eric k. noji, m.d. specialized emergency preparedness: iraq health emergencies in large populations...

ERIC K. NOJI, M.D.ERIC K. NOJI, M.D.

Specialized Emergency Specialized Emergency Preparedness: IraqPreparedness: Iraq

Health Emergencies in Large Health Emergencies in Large Populations Populations

Baltimore, MarylandBaltimore, Maryland16 JUNE 200316 JUNE 2003

Health Response in Potential High Risk

CBRNE Environments

Chemical, Biological, Radiological,

Nuclear,Explosive (CBRNE) Preparedness

Personal Safety and Initial Response Training

• Limited prior experience in CBRNE type response in humanitarian operations, except for naturally occurring infectious disease outbreaks, for example – Cholera/Lassa fever/Ebola virus.

• Evacuation only strategy.

• Limited numbers of adequately trained staff, equipment, procedural knowledge.

NGO CBRNE Preparedness

HistoryHistory CBRNE Agents have been CBRNE Agents have been

used on unprotected civil used on unprotected civil populations on many populations on many occasionsoccasions

Some of the locations Some of the locations where the local population where the local population had no defense werehad no defense were• EthiopiaEthiopia• IraqIraq• AfghanistanAfghanistan• LaosLaos• JapanJapan

CDCCenters for Disease Control

and Prevention

Health Issues Related to the Health Issues Related to the CBRNE EnvironmentCBRNE Environment

• Chemical agentsChemical agents• Biological agentsBiological agents• Radiologic agentsRadiologic agents• Nuclear agentsNuclear agents• Explosives- High YieldExplosives- High Yield

CBRNE AgentsCBRNE AgentsConventional Conventional (Explosive)(Explosive)

ChemicalChemical Biological / Biological / RadoilogicRadoilogic

OnsetOnset InstantInstant RapidRapid Often DelayedOften Delayed

SourceSource ObviousObvious ObviousObvious Often covertOften covert

First Victim First Victim EncounterEncounter

PrehospitalPrehospital PrehospitalPrehospital HospitalHospital

ContainmentContainment EasyEasy Relatively EasyRelatively Easy DifficultDifficult

Decon HelpfulDecon Helpful Usually NotUsually Not YesYes Usually Not*Usually Not*

Biological AgentsBiological Agents• CDC/WHO list of high-likelihood potential bio-terrorist CDC/WHO list of high-likelihood potential bio-terrorist

agentsagents• Prioritized according to: Prioritized according to:

• Ease of disseminationEase of dissemination• TransmissibilityTransmissibility• MortalityMortality• Public health impactPublic health impact• Potential to cause fear and social disruptionPotential to cause fear and social disruption• Need for special preparednessNeed for special preparedness

Sources of Agents for Sources of Agents for Terrorism UseTerrorism Use

World Directory of Collections of World Directory of Collections of Cultures and MicroorganismsCultures and Microorganisms• 453 worldwide repositories in 67 nations453 worldwide repositories in 67 nations• 54 ship/sell anthrax54 ship/sell anthrax• 18 ship/sell plague18 ship/sell plague

International black-market sales International black-market sales associated with governmental associated with governmental programsprograms

Biological AgentsBiological Agents

Category ACategory A• SmallpoxSmallpox• AnthraxAnthrax• PlaguePlague• BotulismBotulism• TularemiaTularemia• Viral Hemorrhagic FeversViral Hemorrhagic Fevers

Ebola, Marburg, Lassa, Argentine HFEbola, Marburg, Lassa, Argentine HF

Category B:Category B: Q fever, Brucellosis, Glanders, VEE, EEV, Q fever, Brucellosis, Glanders, VEE, EEV,

WEV, Ricin, …WEV, Ricin, … Food & water-borne: Salmonella, Shigella, E. Food & water-borne: Salmonella, Shigella, E.

coli 0157:H7, …..coli 0157:H7, …..

Category C:Category C: Nipah virus, Hanta virus, Yellow fever, Nipah virus, Hanta virus, Yellow fever,

Tickborne viruses, ….Tickborne viruses, ….

DiagnosisDiagnosis

-Diagnosis difficult given diseases have been seen by few living clinicians

-Abnormal presentations of classical diseases may be present due to super infection

-Diagnosis critical for epidemiological monitoring

-Accurate data required for potential future prosecution of war crimes

-Psychogenic overlay may cloud the diagnostic process

Syndrome RecognitionSyndrome Recognition• Most bio-terrorist agents initially induce an Most bio-terrorist agents initially induce an

influenza-like prodrome, including fever, influenza-like prodrome, including fever, chills, myalgias, or malaisechills, myalgias, or malaise

• One of four syndromic patterns then follow:One of four syndromic patterns then follow: Rapidly progressive pneumoniaRapidly progressive pneumonia Fever with rashFever with rash Fever with altered mental statusFever with altered mental status Bloody diarrheaBloody diarrhea

Small Pox (Variola major virus)Small Pox (Variola major virus)

Transmitted primarily by aerosol Transmitted primarily by aerosol route, contaminated clothes & linensroute, contaminated clothes & linens

Highly communicableHighly communicable Vaccine can lessen the severity of Vaccine can lessen the severity of

disease if given within 4 days of disease if given within 4 days of exposureexposure

Epidemiological Pattern of Epidemiological Pattern of Smallpox WeaponSmallpox Weapon

New foci of secondary infection

“Contaminated” zone

“Infected” zone

Zone of initialexplosion

Small PoxSmall Pox

30% case fatality rate if untreated30% case fatality rate if untreated One of four biological agents thought One of four biological agents thought

to be most likely used by terroriststo be most likely used by terrorists Incubation 7-17 daysIncubation 7-17 days Prodrome of high fever, malaise, Prodrome of high fever, malaise,

vomiting, headache, myalgiasvomiting, headache, myalgias 2-3 days later get rash beginning on 2-3 days later get rash beginning on

face, hands, forearms face, hands, forearms

Small PoxSmall Pox

Patients infectious until all scabs are Patients infectious until all scabs are shedshed

No treatment, but animal studies No treatment, but animal studies show promise for cidofovirshow promise for cidofovir

Anthrax (bacillus Anthracis)Anthrax (bacillus Anthracis)

Inhalational, gastrointestinal, cutaneousInhalational, gastrointestinal, cutaneous NOTNOT communicable communicable (except maybe cutaneous)(except maybe cutaneous)

Vaccine not available for civilian useVaccine not available for civilian use 20%-80% mortality20%-80% mortality

Anthrax: InhalationalAnthrax: Inhalational

Inhalation of sporesInhalation of spores Incubation: 1 to 43 days Incubation: 1 to 43 days Initial symptoms (2-5 d) Initial symptoms (2-5 d)

• Fever, cough, myalgia, malaiseFever, cough, myalgia, malaise Terminal symptoms (1-2d )Terminal symptoms (1-2d )

• High fever, dyspnea, cyanosisHigh fever, dyspnea, cyanosis• Hemorrhagic Hemorrhagic

mediastinitis/effusionmediastinitis/effusion• Rapid progression shock/deathRapid progression shock/death

Mortality rate in 1957 ~ Mortality rate in 1957 ~ 100% despite Rx 100% despite Rx CDC

Varying Presentations of NYC Varying Presentations of NYC Cutaneous LesionsCutaneous Lesions

AnthraxAnthrax

Resistant to heat, UV, drying, many Resistant to heat, UV, drying, many disinfectantsdisinfectants

Incubation 2-6 daysIncubation 2-6 days Biphasic illness Biphasic illness

• nonspecific flu-like symptomsnonspecific flu-like symptoms• High fever, SOB, chest and abdominal High fever, SOB, chest and abdominal

painpain• Sore throat, runny noseSore throat, runny noseNOTNOT associated associated

AnthraxAnthrax

Treatment – multi-drug antibioticsTreatment – multi-drug antibiotics Prophylaxis – single drug for 60 daysProphylaxis – single drug for 60 days

BotulismBotulism

Illness caused by Illness caused by neurotoxinneurotoxin produced by Clostridium Botulinumproduced by Clostridium Botulinum

NOT due to infection by the bacteriaNOT due to infection by the bacteria NOT contagious, not treatable with NOT contagious, not treatable with

antibioticsantibiotics Can be ingested, Can be ingested, inhaledinhaled, acquired , acquired

through skinthrough skin

BotulismBotulism

Illness is the same regardless of how it is Illness is the same regardless of how it is acquiredacquired

Symptoms: onset hours to several days Symptoms: onset hours to several days after exposureafter exposure• Paralysis – descendingParalysis – descending• Blurry visionBlurry vision• Difficulty swallowing/speakingDifficulty swallowing/speaking• Dry or sore throatDry or sore throat• DizzinessDizziness• weakness weakness

BotulismBotulism

Signs:Signs:• Dilated pupilsDilated pupils• Sagging eye lidsSagging eye lids• Low blood pressureLow blood pressure• Eye muscle weaknessEye muscle weakness• Progressive muscle weakness Progressive muscle weakness

(descending)(descending)

Treatment - supportiveTreatment - supportive

Pneumonic PlaguePneumonic Plague

Caused by infection with Yersinia Caused by infection with Yersinia PestisPestis

Pneumonic form will occur after Pneumonic form will occur after intentional aerosol deliveryintentional aerosol delivery

Incubation period of 1-7 daysIncubation period of 1-7 days

Pneumonic PlaguePneumonic Plague

Symptoms:Symptoms:• Fever, malaise, fatigue, cough, SOBFever, malaise, fatigue, cough, SOB

Signs:Signs:• Classic finding of production of bloody Classic finding of production of bloody

sputum in a previously healthy patientsputum in a previously healthy patient

Treatment: AntibioticsTreatment: Antibiotics

Detection & surveillanceDetection & surveillance

Rapid laboratory diagnosisRapid laboratory diagnosis

Epidemiologic investigationsEpidemiologic investigations

Implementation of control Implementation of control measuresmeasures

Public Health ResponsePublic Health Responseto Bioterrorismto Bioterrorism

WHO GuidanceWHO GuidanceCNBRE Agents of WarCNBRE Agents of War

• Likely weaponized agents listed in a WHO Likely weaponized agents listed in a WHO publication:publication:

• 17 Biological agents17 Biological agents

• 16 Chemical agent16 Chemical agent

• Impossible to prepare for all inevitabilities Impossible to prepare for all inevitabilities but possible to prepare for likely eventsbut possible to prepare for likely events

Public heath response to biological and chemical weapons: WHO guidance, 2nd edition

Concrete Actions

Choices Facing NGOs

• Capability to to protect staff and to safely evacuate them.

• Capability to continue a level of service for those affected by the CBRNE event.

• Prevention capability to protect civilian populations from threats.

TrainingWhat do NGOs Need to Know?

• Range of threats in a particular theater,their treatments and all necessary protective measures

• Prophylactic immunization and pretreatment recommendations

• Sources of technical assistance

• Supplies/knowledge of operation of all relevant material and equipment

[Fit testing all various types of PPE]

• Humanitarian personnel may be pretreated

against likely agents and antidotes for chemical agents must be readily available

• Military/NGO cooperation required for preplanning/preparation/assessment of likely threats [maintaining neutrality at all cost]

• Consider utilization of UN/ Mil/ DOS/ OFDA DART teams to assist with risk assessment

• Impossible to provide mass prophylaxis of potential victims in the field prior to an event

Preplanning/Preplanning/CoordinationCoordination

Personal Protection Personal Protection EquipmentEquipment

What personal protective measures What personal protective measures are practical/ appropriate for your are practical/ appropriate for your organization in a given circumstance.organization in a given circumstance.

Relying on the principal of harm is Relying on the principal of harm is related to the amount in length of related to the amount in length of exposure.exposure.

How other organizations are How other organizations are responding.responding.

TypeType

QuantityQuantity

Whom to be issuedWhom to be issued

Spares and maintenance Spares and maintenance needsneeds

Import and transport issuesImport and transport issues

EquipmentEquipment

PPE ImprovisationPPE Improvisation

How to improvise given local How to improvise given local materials.materials.

Is there any use for primitive Is there any use for primitive respiratory protection (breathing respiratory protection (breathing through wet cloth)?through wet cloth)?

Overall Staff ProtectionOverall Staff Protection

Establishment of Establishment of safe rooms.safe rooms.

Usefulness of Usefulness of duct tape and duct tape and plastic.plastic.

Safety drillsSafety drills

Shelter in place Shelter in place proceduresprocedures

Initial Discovery ProceduresInitial Discovery Procedures

1. REMAIN CALM1. REMAIN CALM

2. If already at the scene, 2. If already at the scene, immediately retreatimmediately retreat to safe to safe location and put on PPE if availablelocation and put on PPE if available

Initial Discovery StageInitial Discovery Stage

To Maintain a safe location:To Maintain a safe location:

Stay upwindStay upwind

Stay uphillStay uphill

If there is a visible cloud, stay well If there is a visible cloud, stay well clear of it (Note: Most chemical and clear of it (Note: Most chemical and biological agents do not produce a biological agents do not produce a visible cloud)visible cloud)

Evacuation StrategiesEvacuation Strategies

How a CBRNE event may change your How a CBRNE event may change your organization strategy.organization strategy.

Majority of organizations reported plans Majority of organizations reported plans for immediate evacuation of personnel at for immediate evacuation of personnel at risk.risk.

Complicating factors:Complicating factors:• Possible quarantine preventing evacuationPossible quarantine preventing evacuation• Evacuation routes contaminatedEvacuation routes contaminated• Exposed victims traveling into areas Exposed victims traveling into areas

considered safe considered safe

DecontaminationDecontamination

What appropriate What appropriate techniques using techniques using available personnel available personnel and materiel.and materiel.

How much water is How much water is required?required?

Can sand be used?Can sand be used?

How about clothing?How about clothing?

DPT 7.0

LAYOUT OF A TYPICAL CASUALTY RECEIVING STATIONDECONTAMINATION

AmbulatoryDecon

DirtyDisposition

LitterDecon

EMTStation

Dirty Clean Evacuate (Clean)

ArrivalPoint

TriageStations

CleanTreatment

CleanDisposition

Arrival Triage/EMTDecon-

tamination Clean Treatment

When is a Safe to When is a Safe to Return?Return?

Who is responsible to Who is responsible to conduct assessments?conduct assessments?

Where can one obtain Where can one obtain assessment assessment information (HIC-information (HIC-Health Information Health Information Center/web site/etc.)?Center/web site/etc.)?

What level of residual What level of residual contamination is contamination is acceptable?acceptable?

Treatment Treatment • Protocols/operational guidelines must be Protocols/operational guidelines must be

established which are available to all established which are available to all individuals and organizations involved in a individuals and organizations involved in a given operation.given operation.

• Experts must be available to guide Experts must be available to guide operations in a potentially rapidly changing operations in a potentially rapidly changing environment.environment.

• USG/ NGO specially trained decontamination USG/ NGO specially trained decontamination teams should be utilized [if available]teams should be utilized [if available]

• Information must be shared in a Information must be shared in a

rapid and reliable fashion [Civil/Military/UN]rapid and reliable fashion [Civil/Military/UN]

Response in the field to biological Response in the field to biological weapon exposureweapon exposure

Need to make decisions rapidly in Need to make decisions rapidly in the absence of datathe absence of data

Access to subject matter experts Access to subject matter experts will be limitedwill be limited

No “textbook” experience to guide No “textbook” experience to guide response response

Need coherent, rapid process Need coherent, rapid process for addressing staff and civilian for addressing staff and civilian safety in midst of crisissafety in midst of crisis

The Immediate Future The Immediate Future 2003 – 20102003 – 2010

A Revolution in A Revolution in biotechnology, genomics biotechnology, genomics and proteomics that will and proteomics that will affect all human beingsaffect all human beings

Resource MaterialResource Material Hope For The Best, Prepare For The Worst: How humanitarian organizations can Hope For The Best, Prepare For The Worst: How humanitarian organizations can

organize to respond to weapons of mass destructionorganize to respond to weapons of mass destruction www.merlin.org.ukwww.merlin.org.uk and and www.lshtm.ac.uk/hpu/docs/wmd.pdfwww.lshtm.ac.uk/hpu/docs/wmd.pdf

• Public heath response to biological and chemical weapons: WHO guidance, 2nd edition www.who.org

Iraq’s Weapons of Mass Destruction: A Net AssessmentIraq’s Weapons of Mass Destruction: A Net Assessment , , International Institute for International Institute for Strategic Studies (IISS), London 2002 Strategic Studies (IISS), London 2002 https://www.iiss.org/confStatement.php?confID=3https://www.iiss.org/confStatement.php?confID=3

Iraq’s Iraq’s WeaponsWeapons of Mass Destruction: The Assessment of the British of Mass Destruction: The Assessment of the British GovernmentGovernment, The Stationery Office, London 2002 , The Stationery Office, London 2002

Resouce Material contResouce Material cont

Terrorism and other Manmade Disasters Web Terrorism and other Manmade Disasters Web based trainingbased training

www.UNDMTP.orgwww.UNDMTP.org US Centers for Disease Control US Centers for Disease Control

www.cdc.govwww.cdc.gov Chemtrac Chemtrac www.chemtrac.comwww.chemtrac.com Agency for Toxic Substances and Disease Registry Agency for Toxic Substances and Disease Registry

ATSDRATSDR

U.S. Department of U.S. Department of Health and Human Health and Human

ServicesServices

Eric K. Noji, M.D., M.P.H.Special Assistant to the US Surgeon General for Disaster Medicine,US Public Health ServicePhone: 202-690-5707 Fax: 202-690-6985Email: Enoji@cdc.gov

For Questions Contact:

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