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®
“Preparing Our Communities”
Welcome!
V 2.9 04/07
® BDLS is a registered trademark of the American Medical Association
1
Faculty Disclosure
• For Continuing Medical Education (CME) purposes as
required by the American Medical Association (AMA)
and other continuing education credit authorizing
organizations:
– In order to assure the highest quality of CME programming,
the AMA requires that faculty disclose any information relating
to a conflict of interest or potential conflict of interest prior to
the start of an educational activity.
– The teaching faculty for the BDLS course offered today have
no relationships / affiliations relating to a possible conflict of
interest to disclose. Nor will there be any discussion of off
label usage during this course.
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2
Biological Events
Chapter 5
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Objectives
• Describe the difference between biological events and
bioterrorism (BT)
• Discuss public health BT surveillance
• Identify the CDC BT Category A agents
• Identify emerging infectious diseases
• Compare and contrast BT and other CBRNE WMD
utilizing the DISASTER paradigm
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Biological Events
Biological events: Natural vs. Intentional
Outbreak of monkey pox in pet
prairie dogs
Release of anthrax in mail
Avian Flu pandemic
Salmonella sprayed on food bar
Natural occurrence of anthrax
Smallpox infection
Bubonic plague outbreak
Aerosolized botulinum toxin
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Bioterrorism Release Types:
Overt or Covert
Covert or Overt ?
Overt
–Notice of release
provided
–May contain a threat
–Designed to create
panic or fear
–May be hoax (white
powder) or credible
threat
Letter
sent to the New York
Post and NBC News:
Containing “white powder”
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Covert or Overt ?
Covert Release
(1763)Captain Simeon Ecuyer had sent
–No notice or
threat
smallpox-infected
blankets
and
handkerchiefs to the Indians surrounding
the fort (as a supposed peace offering)-but
actually an to
early
example of
–Difficult
detect
biological warfare -- which started an
•Persons
care at usual
epidemic
amongseek
the Indians.
medical care facilities
•Early symptoms non-specific
so detection may be delayed
•Focus: Astute clinician make
diagnosis and notify health
department (Detection)
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Potential Methods of Detection
Public Health Surveillance
•
•
•
•
•
•
•
•
•
•
•
Increased number of patients
Increased unexplained deaths
Unusual patient age distribution
Unusual seasonality
Unusual manifestation of disease
Animal die-off
Notifiable disease reporting by physicians & other providers
Automated reporting of laboratory results
Number and type of 911 calls
Number and type of EMS runs
Syndromic surveillance
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CDC Categories BT Agents
Divided into Categories A, B,C based on:
• Quantity of agent available
• Ability to disseminate the agent
• Person-to-person transmission
• Severity of disease
• Public response, panic, etc..
• Overall risk to national security
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Category A Agents
•
•
•
•
•
•
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Anthrax
Smallpox
Plague
Botulinum toxin
Tularemia
Viral hemorrhagic fevers
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Category B Agents
(examples)
• Infectious Agents
– Brucellosis
– Glanders
• Bio-toxins
– Ricin toxin from Ricinus
communis (castor beans)
– Staphylococcal enterotoxin B
• Water safety threats
–Vibrio cholerae
• Food safety threats
–Salmonella species
–Escherichia coli O157:H7
–Shigella
• Viral encephalitis
–Venezuelan Equine Encephalitis
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Why are these Category B
Agents
•Less quantity available than
Category A
•Harder to disseminate
•Less person to person
transmission- if any
•Slightly less severity of
disease
•Less known to public therefore less likely to cause
panic
•Slightly less risk to National
Security
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Category C
• Emerging infectious diseases as bioterrorism agents
– Nipah virus
– Hantavirus
• Emerging infectious disease that posses a significant
public health threat
– Avian Flu
– SARS
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Category A: Anthrax
•Endemic in animals worldwide
with occasional human cases
– Handling infected animal
products (especially cattle,
sheep, horses, mules and
goats)
•Spores used for bioattack
– Aerosolized directly or sent
in mail/packages
•Three forms
–Cutaneous, Inhalation, GI
Anthrax in CSF—US index case
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Anthrax – Clinical Features
• Inhalation
– Incubation: 2-43 days (may be longer)
– Prodrome
• Fevers, malaise, dry cough, chest pain, dyspnea,
myalgia
– Abrupt onset of fulminant illness
• Sudden high fever, respiratory distress, shock
• Meningitis in ~50%
• Actual pneumonia uncommon
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Normal Chest X-Ray
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Widened mediastinum & pleural effusions
Inhalational anthrax
US index case
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Anthrax – Clinical Features
• Cutaneous
– Incubation: 1 to 7days (up to 12 days)
– Erythematous “itchy” papule  ulcer  characteristic
black eschar with surrounding erythema and edema
– Regional adenopathy and systemic symptoms (e.g.,
fever, malaise)
– Most lesions completely resolve
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Anthrax – Clinical Features
• Gastrointestinal
– Incubation period 1-7 days
– Not likely after a bioattack
– Presents as febrile illness with bloody
diarrhea
– Eating undercooked infected meat
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Anthrax Diagnosis
• Blood cultures
– Usually positive in < 24h
• Gram stain pleural fluid or CSF
– Sputum gram stain/culture is usually NOT positive
• Inhalational disease
– Very suggestive if fever and widened mediastinum
• Cutaneous disease
– Culture fluid from under eschar
• Nasal swabs are a poor test
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Anthrax –Treatment
• Ciprofloxacin 400 mg IV q12h
– 10-15 mg/kg for children
– Other fluoroquinolones probably also effective
OR
• Doxycycline 100 mg IV q12h
– 2.2 mg/kg for children
PLUS
• 1 or 2 additional antibiotics
– Clindamycin, rifampin, vancomycin, penicillin,
chloramphenicol, imipenem, or clarithromycin
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Prophylaxis and Infection
Control
•
Prophylaxis
– Ciprofloxacin 500 mg PO BID(Peds:10-15 mg/kg)
or
– Doxycycline 100 mg PO BID (Peds:2.2 mg/kg)
– Continue for 60 days (? 100 days)
– Vaccine available for DOD forces
•
Infection Control
– Standard barrier precautions are needed
– Not transmitted person-to-person
•
Only immunize / prophylaxis exposed at BT attack
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Anthrax Vaccination Schedule
1 2 3
4
5
6
• 6 shots over 18 months, then annual booster
– Dosing schedule is 0.5 mL subcutaneously at each
visit
– Then yearly boosters
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Botulism
Clostridium botulinum
A Toxin Producing Obligate, Anaerobic, Spore Forming,
Gram Pos. Bacillus
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Botulism - General
• Caused by a toxin produced by
Clostridium botulinum
• Sporadic cases and outbreaks caused by
tainted foods
• For bioattack toxin could be delivered as
an aerosol or used to contaminate food /
water
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Botulism - Clinical Features
• 12 to 36 hour “incubation”
– Range 2 h to 8 days
• Clinical recognition is key to diagnosis
• Bulbar palsies: Must be present!
– Ptosis, blurred vision, dry mouth, dysarthria, trouble
swallowing
• Afebrile,“AAO x 3”, difficulty speaking
• Descending skeletal muscle paralysis
• Death: Respiratory muscle paralysis
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17 Year-Old
with Mild Botulism
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Botulism - Treatment
• Supportive care
• Respiratory failure
– Prolonged Ventilator support
• Antitoxin
– State health department obtained
– Prevents further damage
– Does not alter current damage
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Botulism –
Infection Control
Prophylaxis
• No proven prophylaxis at this time
• Investigational Vaccine
Isolation
• Standard precautions (not P-to-P)
Need to contact public health authority immediately:
Others may be exposed to contaminated food source
or agent
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Yersinia pestis
Plague
Yersinia pestis
Source: www.cdc.gov
Gram Neg., Anaerobic, Rod Shaped Bac.
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“Safety Pin” Bipolar on Wright Staining
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Plague - General
• Endemic in animals
throughout the world
– Prairie dogs in the
Southwestern US
• High potential as a BT agent
• Endemic form
– Spread to humans via a
flea vector
– Results in bubonic form
of the disease
• Bioattack
– Most likely aerosolized
– Results in pneumonic
plague
– Release of infected fleas
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Buboes
Source: www.cdc.gov
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Plague – Clinical Features
• Following Aerosolized Bioattack
– 1- 6 day incubation
– Abrupt onset
• High fever, chills, and malaise
• Cough with bloody sputum
• Sepsis
– Severe rapidly progressive pneumonia
– Untreated 100% mortality
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Plague - Diagnosis
• CXR with patchy infiltrates
• Culture of blood and sputum
– Need to inform the laboratory if you suspect
plague … special techniques
• May show characteristic “safety-pin”
bipolar staining
• Sudden # Gm(neg) pneumonia
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Normal Chest X-Ray
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Plague pneumonia
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Plague - Treatment
Preferred: Start within first 24 hours for 10 days
• Streptomycin 1 g IM q12h
– 15 mg/kg/dose for children
– Avoid in pregnant women
• Gentamicin 5 mg /kg IM or IV qd
– Or 2 mg/kg load the 1.7 mg/kg q8h
– For children use 2.5 mg/kg q8h
Alternative
• Doxycycline 100 mg IV q12h
– 2.2 mg/kg/dose q12h for children
• Ciprofloxacin 400 mg IV q12h
– Other fluoroquinolones probably effective
– For children 15 mg/kg/dose q12h
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Plague - Infection Control
Prophylaxis: Treat for 7 days
• Doxycycline 100 mg PO bid
– 2.2 mg/kg for children
• Ciprofloxacin 500 mg PO bid
– 20 mg/kg for children
– other fluoroquinolones probably effective
Isolation
• Droplet precautions (Yes, P-to-P)
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Smallpox
Source: www.cdc.gov
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Smallpox - General
• One of the deadliest disease
– Mortality rate of 30%
• US stopped vaccinating in 1972
• Declared eradicated by WHO
– In 1980, however...
• Bioattack
– Aerosolized virus or by exposure to purposefully
infected terrorists
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Smallpox - Clinical Features
• Incubation period
– 7-17 day (average 12d), Weaponized 3-5 d
• Severe prodrome Key difference!
– 2-3 day of fever, severe myalgias, prostration, occ.
n/v, delerium
– 10% with light facial erythematous rash
• Distinctive rash
– Initially on face and extremities
– Including palms and soles
– Spreads to trunk
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Small Pox - Clinical Features
• Rash
– Macules  papules  vesicles  pustules
– Unlike chicken pox, lesions don’t appear in “crops”
• All lesions in an area are in the same stage of
development
• Lesions are firm, deep, frequently umbilicated
• Rash scabs over in 1-2 weeks
Chickenpox
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Smallpox
Source: www.cdc.gov
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Smallpox
The main diagnostic tool for smallpox
Source: www.cdc.gov
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is the history and physical!
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Smallpox - Treatment
• Vaccination
– In the early stages of disease
• Supportive care
– Penicillinase-resistant antibiotics (for secondary infection)
– Daily eye rinsing
– Adequate hydration and nutrition
• FDA has not approved specific therapy
– Topical idoxuridine for corneal lesions (Dendrid)
– Cidofovir ?
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Smallpox - Infection Control
Prophylaxis
• Vaccine is effective if given within 3 days of
exposure
Isolation
• Airborne and contact precautions
• Febrile illness after potential exposure should
prompt isolation before rash starts
Immediate contact your hospital epidemiologist and
the public health authorities
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Francisella tularensis
Tularemia
Source: www.cdc.gov
Gram Neg. Coccobacillus
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Tularemia - General
• Endemic in North America and Eurasia
• Sporadic human cases spread by ticks or
biting flies
– Occasionally from direct contact with infected
animals (ulceroglandular)
• Bioattack
– Aerosolized bacteria
– Typhoidal tularemia & (+ / - ) pneumonia
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Tularemia - Clinical Features
• Bioattack
– 3-5 day incubation (range 1-14 days)
– Acute febrile illness with prostration
– ~80% will have radiographic evidence of
pneumonia
– May have associated conjunctivitis or skin
ulcer & regional adenopathy
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Tularemia - Diagnosis
• Culture of blood and sputum
– May take weeks to isolate and ID
• Gram negative coccobacillus
– Confirmation may require reference laboratory
– Potential hazard to laboratory personnel
Laboratory must be notified if tularemia
is suspected
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Tularemia - Treatment
Preferred Treatment time varies with Abx
• Streptomycin 1 g IM q12h
– 15 mg/kg for children
• Gentamicin 5 mg / kg IM or IB q day
– for children use 2.5 mg/kg q8h
Alternative
• Doxycycline 100 mg IV q12h
– 2.2 mg/kg for children
• Ciprofloxacin 400 mg IV q12h
– Children 15 mg/kg
– Other fluoroquinolones probably effective
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Tularemia - Infection Control
Prophylaxis: Treat for 14 days
• Doxycycline 100 mg PO bid
– 2.2 mg/kg for children
• Ciprofloxacin 500 mg PO bid
– 15-20 mg/kg for children
• Tetracycline
Isolation:
• Standard precautions (Not P-to-P)
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Viral Hemorrhagic Fevers
Source: www.cdc.gov
Ebola virus
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VHF - General
• Naturally occurring disease
– Transmitted to humans by contact with infected animals or
arthropod vectors.
– Sporadic outbreaks in Africa, parts of Asia and Europe
(Outside of Africa, likely BT event)
• VHF viruses as bioterrorism agents
– Weaponized by several countries
– Aerosolization
• Case fatality rates
– Omsk hemorrhagic fever
– Ebola
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0.5%
90%
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VHF - Clinical Features
• Incubation 2 - 21days
– Depends on virus
• Initial presentation
– Nonspecific prodrome (fever, myalgias, headache, abdominal
pain, prostration)
– Exam may show only flushing of face and chest, conjunctival
injection, and petechiae
• Disease progresses to generalized mucous membrane
hemorrhage and shock occurs
Marburg Disease
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Bolivian Hemorrhagic Fever
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VHF - Diagnosis
• Ancillary testing:
– Thrombocytopenia, leukopenia, AST elevation
common
• Definitive diagnosis requires detection of
antigens or antibodies
– Testing done at CDC
Do not wait to confirm the diagnosis before
notifying the local public health authorities
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VHF - Treatment
• Supportive care
• Ribavirin may be useful
– Best early in the course of illness
– Adults and children: 30 mg/kg IV load
(max 2 g)
• then 16 mg/kg (max 1g) q6h x 4 days
• then 8 mg/kg (max 500 mg) IV q8h for 6 days
– Oral dosing regimen is available
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VHF - Infection Control
Prophylaxis:
None at this time
Vaccine in primates being tested
Isolation: Key!
– Blood and bodily fluids extremely infectious
– Liquid-impervious protective coverings, including
leg and shoe coverings
– Double gloves, Face shields or goggles
– N-95 or better respirators
– Negative pressure room
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Emerging Infectious
Diseases
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Pandemic
A Global Epidemic!
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Past flu pandemics
Credit: US National Museum of Health and
Medicine
1918: “Spanish Flu”
A(H1N1)
1957: “Asian Flu”
A(H2N2)
1968: “Hong Kong Flu”
A(H3N2)
20-40 m deaths
1-4 m deaths
1-4 m deaths
675,000 US deaths
70,000 US deaths
34,000 US deaths
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Put another way …
Life expectancy-USA, 1900-28
70
60
50
40
19
00
.
19
03
.
19
06
.
19
09
.
19
12
.
19
15
.
19
18
.
19
21
.
19
24
.
19
27
.
30
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Pandemic Influenza
www.cdc.gov
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Pandemic Influenza
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Pandemic Influenza Healthcare
Workforce
• Who is going to show up for
work?
• The reports, articles and plans
are alarming!
• Will you?
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Containment
•
•
•
•
•
Limit travel
Isolate ill and quarantine exposed
Trace contacts
Curfews & cancel public gatherings
Prophylaxis & treatment
– Neuramidase inhibitors ?
– Vaccine ?
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D: Detection
I: Incident Command
S: Safety & Security
A: Assess Hazards
S: Support
T: Triage & Treatment
E: Evacuation
R: Recovery
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Detection
There may not be a “scene”
May be hard to detect
Long Incubation period
Symptoms manifest slowly
Non-specific symptoms
Beware of multiple people with similar
Complaints, particularly in the “healthy”
population
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D: Detection
I: Incident Command
S: Safety & Security
A: Assess Hazards
S: Support
T: Triage & Treatment
E: Evacuation
R: Recovery
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Incident Command
• Absence of a “scene” if covert
• Lead role of law enforcement
• Unified command of law enforcement and public
health
• Special public health emergency powers
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Security
• Hospital ingress and egress
– Must be able to secure hospital
• Most bioattacks likely covert
– Patients will come in through ER
– ER becomes the “scene”
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Suspicious Package
• Do not open suspicious
packages
• Secure area
– Shut off ventilation if
possible
• Alert appropriate
authorities
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Assessing Hazards
• Protective isolation & quarantine
• Epidemiologic assessment
• Environmental assessment
• Laboratory diagnosis of ill persons
• Role of immunization, prophylaxis and treatment
• Little role for decontamination
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Personal Protective Equipment
• Degree of protection
– Controversial
• CDC guidelines
– Very conservative
• N-95 respirators, gloves, fluid-impervious
gowns
– Better than nothing
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Support
•
•
•
•
Initially, local management issue!
Local hospital capacity
Local healthcare providers
Is your local community ready?
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Support
Local Hospital Capacity
Coordination & Augmentation
•
•
•
•
Pre-event planning essential for “surge”
Surge facilities for medical care expansion
Expect being overrun with “worried well”
Involvement of local pharmacies
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Support:
Strategic National Stockpile
• Pre-positioned material
managed by CDC and
DHS
• Medications, antidotes,
vaccines, PPE,
equipment,et al.
• 12 hour Push Packages
• Vendor managed
inventory
• Local coordination of
receipt critical
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Triage
Three types of patients:
(1). Ill and need definitive treatment
(2). Exposed but not ill: may need prophylaxis and
quarantine
(3). Not exposed: need reassurance
Difficult to distinguish between groups 2 & 3!
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Evacuation
•
•
•
•
Dedicated treatment facilities
Isolation of patients
Surge capacity implications
Hospital becomes a “scene”
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Recovery
• Law enforcement
• Evidence, apprehension, prosecution,...
• Public health
• Stop spread, identify source, treatment options,...
• Mental health
• Wide-spread panic, “worried-well”, responders,...
• Environmental health
• Viability of weaponized release, “nature” effects,
soiled materials,...
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Summary
Now you can:
• Describe the difference between biological events and
bioterrorism (BT)
• Discuss public health BT surveillance
• Identify the CDC BT Category A agents
• Identify emerging infectious diseases
• Compare and contrast BT and other CBRNE WMD
utilizing the DISASTER paradigm
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Questions?
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