pup biologic warfare

L 11 Epidemics and Emerging Infections 1

Epidemics and Emerging Infections

Hospital Preparedness for Emergencies

Wars of the Future: Biological Warfare and Chemical

Weapons

Teodoro Herbosa MD FPCS Department of Emergency Medicine

College of Medicine University of the Philippines, Manila


Objective

Identify the fundamentals of a hospital preparedness and response plan for epidemics.

Upon completion of this unit, you will be able to:


Biological Hazards

❑ “Terrorism” / Anthrax ❑ SARS ❑ Avian Flu ❑ Dengue ❑ MERSCoV ❑ Ebola

Vulnerability emerging to infectious diseases


Biological Hazards

Tartars used plague-infected

corpses in Kaffa, 1346.


Influenza Pandemic

Nurses work in the Red Cross rooms of Seattle, WA with “influenza masks” on their faces. December 1918 (Courtesy of the National Archives, 165-WW-269B-10)


Basic Dictum

Safety First!


Biological Event

❑ Bacterial agents ▪ Anthrax, Brucellosis, Yersinea pestis

(Plague) & Cholera , Salmonella ❑ Viruses

▪ Smallpox, Hemorrhagic Fever Virus ❑ Biological product

▪ Botulinum toxin, Endotoxins, Mycotoxin, SEB, ricin,


Smallpox – Bangladesh, 1976

A child stricken by smallpox is relatively cured but his health is still threatened by malnutrition and secondary infection. (Courtesy of the National Archives, 76-845)


Biological Event

❑ Infection borne through air, food and water

❑ Incubation period - delay from time of exposure until clinical symptoms arise

❑ Extensive exposure may occur before the primary event is appreciated.


Rare Diseases can be Overseen

Rare color photo of Baby with smallpox. National Archive film footage from Vietnam (RG-428-NPC-38594)


Biological Event

❑ Delivered with conventional explosives

❑ Emergency care, decontamination is necessary (outside the hospital)

❑ Personnel must be trained in patient decontamination


Decontamination Area❑ Storage for decontamination equipment

and supplies ❑ Decontamination area - cooled to reduce

the heat load on personnel caused by their protective equipment

❑ The decontamination site has 3 zones: ▪ Hot zone – incoming casualties ▪ Warm zone – decontamination area ▪ Cold zone – triage and transport


Contamination reduction (warm) zone

Support (cold) zone

Exclusion (hot) zone

wind

CORRIDOR

amp

Access control points

Crowd control line

Decontamination line

Hot line


Decontamination Area

❑ First responders and medical personnel SHOULD PROTECT THEMSELVES

❑ Personal Protective Equipment (PPE) ▪ Protect eyes, lungs and skin



Storage for decontamination equipment and supplies Decontamination area

❑ cooled to reduce the heat load on personnel caused by their protective equipment


Hot zone

Support zone

Decontamination zone

Patients

No special protective gear

hazmat teams with proper protective gear

gross contaminates removed here

remove victim’s contaminated clothing

wash & final rinse/soap & shampoo

wash & rinse

clean stretcher & blankets



❑ First responders (decontamination) protect themselves through PPE.

❑ Personal Protective Equipment (PPE) respiratory equipment

❑ Garments and barrier material



❑ Maximum protection is achieved through use of positive pressure respirators and total body encapsulation.

❑ Surgical mask and a pair of latex gloves provide minimum protection


Personal Protective Equipment

Red Cross workers of Boston, MA removing bundles of masks for American Soldiers from a table where other women are busily engaged in making them. March 1919. (Courtesy of the National Archives, 165-WW-269B-37)


Medical Response

❑ Pandemic ▪ large number of

casualties with similar symptoms

▪ dissemination device ▪ receipt of a warning ▪ hospital may receive

untreated casualties directly from the site

Emergency Hospital at Brookline, MA to care for influenza cases.

October 1918


Medical Response

First responders and medical personnel SHOULD PROTECT THEMSELVES

September 11


Medical Response

Why is the level of Epidemic preparedness so critical?

❑ Because the consequences of not being prepared are so catastrophic

Smallpox Vaccine


Category A The public health systems and primary health-care providers must be prepared to address varied biological agents, including pathogens that are rarely seen. High-priority agents include organisms that pose a risk to national security because they –

❑ can be easily disseminated or transmitted person-to-person;

❑ cause high mortality, with potential for major public health impact;

❑ might cause public panic and social disruption; and

❑ require special action for public health preparedness.


Category A Agents Include:

❑ Variola major (Smallpox): ❑ Bacillus anthracis (Anthrax); ❑ Yersinia pestis (Plague); ❑ Clostridium botulinium toxin

(Botulism); ❑ Francisella tullarensis

(Tularemia);


Category A Agents Include:

❑ Filoviruses - Ebola Hemorrhagic Fever; - Marburg Hemorrhagic Fever; and

❑ Arenaviruses - Lassa (Lassa Fever)

- Junin (Argentine Hemorrhagic Fever) related viruses.


Category B

Second-highest priority agents: ❑ moderately easy to disseminate ❑ cause moderate morbidity and low

mortality ❑ require specific enhancements of CDC’s

diagnostic capacity and enhanced disease surveillance


Category B agents include:❑ Coxiella burnetti (Q fever) ❑ Brucella species (Brucellosis) ❑ Burkholderia mallei (Glanders) ❑ Alphaviruses

▪ Venezuelan encephalomyelitis ▪ Eastern and Western equine

encephalomyelitis ❑ Rich toxin from Ricinus communis (castor beans) ❑ Epsilon toxin of Clostridium perfringens ❑ Staphylococcus enterotoxin B


Category BA subset of List B agents include pathogens that are food or waterborne. These pathogens include, but are not limited to:

▪ Salmonella species ▪ Shigella dysenteriae ▪ Escherichia coli O157:H7 ▪ Vibrio cholerae ▪ Cryptosporidium parvum


Category C

Third-highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of:

❑ availability ❑ ease of production and dissemination ❑ potential for high morbidity and mortality

due to major health impacts


Category C agents include:

❑ Nipah virus ❑ Hantaviruses ❑ Tickbone hemorrhagic fever viruses ❑ Tickbone encephalitis viruses ❑ Yellow fever ❑ Multi-drug resistant tuberculosis


Category C

Preparedness for List C agents requires ongoing research to improve disease detection, diagnosis, treatment and prevention. Linking bio-terrorism preparedness efforts with ongoing disease surveillance and outbreak response activities as defined in CDC’s emerging infectious disease strategy is imperative.


❑ Cholera epidemic, Europe 1830 - 1847 intensive infectious disease diplomacy multilateral cooperation; First International Sanitary Conference, Paris 1851

❑ 1948 WHO Constitution ❑ 1951 WHO adopted International Sanitary

Regulations ❑ International Health Regulations, 1969

History of the IHR


IHR (1969) to monitor and control six serious infectious diseases: Cholera, Plague, Yellow fever, Smallpox, Relapsing fever and Typhus

IHR (1969) - Cholera, Plague and Yellow fever remain of concern WHO must be informed

History of the IHR


1990's resurgence of epidemics Cholera - South America Plague - India Emergence of infectious agents Ebola (48th World Health Assembly, 1995 revision of IHR, May 2001) WHA 54.14, Global health security: epidemic alert and response

History of the IHR


May 2003 resolution WHA56.28 Revision of IHR IGWG sessions in Nov 2004 and Feb/May 2005 58th World Health Assembly adopted IHR (2005) 23 May 2005 resolution WHA58.3.

History of the IHR


International Health Regulations of 2005, Article 5-1 Surveillance

Declaration of Policies

• urges Member States to develop, strengthen and maintain as soon as possible, but no later than five years from entry into force of these regulations, and the capacity to detect, assess, notify and report events in accordance with these regulations.

L 11 Epidemics and Emerging Infections 41DOH – CHD, REGIONAL EPIDEMIOLOGY and SURVEILLANCE UNIT (RESU)

Priority Diseases/Syndromes And Conditions Targeted For Surveillance

Category I (Immediately Notifiable) 1. Acute Flaccid Paralysis 2. Adverse Event Following Immunization (AEFI) 3. Anthrax 4. Human Avian Influenza 5. Measles 6. Meningococcal Disease 7. Neonatal Tetanus 8. Paralytic Shellfish Poisoning 9. Rabies 1.Severe Acute Respiratory Syndrome (SARS)

Category II (Weekly Notifiable) 1. Acute Bloody Diarrhea 2. Acute Encephalitis Syndrome 3. Acute Hemorrhagic Fever Syndrome 4. Acute Viral Hepatitis 5. Bacterial Meningitis 6. Cholera 7. Dengue 8. Diphtheria 9. Influenza-like Illness 10. Leptospirosis 11. Malaria 12. Non-neonatal Tetanus 13. Pertussis •Typhoid and Paratyphoid Fever


Medical Response

First responders must take care that they don't become

victims themselves.


Medical Response

A 1995 NBC exercise in New York City determined the first 100 emergency responders to arrive on scene 'killed'

❑ not adequately prepared or trained to deal with this incident

Los Angeles exercise ❑ doctors admitting that 'victims' have

seriously contaminated hospitals


Why is the level of epidemic preparedness so critical?

Because the consequences of not being prepared are so

catastrophic!

L 10 Complex Emergencies 45

Terrorism

❑ ‘War Within Borders’ ❑ Asia - a nesting place for terrorism and

lead member of the globe in terrorism ❑ Afghanistan ➔ Japan ❑ Vulnerability of non-involved population ❑ Unclear end-point for termination of

further, recurrent acts


Weapons of Mass Destruction (WMD)❑ In warfare for 2500 years ❑ Biological - Tartars used plague-infected

corpses in Kaffa in 1346. ❑ Modern warfare (1915) - Chlorine gas ❑ Nuclear bombs - Hiroshima and Nagasaki,

1945. ❑ Nerve and vesicant agents against Iran ❑ Cyanide against the Kurds


Nuclear Agents❑ Nuclear detonation through

conventional explosives ❑ Activation of Radioactive material ❑ Dissemination through

▪ Food ▪ Water ▪ Direct environmental spread


Injury Profile – Nuclear Agents❑ Thermal injury - burns ❑ Eye injuries - blindness due to blast

flash ❑ Ear injuries - deafness rupture of ear

drums ❑ Penetrating wounds/orthopedic

injuries/head injuries


Radiation Sickness

❑ Irradiation injuries do not make the patient radioactive!

❑ Decontamination before transport

❑ Removal of all clothing ❑ Tepid bathing of skin surface


Biological agents

❑ Infectious disease or toxin that can be used in bioterrorism or biological warfare

❑ Viruses, microorganisms (bacteria and fungi) and their associated toxins

❑ Can be delivered with conventional explosives, air, food and water


❑ Incubation period: delay in time of exposure until clinical symptoms

❑ Some are rapidly fatal ❑ Others are severely incapacitating ❑ Extensive exposure may occur

before the primary event is revealed

Biological Agents


Biological agents

❑ Bacteria - Anthrax, Brucellosis, Plague & Cholera

❑ Viruses - smallpox / hemorrhagic fever

❑ Biological products - Botulinum toxin, endotoxins, mycotoxin


Anthrax

❑


Plague

❑ Bubonic Plague – Enlarged Lymph nodes

❑“Black Death” – Peripheral

gangrene


Smallpox

❑


Chemical Agents

Chlorine gas dispersion during World War I


❑ About 70 chemicals are documented in history as WMD which include:

Chlorine, Phosgene, Cyanide

and Vesicants (‘Nitrogen Mustard’)

❑ Exposure may not be revealed until chemical injuries are recognized

❑ On-site decontamination

Chemical Agents


Nerve Gas (Sarin Gas Attack - Japan)

❑ Sarin - fluorinated phosphinate ❑ Similar to Insecticide - malathion ❑ Attacks the

nervous system


NBC incident – Characteristics

❑ Mass casualties with similar symptoms ❑ Dissemination device ❑ Receipt of warning ❑ Hospital may receive untreated casualties

direct from the site ❑ Rescue personnel could become victims

due to unavailability of information

Fill in the Blank


Hospital Preparedness for NBC Events

❑ Management system for mass NBC casualties

❑ HAZMAT suits and PPE for staff ❑ Education of staff and community

regarding local and regional risks ❑ Training in patient decontamination

Fill in the Blank


Decontamination Protocols

❑ Patients could arrive at hospital prior to decontamination

❑ Risk to health care professionals who would subsequently require decontamination.

❑ Designated Decontamination areas in the Hospital

Fill in the Blank


Review of Objectives As a result of this session, you should be able

to: ❑ Describe the characteristics and

challenges of Complex Disasters. ❑ Identify the salient features of NBC

incidents and the response required. ❑ Outline major health effects and hospital

preparedness for complex disasters.


Summary❑ Epidemics pose challenges for medical

personnel. ❑ Preparedness for an appropriate hospital

response activated is essential, while ensuring the safety of personnel.

❑ EMS may not provide the most effective and immediate medical response.

❑ Successful outcome of the medical care requires adequate preparedness.


Summary

❑ Planning, disciplined & coordinated behavior by personnel, mobilization ability, availability of medical resources, and communication are essential in effective care.

Continue…


Objectives

❑ Identify the fundamentals of a hospital preparedness and response plan for epidemics.

Upon completion of this unit you will be able to:


Exercise

❑ What resources does your hospital have which can be applied to a CBR incident?

❑ What training is required for EM personnel in order to mount a safe and effective hospital response to a CBR incident?

❑ With what other agencies should the hospital be conducting joint CBR exercises?


❑ With whom should the hospital coordinate regularly on CBR issues?

❑ Who should be represented on your hospital’s CBR functional preparedness committee?

Exercise

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