Bioterrorism Roles of State Level Public Health Bioterrorism
Bioterrorism: Roles of State Level Public Health
Bioterrorism vs. Other Disasters w Natural Disasters: Public Health (Health and Medical ) is supportive w Bioterrorism: Public Health Leads with Law Enforcement
Role of Texas Department of Health in Bioterrorism w Epidemic Detection and Investigation w Communication with local, state, & federal health partners w Activation and implementation of the State Emergency Response Plan
Epidemic Detection and Investigation w Early detection, recognition and reporting of disease cases w Rapid laboratory identification of responsible organism w Coordinated response to control the outbreak and prevent transmission
Rapid Laboratory Diagnosis w Rapid identification saves lives. w Appropriate modern technology w Appropriate staffing with 24/7 back-up
Coordinated Response to Control and Prevent w Recommend medical treatment protocols and outbreak control to local physicians and hospitals, including quarantine measures where appropriate w Divert needed antibiotics currently available in the state to areas of the epidemic w Request additional pharmaceuticals through the CDC
External Communications w Communicate with local, state and federal health partners using Health Alert Network. w Notify federal, state and local elected officials of the outbreak including TDH investigative and control activities. w Inform the general public.
Health Alert Network (HAN) w Connecting health partners to TDH and CDC for rapid communication of crucial epidemic and treatment information. w Information is sent to alert local authorities via FAX, email, and pager w Local authorities can communicate back to TDH, CDC, or their local or regional “hub” by the same means
Leadership Role in State Emergency Response Plan w TDH participates in the State Emergency Operations Center w TDH is the lead agency in implementation of the Health and Medical Services Annex H of the State Emergency Management Plan
State Emergency Management w State health department response is integrated within the State Emergency Response w At the first suggestion of an epidemiologically unusual event, EM and law enforcement are informed w Resources of state are coordinated and made available and links to federal assets opened.
Public Health Leads in Bioterrorism w State Health Dept assists local health agency. w Initial detection of illness or identification of microbial threat are core public health functions w Epidemiologic determination of possible exposure means, locations.
Public Health Leads in Bioterrorism w Takes or recommends appropriate control measures and monitors impact w Provides medical/health information for medical care w Provides public information regarding scope of outbreak and actions for public
Public Health Leads in Bioterrorism w Coordinates federal health assets including National Pharmaceutical Stockpile w Advises on cleanup and disposition of the deceased
Public Health in Response Planning w Response is a local responsibility w State and federal assets are to Assist w Coordinate with law enforcement through emergency management w Epidemiologic investigation in tandem with criminal investigation
Emergency Response
Hierarchy w Institution Response w Local Response w County Response w State Response w National Response
Resources w APIC Bioterrorism Readiness Plan: A Template for Healthcare Facilities w Disaster Preparedness Planning and Response in Texas Hospitals w Texas Department of Health w Centers for Disease Control and Prevention (CDC)
Hospital’s Role w Integrate different emergency planning efforts to assure a coordinated response w Identify and prepare for their role in an emergency response to a biological event
Recognition w A rapid increase in the number of previously healthy persons with similar symptoms seeking medical treatment w Cluster of previously healthy persons with similar symptoms who live, work, or recreate in the a common geographical area w Unusual clinical presentation
Hospital Preparedness and Response w Mitigation w Preparedness w Response w Recovery
Federal Response w Department of Health and Human Services (HHS) w Office of Emergency Preparedness (OEP) w Federal Emergency Management Agency (FEMA) w Department of Justice (Do. J) w Department of Defense (Do. D)
Federal Response w Centers for Disease Control and Prevention (CDC) w Food and Drug Administration (FDA) w National Institutes of Health (NIH) w Federal Bureau of Investigation (FBI)
Federal Response w FBI is the lead federal agency for coordinating the federal response to a terrorist incident or threat w FEMA is lead agency in consequence management w CDC has established the Strategic Pharmaceutical Stockpile (NPS)
Texas Department of Health Role (TDH) w TDH is the lead state agency for the public health response to a bioterrorist incident or threat w Primary objective is to determine the etiology and source of the outbreak and identify the most effective and efficient interventions to protect public safety
Local Health Department Role w Lead role in early detection and identification of a bioterrorist event w County plans w ICP's need to participate in the planning process along with safety officers and epidemiologists for local response
Role of Infection Control Practitioner w Significant ! w Rapid identification of an outbreak of community-acquired infection w Notification of local health department w Day-to-day surveillance activities
Surveillance w Critical Care Units w Emergency Room w Ambulatory Clinics w Develop syndrome monitoring system for departments most likely to be first affected by a bioterrorism event
IC Considerations w Epidemiology, Diagnosis and Treatment w Hospital Emergency Management Plan w Local Health Department response w Prepared to take a leadership role in the hospital’s response to the outbreak w Trained professional should be available in the event the ICP is unavailable
References and Further Assistance w Local Public Health Service/State Health Department w Centers for Disease Control w Local FBI Representatives
Web Sites w CDC Bioterrorism www. bt. cdc. gov w Association for Infection Control Professionals and Epidemiologists (APIC) www. apic. org/bioterror/ w For management of Biologic Casualties www. usarmiid. army. mil/education/bluebook. ht ml
Scenario Ø From Aug 29 -Sept 1, five 18 yr old females & two males were seen in Hospital A’s emergency dept with diarrhea & abdominal cramping; stool specimens are taken. Three were admitted.
Scenario Ø Hospital A’s Micro Lab Supv. calls ICP on Sept 1 to report two stool specimens from Aug. 30 are positive for E. coli 0157: H 7; one is negative & four are pending. Ø ICP notifies the treating physician and confers with the local health dept. epidemiologist.
Scenario Ø Hospital B is contacted by local health dept. and reports no cases. Ø Sept. 2 ICP-A interviews 3 hospitalized pts. discovering all are college freshman and informs local health dept. Ø County Medical Director calls college Health Services MD and regional/state/national health dept.
Scenario Ø College Health Services MD confirms three cases treated at infirmary among freshman within last 24 hrs. Ø County Environmental Health Director is notified by County Medical Director. Ø Sept 3 Hospital-A admits another 19 yr old college freshman with bloody diarrhea.
Scenario Ø Sept 4 County Medical Director calls meeting to coordinate information among: Ø College Health Services MD Ø Hospital (A & B) ICPs Ø County Environmental Health Director Ø Local/regional/state TDH epidemiologists Ø CDC representative
Scenario Ø Outbreak investigation is initiated. Ø Flyers are distributed on campus requesting all students to report GI illnesses to 1 -800 SICK Ø E. coli 0157 questionnaire is completed for each suspected or confirmed case. Ø Local media is briefed via the college health services representative.
Scenario Ø CDC reps reviewed all admissions/ED visits for case definition from 8/15 -9/15 at hospitals A & B Ø cases were limited to an on-campus event freshman “Howdy Week” picnic on Aug 27 Ø Total of 27 students had food-borne illnesses; 10 were confirmed as E. coli 0157: H 7 Ø All responded to treatment.
Mental Health Issues and Interventions in Terrorism
What is Terrorism? w The unlawful use of force or violence against persons or property
Terrorism w Terrorism is a unique cause of a crisis used to create a condition of fear and uncertainty, demoralization, and helplessness as a coercive force
Terrorism Overview w Used to support w political, religious, or ideological goals w The threat of the crime can be as devastating as the commission of the act w Kill one, frighten thousands Recent Terrorism – 1993 World Trade Center – 1995 OKC Federal Building – 911 World Trade Center
Mental Health Facts w 10 -35% suffer significant posttraumatic stress after a disaster w Over 50% of disaster workers in the 9/11 WTC can be expected to develop post traumatic stress w The “worried well” – Tokyo Sarin incident – 12 dead – 900 hospitalized – Up to 9000 worried – A 10: 1 ratio of the “Worried Well”
Mental Health Facts w Mental Health Aspects of a mass casualty event may well be the most widespread, long lasting, and expensive consequences – Warwick, 2001
Initial Crisis Intervention Phase 1 -Assembly w Set up a command center and respite center in a safe locationschools/ballrooms/churches w Involve hospital risk management, Medical Director of Infection Control and public relations to communicate with media
Initial Crisis Intervention Phase 1 -Assembly w Have mental health professionals, EMS workers/Disaster relief team, Clergy, Social workers present as appropriate w Non-threatening fact finding information(who, what, where, when, how) w Acknowledge the significant impact of the event
Initial Crisis Intervention Phase 1 -Assembly w Communication Methods w Phase 1 -”Assembly” – – – Mass Media-TV, radio Mouth to mouth Internet Emergency Service Vehicles Handbills “Town” Meeting
Initial Crisis Intervention Phase 2 - the Facts w Who should communicate? – Most appropriate – Most credible – Most prepared • Explain facts known • What is known, what is not known-control rumors, informs, reduce anxiety, and return sense of control
Initial Crisis Intervention Phase 2 – the Facts w Facts – What is known about disease and health effects – Precautions to be taken – Treatments that are available – What is being done to prevent spread of disease – Discuss expected outcomes as known to date
Initial Crisis Intervention Phase 3 w Discuss common signs and symptoms of Stress Management w Discuss typical reactions to terrorism w Discuss signs and symptoms of: – grief - anger – stress - survivor guilt – responsibility guilt
Initial Crisis Intervention Phase 4 Discuss Management Techniques w Personal coping strategies w Self Care strategies w Community Resources w Organizational Resources w Hand out sheets with names and numbers of resources
Therapeutic Conversation as an Initial Crisis Intervention w Thoughts – – What were their thoughts at the time? Help to facilitate an understanding of their experience How can I help you cope? Comfort? What do you think will help? w Reactions – Support and encourage feelings without probing – Emphasis that reactions are a result of the event and not personal weakness
Therapeutic Conversation as an Initial Crisis Intervention w Encouragement – Effective coping and self care-identify immediate needs – Education-handouts of common mental health reactions to similar events – Use of existing resources (social, religious, physical) – Referrals-agencies in your community – Achieving closure
What is a disaster? w Severe/large magnitude w Immediate, coordinated response by government or private sector
Types of Disasters w Natural – Earthquake, floods w Human source – Explosions, fires w Health-related – Accident, catastrophic illness w Social – Hostage, riots
Psychological Impact w Human made disasters are more pathogenic than natural disasters w Terrorism may be the worst-due to the unpredictable, unrestrained nature
Risk Factors w Death w Home destruction/loss w Property Loss w Injury to family/friends w Children involved/hurt/killed w Intentional Cause w Other stressors in life
Risk Factors w Worry about safety of loved one w Familiarity of victims w Other major trauma in past year w Level of personal preparedness w Amount of social support w Access to Resources w Self-Expectations
Phases of Disaster w Threat/Warning w Impact of actual disaster w Heroic w Afterward-honeymoon period w Disillusionment w Reconstruction
Phases of Disaster w. The phases of recovery do not always follow a logical or linear order
Disaster Psychology w Survivors often reject disaster assistance w People may not see themselves as needing help w Stress and grief normal responses w Design the relief efforts for the community needs w Interventions must be appropriate to the phase of the disaster
Types of Terrorism Weapons w Chemical agents such as nerve gas w Blistering agents w Blood agents such as cyanide w Chemical agents such as tear gas w Easy to use and make w More stable than biological w Easier to control w Not contagious w Inexpensive
Types of Terrorism Weapons w Biological Weapons – Viruses such as Smallpox, Ebola, – Encephalitis – Bacterial such as anthrax, botulism, plague – Fungi – Toxins of microbes -ricin, aflatoxin, – botulinum, Staph enterotoxin B
Biological Weapons w Cheap, easily hidden w Weaponized by aerosol, food, water, blood, vectors w Can be very toxic w Short window for intervention w Demoralizing effects
Biological Weapons w Incubation period may allow for widespread distribution w Many unfamiliar to physicians w High psychological impact
Fear of Biological Weapons w Fear of illness and death w Vaccination/Treatment issues w Fear of death and/or disfigurement w Fear of contagion w Emerging diseases-increased level of outbreaks and media coverage of same
Why is Terrorism so Psychologically Damaging? w Unknown type of event w Agents cannot be seen/identified w Lack of protection/fear of contamination or contagion w Lack of warning w Suddenness of events w Serious threat to life
Why is Terrorism so Psychologically Damaging? w Wide scope of destruction/causalities w Intentional w Gruesome situations w High emotional impact/uncertainty w Lack of personal control w Possible long term health problems w Disruption of social systems
Attitude and Reality w Impossible to defend against w Disastrous outcome w High death rate /casualty w Terror! w But defense may be possible, can limit casualties, mortality can be minimized w BE PREPARED, NOT SCARED
Preparation w Proactive – Plan and train – Post-incident management and care
Vaccines
Vaccines for common BT events w Smallpox vaccine for smallpox w Program to vaccinate front line health care workers and public health officials – ACIP-unwise to expand program due to unanticipated health and safety concerns such as myo/pericariditis and unknown long-term sequelae
Smallpox Vaccine w Indicated for people investigating monkey pox/smallpox cases-(pre-vaccination is preferred) w HCW caring for patients up to 14 days postexposure w Contacts of patients-3 hrs/6. 5 feet w Lab workers/cultures
Smallpox Vaccine w Vaccine manufacturer-Wyeth Labs. Dry-vax w Made from vaccinia or cowpox virus in calf lymph w Antibody level less than 5 years w Waning immunity after 10 years
Smallpox Vaccine: Complications of vaccination w Mild – – – Inadvertent inoculation to other sites such as face, eyelid, nose, mouth, genitalia, rectum Erythematous/urticarial rash Stevens-Johnson's syndrome
Smallpox Vaccine: Complications of vaccination w Moderate-severe – Eczema vaccinatum – Generalized vaccinia – Progressive vaccinia
Smallpox Vaccine: Complications of vaccination w Severe – Post vaccinial encephalitis – Vaccinial keratitis
Smallpox Vaccine: Complications of vaccination w Rates – – – 42. 1 cases/million auto inoculation Generalized vaccinia 9. 0 Eczema vaccinatum 3. 0 Progressive vaccinia 3. 0 Post vaccinial encephalitis 2. 0
Smallpox Vaccine w Contraindications – History /presence of eczema in person/family member – Other chronic or acute skin conditions – Immunosuppression – Pregnancy/breastfeeding – Less than 1 year old – Vaccine component allergy
Smallpox Vaccine Administration Post Event w Persons exposed to initial release of virus w Any person who had face-to-face contact or household contact, with a confirmed or suspected smallpox patient at any time until scabs have separated w Lab personnel who process such specimens and persons exposed to infectious medical waste
Anthrax Vaccine (AVA) w Vaccination – 3 subcutaneous injections at 0, 2, 4 weeks – 3 booster vaccinations at 6, 12, 18 months – Annual booster thereafter w Contraindications-any previous anaphylactic reaction from AVA or any of the vaccine componenets
Anthrax Vaccine (AVA) w Immune response – 83% after first dose – 95% after 3 doses – In one clinical trial of millworkers it was 92. 5% effective based on person time of occupational exposure
Anthrax Vaccine (AVA) w Adverse Reactions – Frequent local/mild reactions-severe induration greater than 120 mm, edema, pain, pruritis in 3% – Other mild reactions in 20% – Systemic reactions such as fever, chills, body aches, nausea in 0. 06 % – 1544 reports of adverse events in 1, 859, 000 doses 5% were serious – Death - no causation confirmed in 2 deaths
Anthrax Vaccine(AVA) w Other Serious Adverse Effects(<10%) – – – Cellulitis Pneumonia Guillain-Barre Seizures Cardiomyopathy Sysytemic Lupus
APIC http: //www. apic. org/elearn/BTReadi 2. pdf TDH http: //www. tdh. state. tx. us/bioterrorism/ IDSA http: //www. idsociety. org/BT/To. C. htm CDC http: //www. cdc. gov/ http: //www. bt. cdc. gov/agent/smallpox/response-plan/index. asp http: //www. bt. cdc. gov/agent/agentlist-category. asp State of California http: //www. dhs. ca. gov/lnc/download/btr. pdf US Army Medical Research Institute http: //www. usamriid. army. mil/education/bluebook. html Johns Hopkins University http: //www. jhu. edu/ http: //www. hopkins-biodefense. org/ St. Louis University School of Public Health http: //www. slu. edu/colleges/sph/slusph/Default. htm
- Slides: 86