Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce

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: Overview CDC, AFIP

4. Diseases of Bioterrorist PotentialLearning Objectives • Develop an awareness of the potential agents that might be used in a bioterrorism event • Identify contagious agents • Describe the types of illness caused by the agents • Identify agents that might require public health to provide immunizations or antibiotics to exposed persons • Describe how to respond if a suspicious package or substance is received

5. Biological Agents of Highest ConcernCategory A Agents • Smallpox (Variola major) • Anthrax(Bacillus anthracis) • Plague(Yersinia pestis) • Tularemia(Francisella tularensis) • Botulism (Botulinum toxin) • Viral hemorrhagic fevers (Filoviruses & Arenaviruses) 5

6. Biological Agents of 2nd Highest ConcernCategory B Agents • Q-fever(Coxiella burnetti) • Brucellosis(Brucella species) • Glanders(Burkholderia mallei) • Venezuelan, Western and Eastern encephalomyelitis (Alphaviruses) • Ricin toxin fromRicinus communis (castor bean) • Epsilon toxin from Clostridium perfringens • Staphlococcus enterotoxin B 6

7. Biological Agents of 2nd Highest ConcernFood- or Waterborne Category B Agents • Salmonella species • Shigella dysenteriae • Escherichia coli 0157:H7 • Vibrio cholera • Cryptosporidium parvum 7

8. Types of Illnesses These Agents Can Cause • “Flu-like” illness (fever, sweats, nausea) • Cough and/or pneumonia • Skin ulcers (anthrax, tularemia, plague) • Rashes (smallpox, ebola) • Paralysis (botulism) • Diarrhea & vomiting (food- and water-borne agents) • Headache, confusion

9. Contagious Agents(Person-to-Person Transmission) • Smallpox • Plague pneumonia • Some viral hemorrhagic fevers (e.g., ebola) • Food- and water-borne agents (e.g., salmonella & shigella)

10. Antibiotics Anthrax Plague Tularemia Q Fever Brucellosis Immunization Smallpox Anthrax Agents That May Require Antibiotics or Immunization to Prevent Disease

11. Decontamination:Category A Critical Agents • Decontamination of exposed persons • Showering or washing thoroughly with soap and water adequate for most; bleach not necessary • Decontamination of facilities and equipment • May not be necessary for surfaces contaminated by agents with short survival time (i.e., plague, botulism) • Other agents may require bleach solution, sporicidal chemicals, incineration, and/or autoclaving

12. Infection Control: Category A Critical Agents • Infection control • Standard precautions – all cases • Airborne & contact precautions – smallpox and viral hemorrhagic fevers • Droplet precautions – pneumonic plague

13. Infection ControlStandard Precautions • Standard Precautions – all cases • Disposable, non-sterile gloves • Hand washing after glove removal • Disposable gown or apron, faceshield if splashing anticipated • Change protective gear between cases

14. Infection Control Contact Precautions • Standard precautions plus: • Wear gloves and gown, change after contact with infectious material • Dedicate non-critical patient care items (e.g., stethoscope) to a single patient or disinfect between patients

15. Droplet Precautions Standard Precautions plus: Wear mask when w/in 6 ft of patient Airborne Precautions Standard Precautions plus: Patient in negative air pressure room Wear respiratory protection (such as a HEPA filter mask) Infection Control Droplet and Airborne Precautions

16. Excessive postage Handwritten or poorly typed addresses Incorrect titles Title, but no name Misspellings of common words Oily stains, discolorations, or odor No return address Excessive weight Lopsided or uneven envelope Protruding wires or aluminum foil Excessive security material such as masking tape, string, etc. Visual distractions Ticking sound Marked with restrictive endorsements ("Personal“,"Confidential“) City or state in the postmark does not match the return address Mail SafetyRecognizing Suspicious Packages

17. Mail Safety Handling Suspicious Packages or Letters with a Threatening Message • Donot shake or empty contents • PLACE the envelope or package in a plastic bag or other type of container to prevent leakage of contents • LEAVE the room and CLOSE the door or section off the area to prevent others from entering • WASH your hands with soap and water • Contact local law enforcement

18. Hoaxes and Evaluation of Suspicious Powders • If a suspicious substance is received • Cover substance (do not try to clean up any spilled contents) • Leave the room and close the door • Turn off air conditioning system • Wash hands with soap & water • Report to local law enforcement (call 911) • Notify building security

19. Hoaxes and Evaluation of Suspicious Powders, cont. • Additional steps to take if exposed to a suspicious powder or substance • Remove contaminated clothing & place in plastic bag or other sealed container • Shower with soap & water (bleach is not necessary) • Make a list of all people exposed or in the same room/area as the substance

20. Summary of Key Points • Most of the biological agents of concern produce an initial non-specific or “flu-like” illness. • Standard precautions should be used with all patients following a bioterrorism incident. • Additional precautions are required with a few biological agents, where person-to-person transmission is possible.

21. Summary of Key Points • Notify building security and local law enforcement if a suspicious package or substance is received. • If exposed to a suspicious substance, remove contaminated clothing, and wash with soap and water.

22. 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

23. 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

24. 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

25. Quick References for Health Care Providers • Johns Hopkins Center for Civilian Biodefense • Saint Louis Center for the Study of Bioterrorism and Emerging Infections • Santa Clara County Health Department • Washington State Department of Health http://www.hopkins-biodefense.org http://bioterrorism.slu.edu http://www.sccphd.org/diseasecontrol/bioterrorism.asp http://www.doh.wa.gov/BioTerr/BioTerLHO.htm#Background