Bioterrorism and Vulnerable Populations

1. Bioterrorism and Vulnerable Populations Melanie Fisher, M.D., M.Sc. WVU School of Medicine,� Infectious Diseases

2. Objectives Know the CDC Category A bioterrorism (BT) agents Identify �vulnerable populations� in a bioterrorism event Anticipate the needs of vulnerable populations Initiate careful planning for a BT event to include these vulnerable populations

3. Category A agents Diseases caused by CDC�s Category �A� Agents of Bioterrorism Anthrax Smallpox Tularemia Plague Viral Hemorrhagic Fevers

4. Hypothetical Case Scenario A 36 year old man presented to a local emergency department with fever, chest pain, shortness of breath, and appearing very ill Chest X-ray showed widened mediastinum Within the next 24 hours, numerous additional people presented throughout the county with similar symptoms

5. Chest X-ray showing mediastinal wideningWhat diagnosis should be suspected?

6. Case Scenario (con�d.) Local and state health departments were contacted, and a bioterrorism event was being considered in the differential diagnosis 48 hrs after the initial patient presented, blood cultures were confirmed positive for Bacillus anthracis Patients included previously healthy adults, children (including infants), pregnant women, elderly adults, and people with physical or mental disabilities

7. Case Scenario � Questions Raised Who are the most vulnerable populations in a disaster event? How would the management of these persons be different from the general population? What initial planning is required to meet their needs?

8. Vulnerable Populations Children The Elderly People with Physical Disabilities People with Mental Disabilities Pregnant women

9. The Management of Vulnerable Populations in a Bioterrorism Event Preparedness for the acute care of victims of terrorist incidents must include research, planning, and preparation for a widely diverse group of patients. At any given time in the United States there are approximately: 58 million children under the age of 15 13 million people over the age of 75 54 million people with disabilities 3 million women who are pregnant

10. The Management of Vulnerable Populations in a Bioterrorism Event Vulnerable Populations May Require Alternatives If there is a terrorist incident or public health emergency in your community, look to the public health authorities at the local, state, and federal level as a primary source for these recommendations http://www.bt.cdc.gov/ http://www.fema.gov/

11. Vulnerable Populations � Children General Considerations for Treatment Pediatrics Need to dose by weight Need for multiple forms (liquid; tablets) Some medications and vaccines not licensed for use in children of certain ages

12. Specific Issues Regarding Medications for Children In general, there are three specific issues for decisions regarding medication selection for children: acceptability format dosage

13. Specific Issues Regarding Medications for Children Acceptability � is the drug or vaccine acceptable to use in children? Example: smallpox vaccine Current CDC recommendations caution against its use in children < 1 year old; but during an actual smallpox attack, children may be targets; so, it may need to be considered

14. Specific Issues Regarding Medications for Children Format of Medication � consider: liquid vs. pills vs. chewable pills Example: prophylactic antimicrobials such as doxycycline or ciprofloxacin would need to be available in an oral suspension form (liquid) for children Presently, in the U.S., ciprofloxacin can be reconstituted to a liquid form with a two week shelf life, and doxycycline is available as a liquid

15. Specific Issues Regarding Medications for Children Dosing � pediatric doses are different from adult doses Based on weight, sometimes age Example: antimicrobial streptomycin is given as follows for treatment of tularemia: Infants: 15 mg/kg IM every 12 hr(max dose 2 grams/ day) Older children/Adults: 1g IM twice daily

16. Special Needs of Children in a Bioterrorism Event Some useful medical interventions may be approved or designed for adults but not yet approved for pediatric use Clinicians will have to make decisions about non-approved uses, and adapting adult materials for children

17. Other Issues Regarding Care of Children Pediatric psychiatric issues Pediatric appropriate messages Children separated from parents Day care for critical responders

18. Considering Children in Emergency Response Planning Planning must consider stockpiles of child appropriate materials Planning must consider children who are at home, in school or daycare, or in transit, and those who cannot be reunited with their parents

19. Considering Children in Emergency Response Planning (con�d.) The document �Pediatric Preparedness for Disasters and Terrorism: A National Consensus Conference� provides excellent recommendations

20. Case Scenario: Follow-upChildren Children exposed to anthrax received age and weight based oral suspensions of ciprofloxacin Arrangements made to care for children whose parents were called to work

21. Vulnerable Populations � The Elderly General Considerations for Treatment The Elderly Medication interactions Confusion more common (from medicines etc.) Toxicity may be greater with certain drugs (e.g. gentamicin) Other underlying medical illnesses

22. Care of the Elderly Special Needs of Geriatric Populations Usually, geriatric populations will be treated according to guidelines for the general population Exceptions and cautions: Medication doses may need to be decreased due to reduced renal function in elderly (? Creatinine Clearance)

23. Care of the Elderly Special Needs of Geriatric Populations (Con�d.) Exceptions and cautions: Potential for drug interactions great because elderly often take other medicines Elderly patients may have impaired memory, confusion. Suggestions: Helpline for patients Carry lists with dosages and schedules of their usual medicines

24. Case Scenario: Follow-upThe Elderly For elderly exposed to anthrax, ciprofloxacin prophylaxis given at a dose based on their kidney function Additional nurses helped evaluate elderly for other medical problems; pharmacists helped with medication lists, education

25. Vulnerable Populations � Physical DisabilitiesGeneral Considerations for Treatment Physical disabilities Difficulty accessing care Other underlying illnesses common May need home or nursing home based treatment

26. Care of those with Physical Disabilities Emergency Planning for People with Disabilities According to the U.S. Census Bureau, America�s disability population includes: 54 million men, women and children with mental, emotional and/or physical disabilities that impact hearing, vision and mobility. People with disabilities should be included in emergency preparedness planning and response

27. Analyzing Needs within the Community National Organization on Disability (NOD) Questions for Emergency Management Planners: What is it like to be a person with a disability during and after an emergency? Can one hear or understand the warnings? Can one quickly exit a home or workplace? Do workers/ citizens know where to assemble in order to receive assistance if a small area has to be evacuated?

28. Analyzing Needs within the Community National Organization on Disability (NOD) Questions for Emergency Management Planners: Can one move about the community after escaping? Are there special necessary or even vital daily items (medicines, power supplies, medical devices) that are not likely to be available in emergency shelters? Are basic services like restrooms and showers available and accessible to people with disabilities?

29. National Organization on Disability (NOD)Suggestions for Emergency Management Planners Identify those in the community who might have special needs Customize awareness and preparedness messages and materials for specific groups Educate citizens with disabilities about realistic expectations of service Learn from the knowledge, experiences of the disability community Work with institutional and industry-specific groups that can offer support to emergency professionals

30. Planning and Preparing to Protect People with Disabilities (con�d.) According to the National Organization on Disability (NOD): 61% of people with disabilities have not made plans to quickly evacuate their homes 50% of people with disabilities who are employed say no plans have been made for a safe evacuation at their workplace 58% of people with disabilities do not know whom to contact in the event of a disaster

31. Case Scenario: Follow-upPhysical Disabilities At points of distribution for antimicrobial prophylaxis, wheelchair access, ramps as well as proper toilet facilities were made available Personnel were assigned to help hearing and sight impaired

32. Mental disabilities Failure to access care Single-dose therapy preferable due to compliance issues May need home or nursing home based treatment

33. Care of those with Mental Disabilities Issues in the Care of People with Mental Disabilities Treatment, in general, will be the same as the healthy population Some important considerations still exist for this group regarding: Medication assistance Transportation Reluctance to reach or receive care Adaptations to changing circumstances

34. Care of those with Mental Disabilities Issues in the Care of People with Mental Disabilities (con�d.) Patients require their regular psychotropic medicines to cope with the medical therapy given for the event Many psychotropic drugs may interact with other medications Simple dosing schedules are helpful

35. Care of those with Mental Disabilities Issues in Seeking and Accessing Care Persons with dementia or emotional disease may fail to reach care, not recognize medication needs, and may need help with transportation Alternate access for treatment may help Plan for someone to assume responsibility for patient who does not have clinical decision making capacity Community registers of those needing care and those responsible are both sensitive and useful

36. Case Scenario: Follow-upMental Disabilities Additional personnel were assigned to assist as guides, care givers Simple dosing schedules utilized Nurses helped assure that patients received their usual psychotropic and other medications

37. Vulnerable populations � Pregnant Women General Considerations for Treatment Pregnancy Many drugs must be avoided in pregnancy Need to consider preserving health of mother Risk to pregnancy vs. risk to mother

38. Care of Pregnant Women Patients Who Are Pregnant: Following a disease outbreak, public health agencies will issue guidelines for the treatment of special populations such as pregnant women When guidelines have not yet been issued, clinicians will need to make judgments based upon the potential risk to the pregnancy from using a particular medication and the risk to the mother from withholding treatment or prophylaxis. These must be judged on a case-by-case basis.

39. Care of Pregnant Women Patients Who Are Pregnant: The Journal of the American Medical Association (JAMA) has published recommendations for pregnant patients based on the balance of risks to benefits (http://jama.ama-assn.org/cgi/content/full/287/17/2236) In addition, nearly every medication has an assigned pregnancy category, and this will help guide the risk-to-the-pregnancy portion of the calculation

40. Care of Pregnant Women Vaccination Decisions Must be judged on a case-by-case basis Example: Should smallpox vaccine be given to pregnant women? Pre-event setting: generally �NO� Post-exposure to actual smallpox event: may consider giving vaccine if risk of exposure significant This is a Risk vs. Benefit issue (based on changing perceptions of benefits against fixed risks)

42. Case Scenario: Follow-upPregnant Women National recommendations given to give ciprofloxacin to pregnant women exposed to anthrax (because threat of the disease greater than the potential risk to fetus) Follow-up arranged

43. VMC / WV Prepares Multidisciplinary Response:

44. VMC / WV Prepares A Bioterrorism event would require a rapid response by trained professionals To help deal with epidemic, bio-terrorist or other disaster events effectively, efficiently, and professionally the Virtual Medical Campus (VMC) at West Virginia University has developed three courses through a grant from the U.S. Department of Health and Human Services (DHHS)/Health Resources and Services Administration (HRSA).

45. VMC / WV Prepares WV Prepares Project has 3 online courses: Terrorism Recognition & Reporting Multidisciplinary Response Acute Care of Patients from WMD Events

46. VMC / WV Prepares

47. Summary CDC category �A� agents of Bioterrorism include anthrax, smallpox, botulism toxin, plague, tularemia, and Viral Hemorrhagic Fevers Vulnerable populations in a terrorist attack include children, elderly, those with physical or mental disabilities, and pregnant women

48. Summary (con�d.) Planning for a BT attack must include special needs of vulnerable populations More information and training available through VMC/WV Prepares � Online courses