Transcript Preparing and Responding to Bioterrorism: Information for

Preparing for and Responding to
Bioterrorism: Information for
Primary Care Clinicians
Northwest Center for Public Health Practice
University of Washington School of Public Health and Community Medicine, July 2002
Acknowledgements
This presentation, and the accompanying instructor’s manual
(current as of 7/02), were prepared by Jennifer Brennan Braden, MD,
MPH, at the Northwest Center for Public Health Practice in Seattle, WA,
and Jeff Duchin, MD with Public Health – Seattle & King County and
the Division of Allergy & Infectious Diseases, University of WA, for the
purpose of educating primary care clinicians in relevant 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
The Centers for Disease Control and Prevention
Project Coordinator
Judith Yarrow
Health Policy & Analysis, University of WA
Design and Editing
UW Northwest Center for Public Health Practice
Jane Koehler, DVM, MPH
Communicable Disease Control,
Epidemiology and Immunization
section, Public Health - Seattle & King
County
Ed Walker, MD; University of WA
Department of Psychiatry
Introduction to Bioterrorism
UW Northwest Center for Public Health Practice
Introduction to Bioterrorism
Learning Objectives

Define bioterrorism

Describe the general characteristics of
potential agents of biological terrorism

List epidemiologic clues that suggest a
deliberate, as opposed to spontaneous,
source of disease

Know the reporting requirements if an
intentional disease source or other reportable
condition is suspected
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What Is Bioterrorism?
Definition

Terrorism (FBI definition): "The unlawful use
of force or violence against persons or
property to intimidate or coerce a
government, the civilian population, or any
segment of it, in furtherance of political or
social objectives."
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What Is Bioterrorism?
Definition

The intentional use of micro-organisms or toxins
derived from living organisms to produce death or
disease in humans, animals, or plants.

The goal of bioterrorism is to produce fear in the
population with subsequent disruption of society.
What Is Bioterrorism?
Potential

An overt attack is announced.

Resembles the traditional HAZMAT event:
explosives, chemical exposures.

First responders are likely to be traditional firstresponders: fire, HAZMAT, police.
What Is Bioterrorism?
Definite

A “covert attack” is unannounced.

Thought to be likely scenario with
bioterrorism.

First responders are likely to be health care
providers, including emergency departments,
primary care physicians, and hospitals.
History of Bioterrorism

Biological warfare (BW) was used as
far back as 6th century BC.
 Examples of past BW:
 14th Century: Mongols catapulted corpses
with bubonic plague over walls into Crimea.
 15th Century: Pizarro presented native South
Americans with smallpox-contaminated
clothing.
 1940: Japan’s “Unit 731” dropped plagueinfected fleas over Manchuria & China.
UW Northwest Center for Public Health Practice
History of Bioterrorism
Recent Examples

1984: Rajneeshee Cult contaminated restaurant
salad bars with Salmonella typhimurium.

1995: Aum Shinrikyo cult attempted
unsuccessfully to disperse BW agents in
aerosol form; sarin gas attack in Tokyo.

2001: Anthrax-contaminated letters to U.S.
media and government offices.
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History of Bioterrorism
State-sponsored Bioweapons Research

1972 Biological Weapons Convention


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Treaty prohibiting stockpiling and research into
biological agents for offensive purposes
Ratified by >140 countries
Not adhered to in some countries (former Soviet
Union)
United States Bioweapons program


Offensive program: 1943-1969
Defensive program: 1953-today at USAMRIID
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Recognition of a BT Event
Surveillance/Detection

Goal: Detect unusual medical events sooner
rather than later

Depends on ability to identify a greater than
expected number of “cases” or syndromes

Requires sensitivity to unusual clusters of
disease syndromes compatible with naturally
occurring or BT-related outbreaks
Recognition of a BT Event
Surveillance/Detection

Identify local experts to assist with
evaluation/diagnosis
 Infectious
 Hospital
 Public
disease specialists
epidemiology team
health
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Recognition of a BT Event
General Characteristics

Many agents initially produce a
nonspecific and/or flu-like illness

Aerosol dissemination
 Not detectable: odorless, colorless, tasteless
 Particle size 1-5um
 Potential wide-spread dissemination

May require special treatment approach
UW Northwest Center for Public Health Practice
Recognition of BT Event
Epidemiologic Clues I

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
Increase in persons ill with a similar or unusual
syndrome
Increase in unexplained disease or deaths
Single case of disease due to an uncommon
agent
Unexpected geographic or seasonal distribution of
disease
Unusual age distribution
E.g., varicella, measles in adults
Recognition of BT Event
Epidemiologic Clues II

Illness in persons with common ventilation system
or other exposure

Atypical route of transmission
E.g., aerosol botulism

Unusual illness among animals preceding or
accompanying human illness

Failure to respond to usual antibiotic therapy
Recognition of BT Event
Surveillance/Detection


By Washington State statute (RCW 70.05.090),
physicians are to report diseases to the local
health jurisdiction

Dangerous contagious or infectious diseases

Other diseases required by the state Board of
Health to be reported
Link to current notifiable conditions in
Washington State:
http://www.doh.wa.gov/EHSPHL/Epidemiology/CD/
NotifyCondsPosters/docposter.pdf
This link will take you away from the educational site
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Recognition of BT Event
Surveillance/Detection

By Washington State statute (RCW 68.50.010), the
following criteria are to be used to report deaths to
the Medical Examiner…
 ….when death is due to a suspected contagious
disease that may be a public health hazard
Recognition of BT Event
Surveillance/Detection

Effective September 2000, the following are
immediately reportable to the local health
jurisdiction

All suspected illnesses caused by potential
bioterrorism agents

Unexplained critical illness or death

Rare diseases of public health importance
UW Northwest Center for Public Health Practice
Introduction to Bioterrorism
Summary of Key Points

A biological attack is likely to be covert.

Primary care clinicians are likely to be among
the first to see affected persons.

Many agents of BT potential initially produce a
nonspecific illness.
UW Northwest Center for Public Health Practice
Introduction to Bioterrorism
Summary of Key Points

Patient history and epidemiologic clues are
important elements in BT recognition.

Clinicians must be alert to unusual clusters of
illness and know how to report illness caused by
suspected BT agents.
UW Northwest Center for Public Health Practice
Resources
These links will take you away from the educational site

Centers for Disease Control & Prevention
http://www.bt.cdc.gov

Johns Hopkins Center for Civilian Biodefense
Studies fact sheets and links to other info,
including JAMA series from Working Group on
Civilian Biodefense
http://www.hopkins-biodefense.org/

USAMRIID http://www.usamriid.army.mil
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Resources
These links will take you away from the educational site

St. Louis University Center for the Study of
Bioterrorism and Emerging Infections — fact
sheets and links http://bioterrorism.slu.edu/

Office of the Surgeon General: Medical Nuclear,
Biological and Chemical Information
http://www.nbc-med.org

Washington State Department of Health
(877)-539-4344 - 24-hour emergency number
http://www.doh.wa.gov
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Resources
These links will take you away from the educational site

Tucker JB. Historical trends related to
bioterrorism: an empirical analysis. Emerging
Infect Dis [serial online] 1999 Jul-Aug; 5(4).
http://www.cdc.gov/ncidod/eid/index.htm
 Other
BT-related articles in EID
http://www.cdc.gov/ncidod/eid/bio_links.htm

BT-related JAMA articles
http://pubs.ama-assn.org/bioterr.html

Public Health - Seattle & King County
http://www.metrokc.gov/health
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In Case of An Event…
Web Sites with Up-to-Date Information and
Instructions
These links will take you away from the educational site

Centers for Disease Control and Prevention
http://www.bt.cdc.gov/EmContact/index.asp

Saint Louis University, CSB & EI
http://bioterrorism.slu.edu/hotline.htm

WA State Local Health Departments/Districts
http://www.doh.wa.gov/LHJMap/LHJMap.htm

Level A Lab Protocols: Presumptive Agent ID
http://www.bt.cdc.gov/LabIssues/index.asp
UW Northwest Center for Public Health Practice
In Case of An Event…
Web Sites with Up-to-Date Information and
Instructions
These links will take you away from the educational site

FBI Terrorism Web Page
http://www.fbi.gov/terrorism/terrorism.htm
WA State Emergency Mgt Division – Hazard Analysis
Update http://www.wa.gov/wsem
 Mail Security
http://www.usps.com/news/2001/press/serviceupdates.htm

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Links to your state health department
http://www.astho.org/state.html

NIOSH – Worker Safety and Use of PPE
http://www.cdc.gov/niosh/emres01.html
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