Transcript Bio-Terrorism and the Respiratory Therapist

Bio-Terrorism Overview for
the Respiratory Therapist
By: UMDNJ-SHRP Respiratory
Therapy Education Program
Faculty
What is Bio-Terrorism?
• Key Components:
– Advanced planning/coordination by terrorists.
– Strong potential for panic among lay and medical
personnel
– Causes a population to significantly change their
routine and behavior
– Potential for massive numbers of victims
– Potential for mimic of endemic infectious diseases
• “Medical defense against biological warfare or terrorism
is an area unfamiliar to most military and civilian health
care providers.” USAMRIID February 4, 2001
Historical Overview
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Bio-warfare has been around since 300 B.C. via
contamination of food/water and via inoculated fabrics
In 1346, Tartars catapulted bodies of plague victims
over the walls of Kaffa in the Ukraine.
During the French and Indian War (1754-67), British
forces gave blankets contaminated with smallpox to
susceptible Indian tribes.
1932-42: In Japan, plague infected rats were fed upon
by fleas, which were released over chinese cities.
1943: Tularemia used by Germans to disable Russians
1982: Russians weaponize and use “Glanders” on
Afghani troops
1984: The Rajneeshee cult contaminated 10
restaurants with Salmonella in Wasco County, Oregon.
2001: DC, NY and NJ: Anthrax attacks via mail.
Indicators of Possible
Bio-Attack
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High Acuity Cases
Unusual “Constellation”
of Symptoms
Unusual or not naturally
occurring disease entity
Large number of cases
or entities
Point-source outbreak-Limited geographical
areas
Aerosol route Delivery
• High morbidity and/or
mortality
• Low attack-rate in
persons in filtered air
• Sentinel dead animals,
esp. multiple species
• No natural vector
• Large number military
and civilian casualties
Bioterrorism: Routes of Infection
• Inhalation route
– Has the greatest potential for mass casualties
– Aerosol dispersal most likely route
• Percutaneous, e.g. anthrax as “wool
sorters disease”
• Oral, i.e. intake of contaminated food and
water
What This Means
• Respiratory Therapists will care for
victims (ER, ICU)
• Are Medical Personnel (RTs) Prepared?:
– early recognition
– innoculations: smallpox, anthrax
– Isolation and barrier techniques
• RTs have a responsibility to:
– protect themselves & others
– know how to treat these victims.
– report suspicious illnesses
• Prepare, Anticipate, Recognize, Act
Bioagents Most Likely to Be
Used by Terrorists
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Smallpox
Plague
Anthrax
Tularemia
Botulisum Toxin
Salmonella/Typhoid Fever
Q-Fever
Brucellosis
Others Agents: Staph Enterotoxin B, Ebola,
Ricin (poison)
Smallpox (Variola Major)
• Incubation Period: 7 - 17 days
• Natural Occurrence: Last case in Somalia, 1977.
• Droplet & Airborne Precautions – 17
days. Most contagious in “early rash” phase.
• Presentation: Fever, backpain, vomiting,
malaise, headache, rigors; papules to
pustular vessicles face/ extremities.
• DX: Modified silver stain, PCR and viral
isolation IHC
• TX: Immediate vaccination (if exposure <
5 days) and supportive care.
Pulmonic Plague (Yersinia Pestis)
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Incubation Period: 1 - 6 days
Natural Occurrence: 5 - 15 cases/Yr. in US.
Droplet Precautions
Presentation: High fever, chills, hemoptysis,
shock, stridor, B/S crackles, ARF. High
mortality (> 75%) with late diagnoisis.
• DX: Gram stain, C&S, Immunoassay for
capsulated antigen
• TX: Streptomycin 30 mg/kg/day IM. Oral
Doxycycline or Ciprofloxin. No vaccine.
Inhaled Anthrax (Bacillus Anthraxis)
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Incubation period 1-6 days up to 45 days
Natural Occurrence: Few via Inhalation.
No Known Human-to-Human Transmission
Presentation: Fever, malaise, cough, mild chest
discomfort; later dyspnea, diaphoresis, stridor,
cyanosis, hypotension, hemorrhagic meningitis.
50% Mortality, with treatment.
• DX: Mediastinal widening w/o infiltrates on
CXR, Serology, Gram stain, PCR
• TX: Supportive care, Doxycycline 200 mg IV then
100 mg IV Q12 hr. Vaccine - high risk groups.
Tularemia (Francisella Tularensis)
• Incubation Period: 1 - 10 days (avg. 3-5)
• Natural Occurrence: 200 cases annually in US from
animal sources
• Human-to-Human Transmission: None known, but
highly infectious via aerosol.
• Presentation: fever, headache, malaise, chest
discomfort, productive/non-productive cough,
anorexia and conjuntival and periorbital edema. 1020% Mortality.
• DX: CXR- mediastinal lymphoadenopathy,
Serology(ELISA), C&S, PCR & IHC
• TX: Supportive, Streptomycin or gentamycin. No
current vaccine.
Botulism (Clostridium Botulism)
• Incubation Period: 1 - 5 days
• Natural Occurrence: 30 cases annually
• Human-to-Human Transmission: None known
• Presentation: Descending paralysis, ptosis,
blurred vision, diplopia, malaise, dizziness,
dysarthia, and disphonia
• DX: Serology, toxin assays/ anaerobic
cultures of blood or stool, EMG studies
• TX: Antitoxin 1 vial (10 ml) IV
Typhoid Fever (Salmonella Typhi)
• Incubation Period: 2-5 Days
• Occurrence: 400 cases annually in US, mostly
among travelers. 21 million cases worldwide. 5%
asymptomatic, but carriers (“Typhoid Mary”)
• Presentation: Fever, Chills, Delerium, Malaise;
Diarrhea/vomiting uncommon.
• DX: Blood/stool C&S, clinical presentation,
Recent history (e.g., travel). 12-30% mortality.
• Tx: Antibiotics (Levaquin), supportive
(Hydration), Prevention via vaccination.
Q-Fever (Coxiella Burnetii)
• Incubation Period: 2-3 weeks
• Natural Occurrence: Rare, but most often found in
farmers; sheep/dairy workers and meat handlers. Very
Resistant to Heat and environment.
• Transmission: Via open wound contact with animal or
dust inhalation. Very contagious via aerosol.
• Presentation: 50% asymptomatic, Flu-like & GI
symptoms. 1-2 week acute stage duration. Acute
symptoms resolve. Chronic can develop and cause
endocarditis and liver dysfunction.
• Dx: Seriologic Testing for antibodies.
• Tx: Antibiotics--Doxycycline & quinolones for 4 years.
Vaccine in Australia, but not US.
Brucellosis (Brucella Melitenis)
• Incubation Period: 5-20 Days
• Natural Occurrence: 200 annually in US.
• Transmission: Mainly via unpasteurized milk and
contact with infected meat. Highly infectious
via aerosol.
• Presentation: Acute-Flu-like symptoms; ChronicChronic fatigue, depression
• Dx: Blood C&S, Clinical presentation, Hx.
• Tx: Supportive, Antimicrobials
SEB: Staphyloccocal Enterotoxin B
• SEB causes symptoms when inhaled in very low
doses.
• Standard Precautions
• Latent period: Inhalation 3-12 hrs.
• Presentation: non-specific flu, non-productive
cough, retrosternal pain, dyspnea.
• DX: Suspicion, ELISA, PCR; no CXR
abnormalities
• TX: Oxygen, hydration; CMV w PEEP,
vasopressors and diuretics
Ebola Hemmorrhagic Fever
• Incubation Period: 2 to 21 days
• Natural Occurrence: 1,000 to 3,000 cases
annually, mainly in Central Africa. Isolated: 1976
• Transmission: Highly contageous via contact
with blood/bodily fluids. Rarely, airborne
transmission. Unknown natural reservoir!
• Presentation: Early: Flu-like symptoms. Later:
GI symptoms, red eyes, external/internal
bleeding.
• DX: Enzyme-linked Immunosorbent Assay
(ELISA), Polymerase Chain Reaction (PCR).
• TX: Supportive. No vaccine. 50-90% Mortality
Ricin (Poison/Toxin)
• Potent poison made from waste of castor bean
processing.
– 500 mcg (amt. on a pinhead) is generally fatal.
• Exposure is generally deliberate (G. Markov,
London, 1978)…No person-to-person transmission.
• Presentation: Symptoms w/I 6-8 hrs
– Inhalation: Dyspnea, Cyanosis, Pul. Edema
– Ingestion: GI symptoms, Seizures, Hypotension,
Liver/Kidney Failure
• DX: Toxicology, Recent HX, Symptoms
• TX: Supportive, Discard clothes, Wash skin, No
antidote!!!
Epidemiologic Clues
• Large # of people
w/ similar
disease/syndrome
• Large # of
unexplained
illnesses or deaths
• Unusual illness in
population
• Higher morbidity /
mortality
• Single case of
uncommon agent
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denominator in
all/most cases.
– e.g., Legionnaires
Disease
Medical Response to Bioterrorism
“Ten Commandments”
1. Maintain an index of
suspicion
2. Protect thyself
3. Assess thy patient
4. Decontaminate PRN
5. Establish a
Diagnosis
6. Render thy patient
prompt treatment
7. Practice good infection
control
8. Inform thy authorities
9. Assist in Epidemiologic
Investigation
10. Maintain, Update thy
proficiency & Spread
the gospel.
What RTs Can and Should Do
• Always use Protective Equipment, Especially in the ED
and ICU.
– Treat all critically ill medical patients as if…
– Proper use of Protective Equipment: Seal mask from bridge of
nose down…don’t pinch nose.
• Get Educated: Understand Etiology/Pathology, Clinical
Pres., Tx & Prevention of Bio-Agents
• Be Aware: If It Seems Unusual, Maybe it Is!!!
• Get Vaccinated!!!
• Don’t Panic…Panic can be contageous too!
• Don’t become another casualty!!!
• Report suspicious cases per institutional protocol.
What RT Departments Can/Should
Do?
• Understand that another terrorist attack
(Bioterrorism or otherwise) is more a question of
when, not if !!!
• Understand the Hospital/Organization’s Disaster
Plan.
• Devise an Effective Departmental Disaster Plan,
consistent with that of the Organization.
• Protect & Support your staff through education,
as well as proper equipment and staffing.
• Practice Simulated Emergency Drills.
Important Contacts:
• Institutional-specific chain of command
• NJ Dept. of Health & Sr. Services
• 1-609-588-7500 or -3121
• 1-609-392-2020 (after hours)
• NJ Poison Information and Education System
• 1-800-222-1222
• NJ Office of Emergency Management
• 1- 609-882-2000
• NJ Dept. of Environmental Protection
• 1-877-WARNDEP (1-877-927-6337)
Take Home Messages
• Educate & Prepare yourself and your staff/coworkers!
– In-services, Drills, Proper Staffing & equipment
• Work with your Emergency Medical and Nursing
staff to develop an effective action-plan.
• Conduct disaster drills on all shifts.
• Be Aware and Cautious…But don’t Panic
• Contact your local office of Emergency
Preparedness.
Selected References
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Christopher GW, Cieslak TJ, Pavlin JA, Eitzen EM. Biological
Warfare, a historical prospective. JAMA. 1997; 278:412-417
USAMRIID Medical Management of Biological Casualties Course
(6H-F26) 01 February 2001
CDC. Mandatory reporting of infectious diseases by clinicians.
MMWR 1990:39(RR-9);1-11, 16-17.
National Notifiable Disease Surveillance System. Available at:
http://www.cdc.gov/epo/dphsi/nndsshis. htm
National Electronic Telecommunications System for Surveillance.
Available at: http://www.cdc.gov/epo/dphsi/netss.htm
Clinical Case I
• You are the RT in the ER treating an
dyspneic child when you overhear a mother
tell the pediatrician: “I don’t understand it. My
Joey had chickenpox as a preschooler and
Susie had the vaccine. How could they have
chickenpox? There are many really sick kids
with chickenpox on their arms & legs who
went to the Columbus Day parade.” The ER
has had several cops with severe
“chickenpox.” There was a report of an
explosion at the parade. What is your
suspicion? What actions would you take and
recommend?
Clinical Case II
• The newspaper reports that large numbers
of rats are found dead. Transit workers
and subway riders are in your ER
complaining of dyspnea, high fevers, chills
and hemoptysis. Auscultation finds
bilateral crackles and stridor.
• What is your suspicion?
• What lab test will be helpful?
• What action would you take and
recommend?
Clinical Case III
• A TV station reports that a terrorist group claims to have
attacked Coney Island with a bioagent. Witnesses
reported a cloud of white dust. As a therapist at a
Brooklyn hospital you have seen numerous patients from
that area with fever, headache, malaise, chest
discomfort, non-productive cough and tachypnea. Exam
reveals an acutely ill patient with a widened
mediastinum, peripheral cyanosis and diaphoresis.
• What is your suspicion?
• What actions would you take and recommend?
• What diagnostic test should be performed?