Bio-Terrorism and the Respiratory Therapist

1. Bio-Terrorism and the Respiratory Therapist Prepare, since it is not a question of “if” but rather “when.” Prof. Thomas J. Johnson

2. Disclaimer Since medicine is an ever-changing science with new research and clinical experience broadening our knowledge, changes in pharmacologic treatment and other care occur. Although the author has made every effort to insure that the information contained meets that standards at the time of publication, the possibility of human error exists. Therefore the author nor the University cannot guarantee that the data contained is complete in every respect and that they are not responsible for any errors or omissions. The reader is strongly encouraged to confirm the information contained herein with other sources. Prof. Thomas J. Johnson

3. Biological Warfare in History • In its three main forms --contamination of food and water, use of micro-organisms or toxins, and the use of inoculated fabrics -- bio-warfare has been around since 400 - 300 B.C1. • During the French and Indian War, British forces generously gave blankets deliberately contaminated with smallpox to attack immunologically naive indigenous tribes.2 • Mayor A. Dirty Tricks in Ancient Warfare. Mil Hist Quart. 1997:10, 1: 32-37 • Christopher GW, Cieslak TJ, Pavlin JA, Eitzen EM. Biological Warfare, a historical prospective. JAMA. 1997; 278:412-417 Prof. Thomas J. Johnson

4. Bio-Terrorism • “Medical defense against biological warfare or terrorism is an area unfamiliar to most military and civilian health care providers.” USAMRIID February 4, 2001 • Potential for massive numbers of victims • Potential for panic among lay and medical personnel • Potential for mimic of endemic infectious diseases. Prof. Thomas J. Johnson

5. Unusual or not naturally occurring disease entity Large number of cases or entities Point-source outbreak Aerosol route of infection High morbidity and/or mortality Limited geographical areas Low attack-rate in persons in filtered air Sentinel dead animals, esp. multiple species No natural vector Large number military and civilian casualties USAMRIID Medical Management of Biological Casualties Course (6H-F26) 01 February 2001 Indicators of Possible Bio-Attack Prof. Thomas J. Johnson

6. Clinical Case Alpha • You are the respiratory therapist treating an asthmatic child when you overhear a mother tell the pediatrician: “I don’t understand it. My Joey had chickenpox as a preschooler and Susie had the vaccine. How could they have chickenpox? There are many kids with chickenpox in the neighborhood who went to the Columbus Day parade.” The ER has had several cops with “chickenpox.” There was a report of an explosion at the parade. What is your diagnosis? What lab tests are indicated? Prof. Thomas J. Johnson

7. Bioterrorism: Routes of Infection • Aerosol weapons primary dispersal • Percutaneous, e.g. anthrax as “wool sorters disease” • Oral, i.e. intake of contaminated food and water • Inhalation route has the greatest potential for mass casualties Prof. Thomas J. Johnson

8. Clinical Case Beta • The Daily Planet reports that large numbers of rats are found dead. Transit workers and subway riders are in your ER complaining of high fevers, chills and hemoptysis. Auscultation finds bilateral crackles. • What lab test will be helpful? • What bioagent may be responsible? Prof. Thomas J. Johnson

9. Bioagents Most Likely to Succeed • Smallpox, anthrax, plague, tularemia, botulinum toxin, mycotoxin and viral hemorrhagic fevers. • Salmonella*, Brucellosis, Wheat smut, and others *The FBI reported that between August and September of 1984 the Rajneeshee cult contaminated 10 restaurants with Salmonella in Wasco County, Oregon Prof. Thomas J. Johnson

10. Clinical Case Chi • Terrorist occupying a hotel released a smoke bomb before committing suicide. Several days later, several police horses at the scene died. Additionally numerous police and newspeople who were there are sick with flu-like symptoms: fever, malaise, cough, mild chest discomfort. • Suggest lab tests • Suggest a possible bioagent Prof. Thomas J. Johnson

11. What This Means • Respiratory Therapists are vital to the care of victims • Respiratory Care is unprepared • Respiratory Therapists have a responsibility to know how to treat these victims. • Preparation, Anticipation, Recognition, Action-Plan Issues Prof. Thomas J. Johnson

12. Clinical Case Delta • A TV station reports that a terrorist group claims to have attacked Coney Island with a bioagent. As a therapist at a Brooklyn hospital you have seen numerous patients with fever, headache, malaise, chest discomfort, non-productive cough, anorexia, and conjuntival and periorbital edema. • What diagnostic test should be performed? • What lab tests? • What bioagent do you suspect? Prof. Thomas J. Johnson

13. Inhalational Anthrax • Incubation period 1-6 days up to 45 days • Annual Occurrence: None • Human-to-Human Transmission: None known • Presentation: Fever, malaise, cough, mild chest discomfort; later dyspnea, diaphoresis, stridor, cyanosis, hypotension, hemorrhagic meningitis • DX: Mediastinal widening w/o infiltrates on CXR, Serology, Gram stain, PCR • TX: Standard precautions for HCW; doxycycline 200 mg IV initial then 100 mg IV Q12 hr. Prof. Thomas J. Johnson

14. Pulmonic Plague • Incubation Period: 2 - 3 days • Natural Occurrence: 2 or 3 cases annual • Droplet Precautions • Presentation: High fever, chills, hemoptysis, toxemia, shock, stridor, B/S crackles, ARF • DX: Gram stain, C&S, Immunoassay for capsulated antigen, PCR, Immunohistochemical stains (IHC) • TX: Streptomycin 30 mg/kg/day IM Prof. Thomas J. Johnson

15. Tularemia • Incubation Period: 1 - 10 days (avg. 3-5) • Natural Occurrence: 150 cases annual from animal sources • Human-to-Human Transmission: None known • Presentation: fever, headache, malaise, chest discomfort, productive/non-productive cough, anorexia and conjuntival and periorbital edema. • DX: CXR- mediastinal lymphoadenopathy, Serology(ELISA), C&S, PCR & IHC • TX: Standard precautions, Streptomycin or gentamycin Prof. Thomas J. Johnson

16. Smallpox • Incubation Period: 7 - 17 days • Natural Occurrence: None • Droplet & Airborne Precautions – 17 days • Presentation: Fever, backpain, vomiting, malaise, headache, rigors; papules (2-3 days) to pustular vessicles face and extremities. • DX: Giemsa or modified silver stain, PCR and viral isolation IHC • TX: Immediate vaccination and supportive care Prof. Thomas J. Johnson

17. Botulism • Incubation Period:1 - 5 days • Natural Occurrence: 30 cases annually • Human-to-Human Transmission: None known • Presentation: Ptosis, blurred vision, diplopia, malaise, dizziness, dysarthia, and disphonia • DX: Serology, toxin assays/ anaerobic cultures of blood or stool, EMG studies • TX: Antitoxin 1 vial (10 ml) IV Prof. Thomas J. Johnson

18. SEB: Staphyloccocal Enterotoxin B • SEB causes symptoms when inhaled in very low doses. • Standard Precautions • Latent period: Inhalation 3-12 hrs. • Presentation: non-specific flu, non-productive cough, retrosternal pain, dyspnea. • DX: Suspicion, ELISA, PCR; no CXR abnormalities • TX: Oxygen, hydration; CMV w PEEP, vasopressors and diuretics Prof. Thomas J. Johnson

19. Large # of people w/ similar disease/syndrome Large # of unexplained illnesses or deaths Unusual illness in population Higher morbidity / mortality Single case of uncommon agent Unusual/unexplained co-existing diseases in one pt. Epidemiologic Clues Prof. Thomas J. Johnson

20. Maintain an index of suspicion Protect thyself Assess thy patient Decontaminate PRN Establish a Diagnosis Render thy patient prompt treatment Practice good infection control Inform thy authorities Assist in Epidemiologic Investigation Maintain, Update thy proficiency & Spread the gospel. Medical Response to Bioterrorism Ten Commandments Prof. Thomas J. Johnson

21. Take Home Message • Educate your people! • Contact your local office of Emergency Preparedness • Work with your Emergency Medical and Nursing staff to develop an action-plan. • Conduct disaster drills on all shifts. Prof. Thomas J. Johnson