2015 National Disaster Life Support Foundation, Inc. All

 2015 National Disaster Life Support Foundation, Inc. All

2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Session 4 Lesson Eight Biologic Disasters 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Objectives Describe six key factors that compose the chain of infection Identify clinical and epidemiologic clues suggestive of a biologic disaster Discuss actions that can be taken to protect the health, safety, and

security of responders and affected populations in a biologic disaster Describe essential infection control strategies to prevent the spread of biologic agents Discuss appropriate clinical management guidance for CDC category A biologic agents 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Background 2015 National Disaster Life Support Foundation, Inc. All rights reserved. Infectious diseases are a threat to everyone

Rising global concern about epidemics/pandemics, emerging infections, bioterrorism Public health and medical professionals are at the front lines of detection, diagnosis, treatment, and response BDLS v.3.2 Key Terms Emerging infection Newly recognized, new population, new virulence or resistance Epidemic An illness in higher than

expected numbers Pandemic Epidemic across large geographic region A disease outbreak in one country = A CONCERN FOR ALL 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Infectious agent Chain of Infection Susceptible host Reservoirs Portal of entry

Portal of exit Mode of transmission 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Bioterrorism/Biowarfare Both involve use of a biologic agent or product to cause harm A matter of scale Difficult to detect research, production, transportation of BT agents A criminal act that requires Public Health + Law Enforcement/military 2015 National Disaster Life Support Foundation, Inc. All rights reserved.

BDLS v.3.2 CDC Categories A 2015 National Disaster Life Support Foundation, Inc. All rights reserved. B C BDLS v.3.2 Detection Situational Awareness The first to detect a biologic event incident will be a healthcare provider (primary care, school nurse, prehospital personnel, etc.) who: Has a high index of suspicion Notes something unusual happening

Seeks the answer 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Detection Situational Awareness EMS Multiple calls in same area, same complaints Primary Care Provider Unusual patterns of disease, increased numbers of patients with unusual disease, disease affecting different ages or healthy patients Public Health Patterns at multiple facilities, atypical season for event

Medical Examiner Rapid rise in mortality rate 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Epidemiologic Clues Increase in number of unexplained deaths Atypical age distribution Unusual seasonality Uncommon manifestation of disease or new cluster of

symptoms 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Detection Bioterrorism Agents Victims initially may present with subtle symptoms or those resembling normal disease, such as flu-like symptoms Few tests available for quick diagnosis 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Symptom / Finding Potential BT Disease

Differential Diagnoses Chest x-ray with wide mediastinum Anthrax Trauma, cancer, postoperative Symmetric/flaccid paralysis Botulism Guillain-Barre syndrome Hemoptysis Pneumonic plague, inhalational anthrax TB, pneumonia, carcinoma, PE, cancer, trauma Pox-like rash

Smallpox Chickenpox, monkeypox, cowpox Diarrhea (maybe bloody) Cholera, shigellosis Multiple diseases 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Incident Management Public Health Notification Likely no scene as in other events but more diffuse Lead agency will be public health

Conduct epidemiologic investigation Identify those who need prophylaxis, treatment, and quarantine Public health authorities MUST be alerted as soon as any biologic event is suspected (emerging infection, unusual disease incident or patterns, or bioterrorism) 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Safety and Security Infection Control With all biologic events, cornerstone of management and limitation of effects is infection control

Even bioterrorism agents can be prevented and controlled by basic infection control Precautions based on mode of transmission If unsure, wear most protective gear Consult infectious disease specialist 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Assess the Hazard Preventing Disease Spread Medical Public Health Infection control

Immunizations Sheltering in place Chemoprophylaxis Social distancing Infection control Risk communication Isolation/quarantine 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Triage and Treatment Bioterrorism Threats Scott Smith/CDC Scott Smith/CDC 2015 National Disaster Life Support Foundation, Inc. All rights reserved.

BDLS v.3.2 Smallpox Severe prodrome Fever, body aches Prostration, delirium Rash: 2-3 days later Palms, soles, face

Crops of vesicles All in same stage Michael Schwartz/CDC Very contagious Differentiate: monkeypox, chickenpox 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Smallpox Diagnosis: clinical Treatment: vaccination

(if <3 days) Special tests at CDC and some state labs James Gathany/CDC Supportive care, +/- antivirals Airborne and contact precautions Negative-pressure room 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Anthrax

Inhalational: Flu-like symptoms, SOB, CP Evolves to severe respiratory distress, shock High fatality rate Cutaneous: small itchy bumps turn into deep black ulcers, swollen lymph nodes Can be natural or bioterrorism 2015 National Disaster Life Support Foundation, Inc. All rights reserved. James Steele/CDC James Steele/CDC BDLS v.3.2

Anthrax Diagnosis: clinical CXR: wide mediastinum, effusions, infiltrates Blood/sputum cultures Early antibiotics for treatment and prophylaxis Standard PPE Arthur Kaye/CDC

No person-to-person spread 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Pneumonic Plague High potential for use as bioweapon Easy to grow and aerosolize Person-to-person spread, high mortality rate Abrupt onset of flu-like

symptoms Brachman/CDC Progresses to severe pneumonia, sepsis 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Pneumonic Plague Clinical diagnosis CXR: patchy infiltrates Blood/sputum cultures

Early antibiotics for treatment/prophylaxis Highly contagious Droplet precautions Bettmann/Corbis 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Botulism Gradual onset of symptoms Facial paralysis

Difficulty speaking and swallowing Blurry vision Progresses to muscle weakness, diaphragm paralysis 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Botulism Diagnosis: clinical Must stay on ventilator until toxin wears off

Weeks to months Antitoxin available Confirmed by toxin assay Limited supply for episodic single cases Standard PPE Not contagious 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Tularemia

High potential to be weaponized Symptoms: acute febrile illness Prostration Conjunctivitis Likely attack via aerosol Lymph node swelling Brachman/CDC With/without pneumonia

2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Tularemia Diagnosis: CLINICAL Gram stain, cultures, antibody tests 80% CXR with pneumonia Treatment/prophylaxis with antibiotics Standard PPE

Not contagious 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Viral Hemorrhagic Fevers Examples: Ebola, Marburg, Lassa, Omsk Potential to be weaponized Fatality rate has been up to 90% Symptoms depend on virus

Flu-like symptoms, rash, joint pains, vomiting, diarrhea Bleeding from everywhere, shock 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Viral Hemorrhagic Fevers Diagnosis: clinical Multiple tests available depending on stage Presume VHF if: Severely ill, fever + bleeding from 2 sites

High index of suspicion with travel to area with outbreak or close contact Treatment: supportive No prophylaxis Extremely contagious Lyle Conrad/CDC 2015 National Disaster Life Support Foundation, Inc. All rights reserved. Blood and body fluids

PPE more than universal precautions BDLS v.3.2 Triage and Treatment Summary Recognition is key any pattern outside norm Different ages, severity, populations, symptoms, etc Early on, most have flulike symptoms Diagnosis clinical requires high index of suspicion

Largely supportive treatment, some respond to antibiotics or vaccines Responder safety and infection control paramount 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Issues to Consider Vaccination, Chemoprophylaxis, and Treatment Medications How many doses are available? How easy is it to mass vaccinate?

Can you accomplish vaccination in time? Provider safety/infection control Do you have enough PPE for multiple patients? Is PPE worn 100% of the time? How will you ensure compliance with prophylaxis? 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Evacuation and Recovery Evacuation Issues with moving

patients and protecting transporting staff Issues with using public transportation to seek medical care Issues with identifying receiving facilities capable and willing to accept patients 2015 National Disaster Life Support Foundation, Inc. All rights reserved. Recovery Stop the reemergence of disease Address stigma for both survivors and treatment facilities Healthcare can be hardest hit sector for casualties BDLS v.3.2 Lesson Summary

Biologic disasters require observation for both clinical and epidemiologic clues There is increasing global concern about the possibility of bioterrorism Medical and public health professionals play a key role in preparedness, early identification, and intervention 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Questions? 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2

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