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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: Smallpox 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. Smallpox Overview • Two strains: variola major and variola minor • Variola minor – milder disease with case fatality typically 1% or less • Variola major – more severe disease with average 30% mortality in unvaccinated • Person-to-person transmission

  6. SmallpoxOverview • Killed approximately 300,000,000 persons in 20th century • Routine smallpox vaccination in the U.S. stopped in 1972 • WHO declared smallpox eradicated in 1980 • Vaccine has significant adverse effects • No effective treatment 6

  7. SmallpoxOverview • Person-to-person transmission • Average 30% mortality from variola major in unvaccinated • A single case is considered a global public health emergency 7

  8. Smallpox Transmission • Infectious dose extremely low • Spread primarily by droplet nuclei >aerosols > direct contact • Maintains infectivity for prolonged periods out of host • Contaminated clothing and bedding can be infectious 8

  9. Smallpox Transmission • Transmission does not usually occur until after febrile prodrome • Coincident with onset of rash • Slower spread through the population than chickenpox or measles • Large outbreaks in schools were uncommon • Less transmissible than measles, chickenpox, influenza 9

  10. SmallpoxTransmission • Secondary cases primarily household, hospital, and other close contacts • Secondary attack rate 37-87% among unvaccinated contacts • Patients with severe disease or cough at highest risk for transmission • Greatest infectivity from rash onset to day 7-10 of rash • Infectivity decreases with scab formation and ceases with separation of scabs 10

  11. SmallpoxCase Definition • Clinical case definition • An illness with acute onset of fever 101F followed by a rash characterized by vesicles or firm pustules in the same stage of development without other apparent cause • Laboratory criteria for confirmation (Level C/D* lab) • Isolation of smallpox virus from a clinical specimen, OR • Identification of variola in a clinical specimen by PCR or electronmicroscopy *initial confirmation of outbreak requires testing in level D lab (I.e., CDC)

  12. SmallpoxCase Classification • Case classification • Confirmed: laboratory confirmed • Probable: meets clinical case definition & has an epi link to another confirmed or probable case • Suspected: • Meets clinical case definition but is not laboratory-confirmed and does not have an epi link OR • Atypical presentation not lab confirmed but has an epi link to a confirmed or probable case

  13. SmallpoxClinical Features • Prodrome (incubation 7-19 days) • Acute onset of fever, malaise, headache, backache, vomiting, occasional delirium • Transient red rash • Exanthem(2-3 days later) • Preceded by enanthem on oropharyngeal mucosa • Begins on face, hands, forearms • Spread to lower extremities then trunk over ~ 7 days • Synchronous progression: flat lesions  vesicles  pustules  scabs CDC Lesions most abundant on face and extremities, including palms/soles 13

  14. SmallpoxClinical Course WHO

  15. SmallpoxClinical Progression WHO 15

  16. SmallpoxClinical Progression Day 10 Day 14 Day 21 Thomas, D.

  17. SmallpoxClinical Types • Ordinary smallpox: 90% of cases • Case-fatality average 30% • Occurs in non-immunized persons • Modified smallpox • Milder, rarely fatal • Occurs in 25% of previously immunized persons and 2% of non-immunized persons • Fewer, smaller,more superficial lesions that evolve more rapidly 17

  18. SmallpoxClinical Types • Hemorrhagic smallpox: <3% of cases • Immunocompromised persons and pregnant women at risk • Shortened incubation period, severe prodrome • Dusky erythema followed by petechiae & hemorrhages into skin and mucous membranes • Almost uniformly fatal within 7 days 18

  19. SmallpoxClinical Types • Malignant or flat-type smallpox: 7% of cases • Slowly evolving lesions that coalesce without forming pustules • Associated with cell-mediated immune deficiency • Usually fatal • Variola sine eruptione • Occurs in previously vaccinated persons or infants with maternal antibodies • Asymptomatic or mild illness • Transmission from these cases has not been documented 19

  20. Malignant Smallpox Thomas, D.

  21. SmallpoxComplications • Encephalitis • 1 in 500 cases Variola major • 1 in 2,000 cases Variola minor • Corneal ulceration • Blindness in 1% of cases • Infection in pregnancy • High perinatal fatality rate • Congenital infection 21

  22. SmallpoxMedical Management • Respiratory and contact isolation for hospitalized cases • Negative pressure room; HEPA-filtered exhaust • All health care workers employ aerosol and contact precautions regardless of immunization status • No specific therapy available • Supportive care: fluid and electrolyte, skin nutritional 22

  23. SmallpoxMedical Management • Antibiotics for secondary infection • Antiviral drugs under evaluation • Notify Public Health and hospital epidemiology immediately for suspected case 23

  24. SmallpoxOutbreakManagement • Case identification, isolation, and immunization • Rapid identification of contacts • Immediate vaccination or boosting of ALL potential contacts including health care workers (ring vaccination) • Vaccination within 4 days of exposure may prevent or lessen disease • Isolation with monitoring for fever or rash • 18 days from last contact with case • Respiratory isolation if possible for febrile contacts 24

  25. SmallpoxOutbreakManagement • Priority groups for vaccination in a smallpox outbreak include persons involved in the direct medical or public health evaluation of confirmed, probable, or suspected smallpox patients • Passive immunization (VIG) • Potential use for contacts at high risk for vaccine complications • Pregnancy, skin disorders, immunosuppression • VIG not readily available More on CDC's response plan...

  26. SmallpoxDefinition of a Contact • Contact: A person who has had contact with a suspected, probable or confirmed case of smallpox • Cases should be considered infectious from the onset of fever, until all scabs have separated • Close contact: Face-to-face contact (6ft) with a smallpox case

  27. Smallpox Outbreak ManagementPre-release Vaccination • Select individuals vaccinated to enhance smallpox response capacity • Smallpox Response Teams • Designated public health, law enforcement, and medical personnel in each state/territory • Investigate, evaluate, and diagnose initial suspect cases of smallpox • Select personnel at acute care health care facilities (Smallpox Health Care Teams) ACIP, June 2002

  28. Smallpox Vaccine • Made from live Vaccinia virus • ~ 200 million doses in U.S. stores • Intradermal inoculation with bifurcated needle (scarification) • Pustular lesion or induration surrounding central lesion (scab or ulcer) 6-8 days post-vaccination • Low grade fever, axillary lymphadenopathy • Scar (permanent) demonstrates successful vaccination (“take”) • Immunity not life-long WHO 28

  29. Smallpox VaccineAdministration Vaccine admin instructions JAMA 1999;281:1735-45 WHO 29

  30. Smallpox Vaccine“Take” WHO 30

  31. Smallpox Vaccine Complications • More common in children and primary vaccinees • Most common: secondary inoculation • Skin, eye, nose, genitalia • 50% of all complications • 529/million (30% in one study were contacts) • Severe reactions less common • Primary vaccination ~ 1 death/million • Revaccination ~ 0.2 deaths/million

  32. Smallpox Complication Rates for Primary Vaccination • Less common • Post-vaccination encephalopathy (7-42.3/million)* • Post-vaccination encephalitis (12.3/million) • 25% fatal; 23% neurological sequelae • Progressive vaccinia/vaccinia necrosum (1.5/million) • Generalized vaccinia (241.5/million): severe in 10% • Eczema vaccinatum (38.5/million) • Fetal vaccinia - rare Sourced: MMWR June 22, 2001 / 50(RR10);1-25. Vaccinia (Smallpox) Vaccine Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001 *Vaccines 3rd Ed. Plotkin SA, Orenstein WA. W.B. Saunders, Phila. 1999 32

  33. Smallpox Vaccine Pre-exposure Contraindications • Immunosuppression • Agammaglobulinemia • Leukemia, lymphoma, generalized malignancy • Chemo- or other immunosuppressive therapy • HIV infection • History or evidence of eczema • Household, sexual, or other close contact with person with one of the above conditions • Life-threatening allergy to polymixin B, streptomycin, tetracycline, or neomycin • Pregnancy 33

  34. Distinguishing Smallpox from Chickenpox: SimilarEpidemiologic Features • Incubation period 14 (10-21) days • Person-to-person transmission • Seasonal transmission of disease highest during winter and early spring

  35. Chickenpox (varicella) Most cases occur in children Expected case fatality rate 2-3/100,000 Secondary attack rate of 80% among susceptible household contacts Smallpox (variola) Most of the population expected to be susceptible Expected case fatality rate averages 30% Secondary attack rate ~60% in unvaccinated family contacts Distinguishing Smallpox from Chickenpox: Epi Featuresthat Differ

  36. Chickenpox (varicella) Lesions superficial Rash concentrated on trunk Lesions rarely on palms or soles Lesions in different stages of development Rash progresses more quickly Smallpox (variola) Lesions deep Rash concentrated on face & extremities Lesions on palms & soles Lesions in same stage of evolution on any one area of body Rash progresses slowly Distinguishing Smallpox from Chickenpox: Clinical Featuresthat Differ CDC

  37. Smallpox Surveillance • Pre-event • Development of a listing of surveillance partners, points of contact, and mechanisms for reporting • Establishing sentinel surveillance for generalized febrile vesicular-pustular rash in health care settings • Post-event: • Once a confirmed case of smallpox is identified in your jurisdiction, active surveillance for suspected, probable, and confirmed cases should be initiated

  38. Smallpox Surveillance, cont. • Contact tracing, interviewing, and vaccination • Monitored for vaccine “take” • Non-symptomatic contacts monitored for fever or rash • 18 days beyond last contact OR • 14 days beyond successful vaccination • Followup • Laboratory results & epi links • Case outcomes/complications • Vaccine adverse events (for VAERS)

  39. Smallpox Summary of Key Points • Smallpox is transmitted person to person; standard and airborne precautions should be initiated in all suspected cases until smallpox is ruled out. • Smallpox cases should be considered infectious from the onset of fever until all scabs have separated.

  40. Smallpox Summary of Key Points • Vaccine-induced immunity wanes with time; therefore most people today are considered susceptible to smallpox infection. • In a smallpox outbreak, vaccination is indicated for all case contacts, including health care workers and case investigators. • Smallpox surveillance includes pre-event rash surveillance, post-event surveillance for active cases, and follow-up of cases, contacts, and vaccine recipients.

  41. Smallpox Summary of Key Points • Epidemiologic features that differentiate smallpox from chickenpox include a higher case fatality and a lower attack rate. • Clinical features differentiating smallpox from varicella include differences in lesion progression and distribution, illness course and presence of a febrile prodrome.

  42. 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

  43. 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

  44. 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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