. Pneumonic PlagueClinical Presentation • Other symptoms include headache, chills, malaise, myalgias • Rarely, cervical bubo present • Rapid progression to respiratory failure & shock

  14. Bubonic Plague • Incubation: 2-8 days • Sudden onset nonspecific symptoms: fever, chills, malaise, muscle aches, headache • Regional lymphadenitis (buboes) • Swollen, very painful lymph nodes • Typically inguinal, femoral, axillary, or cervical • Erythema overlying skin • May have surrounding edema • Concurrent with or shortly after onset of other symptoms

  15. Septicemic & Bubonic Plague Source: CDC NVBID

  16. PlagueInfection Control • Person-to-person transmission via respiratory droplets • Standard respiratory droplet precautions • Treatment = 10 days antibiotics • Case isolation for at least the first 48 hrs of antibiotic treatment • Bubonic plague - standard precautions

  17. PlagueInfection Control • Antibiotic prophylaxis for close contacts Duration: 7 days or duration of risk of exposure + 7 days • Close contacts refusing prophylaxis: Observe 7 days after last exposure and treat if fever or cough develop • Bubonic contacts: Observe 7d and treat if symptoms develop

  18. Plague Summary of Key Points • The most likely presentation in a BT attack is pneumonic plague. • Unlike other forms of plague, pneumonic plague is transmitted person to person, and thus respiratory droplet precautions are indicated in suspected cases until 48 hours after the initiation of antibiotic therapy.

  19. Case Reports • Plague Plague Pneumonia - CA. MMWR 1984;33(34) Pneumonic Plague -- Arizona, 1992. MMWR 41(40)

  20. Clostridium Botulinum • C. botulinum spores found in soil worldwide • Toxin causative agent of botulism • Types A-G; A,B&E most commonly associated with human disease • Most potent toxin known (lethal dose 1ng/kg) • Inactivated by chlorine (~20min) and sunlight (1-3hrs); destroyed by heat (5min at 85C) • Absorbed into circulation via mucosal surface or wound, not intact skin • Interferes with nerve transmission  paralysis

  21. Clostridium BotulinumEpidemiology • Approximately 100 reported cases botulism/year in the U.S. • Infant most common (72%) • Food-borne not common • Incubation (food-borne): 12-72hrs (range 2hr-8d) • Dose dependent • Could be less following a BT attack • No person-to-person transmission • Death 60% untreated; <5% treated

  22. Botulism & Bioterrorism • Weaponized by former U.S. and Soviet offensive BW programs • Iran, Iraq, N. Korea, Syria believed to have developed/be developing toxin as a weapon • Aerosol use or food supply sabotage most likely

  23. BotulismClinical Forms • Food-borne • Toxin produced anaerobically in improperly processed orcanned, low-acid foods contaminated by spores • Wound • Toxin produced by organisms contaminating wound • Infant • Toxin produced by organisms in intestinal tract • Inhalation botulism • No natural* occurrence, developed as BW weapon *3 accidental cases in veterinary personnel, W. Germany, 1962

  24. Botulism: Case Definition • Ingestion of botulinum toxin results in an illness of variable severity. Common symptoms are diplopia, blurred vision and bulbar weakness. Symmetric paralysis may progress rapidly. • Laboratory* criteria for diagnosis: • Detection of botulinum toxin in serum, stool or patient’s food (food-borne) or other clinical specimen (“botulism, other”) OR • Isolation of Clostridium botulinum from stool (food-borne) or other clinical specimen *Assay available at CDC & some state public health labs MMWR 1997;46(RR-10)

  25. Botulism: Case Classification • Botulism, Food-borne • Probable: Clinically compatible with an epidemiologic link • Confirmed: Clinically compatible case that is laboratory confirmed or that occurs among persons who ate the same food as persons who have laboratory-confirmed botulism • Botulism, Other • Confirmed: Clinically compatible case that is laboratory confirmed in a patient  1 yr* who has no history of ingestion of suspect food and has no wounds *age parameter may not apply in BT MMWR 1997;46(RR-10)

  26. BotulismTreatment • Ventilatory assistance and supportive care • Standard precautions • Botulinum antitoxin • Most effective if given early: does not reverse effect of toxin already bound to nerve receptor • Trivalent equine product against types A,B, and E currently available from CDC • Heptavalent (A-G) antitoxin - investigational • Monovalent human anti-serum for infant botulism -investigational

  27. BotulismProphylaxis • Pre-exposure • Prophylaxis for at-risk lab workers and military with investigational vaccine • No pre-exposure prophylaxis recommended for general public • Post-exposure: close monitoring of those exposed; treat with antitoxin at first signs of illness

  28. Botulism Summary of Key Points • An outbreak of botulism occurring with a common geographic factor, but with no common food exposure, would suggest a deliberate aerosol exposure. • Inhalational botulism does not occur naturally, and any potential cases suggest a deliberate source of infection.

  29. Botulism Summary of Key Points • Gastrointestinal symptoms may not occur with inhalational botulism or with food-borne botulism (e.g., resulting from deliberate contamination of the food supply). • Botulinum antitoxin must be administered as soon as possible for optimum results.

  30. BotulismCase Reports MMWR Morb Mortal Wkly Rep 1999;48(21) • MMWR Morb Mortal Wkly Rep 1995;44(48)

  31. Resources http://www.bt.cdc.gov/ • Centers for Disease Control & Prevention • Bioterrorism Web page: • CDC Office of Health and Safety Information System (personal protective equipment) • USAMRIID -- includes link to on-line version of Medical Management of Biological Casualties Handbook • Johns Hopkins Center for Civilian Biodefense Studies http://www.cdc.gov/od/ohs/ http://www.usamriid.army.mil/ http://www.hopkins-biodefense.org

  32. Resources • Office of the Surgeon General: Medical Nuclear, Biological and Chemical Information • St. Louis University Center for the Study of Bioterrorism and Emerging Infections • Public Health - Seattle & King County http://www.nbc-med.org http://bioterrorism.slu.edu http://www.metrokc.gov/health

  33. Resources http://www.doh.wa.gov • Washington State Department of Health • Communicable Disease Epidemiology • (206) 361-2914 OR • (877) 539-4344 (24 hour emergency) • Association for Professionals in Infection Control • MMWR Rec & Rep. Case definitions under public health surveillance. http://www.apic.org/bioterror 1997;46(RR-10):1-55

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