Unusual Illness: Initial Investigation and Management

1. Unusual Illness: Initial Investigationand Management Part 12 of 13 Comments and contributions are encouraged: please e-mail DRcomments@hpa.org.uk HPA Centre for Infections Reviewed April 2009

2. Unusual Illness – is it a deliberate release? • Overt release - relatively easy to recognise • emergency services will probably be involved first • PH role will be identifying agent and giving health advice • Covert Release – probably first recognised by health professionals, clinicians or laboratories • need for awareness against a background of atypical presentations of endemic disease

3. When to Suspect Deliberate Release [1] • Ill people with similar disease or syndrome presenting around the same time • Cases of unexplained disease, syndrome or death • Single case of disease caused by uncommon agent • Failure of a common disease to respond to usual therapy • Recognised illness occurring in an unusual setting or key sector within a community

4. When to Suspect Deliberate Release [2] • Disease with unusual geographic or seasonal variation • Multiple atypical presentations of disease agents • Similar typing of agents isolated from temporally or spatially distinct sources • Unusual, atypical, genetically engineered or antiquated strain of agents

5. When to Suspect Deliberate Release [3] • Simultaneous outbreaks of similar illness in non-contiguous areas • Deaths or illnesses among animals that precedes or accompanies illness or death in humans • Suspected or known deliberate release in other countries

6. “The Initial Investigation and Management of Outbreaks and Incidents of Unusual Illnesses” • Document available on the HPA CfI websitehttp://www.hpa.org.uk/deliberate_accidental_releases • Aids decision making for health professionals and other health protection personnel involved in the initial investigation, management and response to cases of unusual illness. May also assist in determining if an incident is due to natural or accidental cause or deliberate release. Specific guides for: • Histopathologists & APTs • Local Laboratories • Occupational Health Services • Ambulance service • Hospital clinicians • General Practitioners • Public Health Professionals

7. Initial classification of possible aetiology of an outbreak/incident of unusual illness Cases of unusual illness detected • Consider: • how cases have been detected • timescale of detection • geographical location • which section of the community (who) has been affected • common clinical features • Cases: • detected by emergency services/A&E departments /general public/CHaPD/NPIS • detected over minutes to hours (ACUTE) • occur in circumscribed geographical area • occur in people who may have shared a known common exposure • Cases: • detected by vigilance of healthcare professionals/general public/routine surveillance • detected over hours to days or days to weeks (DELAYED) • may or may not occur in geographical clusters • may or may not occur in people who have shared a known common exposure ACUTE Likely aetiologies: CHEMICAL Biological toxins Radiological Epidemic hysteria Infectious agents DELAYED Likely aetiologies: INFECTIOUS AGENTS RADIOLOGICAL Chemical Psychological (Nutritional)

8. Managing Biological Incidents • Set incident control team early - Agenda - Membership • If suspect a deliberate release - inform police • Seek expert advice –make sure have access to list of telephone numbers

9. Managing Biological Incidents • Formulate case definitions • Active case finding • Appropriate investigation of cases • Producing ‘best available advice’ for management of cases • COMMUNICATION

10. Emergency Clinical Situations Algorithm Immediate actions when unusual clinical presentations occur - see HPA website at: http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1160495617061?p=1160495617061

11. Potential BW Agents: Category A(CDC Classification) • Easily disseminated or transmitted person-person • High mortality – major public health impact • Public panic and social disruption • Special action for public health preparedness • Anthrax (Bacillus anthracis) • Plague (Yersinia pestis) • Botulinum toxin • Smallpox • Tularemia (Francisella tularensis) • Viral haemorrhagic fevers

12. Potential BW Agents: Category B • Moderately easy to disseminate • Moderate morbidity, low mortality • Require enhancement of diagnostic capacity and surveillance • Q fever (Coxiella burnetii) • Brucellosis (Brucella spp.) • Glanders & melioidosis (Burkholderia mallei / pseudomallei) • VEE, EEE and WEE • Enteric pathogens • Other toxins

13. Potential BW Agents: Category C • Emerging agents • Availability • Easy to produce and disseminate • Potential for high mortality and morbidity • Nipah virus • Hantaviruses • Tickborne HF • Tickborne encephalitis • Yellow fever • MDRTB

14. The Main Biological Threats • Anthrax • Plague • Botulinum Toxin • Tularemia • Smallpox • VHF