Preparing for and Responding to Bioterrorism Information for

Preparing for and Responding to Bioterrorism: Information for Primary Care Clinicians Northwest Center for Public Health Practice University of Washington School of Public Health and Community Medicine, July 2002

Acknowledgements This presentation, and the accompanying instructor’s manual (current as of 7/02), were prepared by Jennifer Brennan Braden, MD, MPH, at the Northwest Center for Public Health Practice in Seattle, WA, and Jeff Duchin, MD with Public Health – Seattle & King County and the Division of Allergy & Infectious Diseases, University of WA, for the purpose of educating primary care clinicians in relevant aspects of bioterrorism preparedness and response. Instructors are encouraged to freely use all or portions of the material for its intended purpose. The following people and organizations provided information and/or support in the development of this curriculum. A complete list of resources can be found in the accompanying instructor’s guide. Patrick O’Carroll, MD, MPH The Centers for Disease Control and Prevention Project Coordinator Judith Yarrow Health Policy & Analysis, University of WA Design and Editing UW Northwest Center for Public Health Practice Jane Koehler, DVM, MPH Communicable Disease Control, Epidemiology and Immunization section, Public Health - Seattle & King County Ed Walker, MD; University of WA Department of Psychiatry

Bioterrorism Preparedness and Response CDC UW Northwest Center for Public Health Practice

Bioterrorism Preparedness & Response Learning Objectives n Be familiar with: n The role of the clinician in bioterrorism preparedness and response n The roles of local and national agencies involved in bioterrorism preparedness and response UW Northwest Center for Public Health Practice

Bioterrorism Preparedness & Response Learning Objectives n Be familiar with: n The purpose and functions of the Health Alert Network (HAN) and the National Pharmaceutical Stockpile (NPS) n How to contact the appropriate local agency to report potential bioterrorism or other public health concerns UW Northwest Center for Public Health Practice

Bioterrorism Preparedness & Response Crisis & Consequence Management n Crisis management: law enforcement response to terrorist acts n n Local, state, federal law-enforcement agencies Consequence management: response to the disaster focusing on the alleviation of damage, loss, hardship, or suffering Public health, medical, & emergency mgt personnel n Falls under ESF-8 (public health) of Federal Disaster Response Plan n PDD-39 UW Northwest Center for Public Health Practice This link will take you away from the educational site

National Responders n n n n Health and Human Services (HHS) Centers for Disease Control and Prevention (CDC) Federal Emergency Management Agency (FEMA) FBI Environmental Protection Agency (EPA) Department of Agriculture Department of Defense

State and Local Responders n n n Health care providers & facilities Local and state health departments Emergency management agencies Search & Rescue, EMS, & HAZMAT teams Volunteers n n Law enforcement, National Guard State emergency management agency Political leaders Community service organizations

National Preparedness 1999 Initiative n National Bioterrorism Preparedness and Response Initiative n 1999 DHHS Initiative to prepare the nation to respond to potential BT activity n CDC designated lead in upgrading nation’s public health capacity and in developing a BT preparedness & response plan More on 1999 Initiative. . . UW Northwest Center for Public Health Practice This link will take you away from the educational site

National Preparedness CDC Activities n CDC bioterrorism preparedness & response activities n Preparedness and prevention n Detection and surveillance n Diagnosis and characterization of biological and chemical agents n Response More on CDC program. . . UW Northwest Center for Public Health Practice This link will take you away from the educational site

National Preparedness CDC Activities, cont. n CDC bioterrorism preparedness & response activities n Education and training n Improved communication systems – HAN, LRN n National Pharmaceutical Stockpile UW Northwest Center for Public Health Practice

National Preparedness Other DHHS activities n Medical Consequence Management: HHS Office of Emergency Preparedness (OEP), expanding efforts to develop medical response capabilities at local and national levels UW Northwest Center for Public Health Practice

National Pharmaceutical Stockpile Purpose n Provides resources to respond to both biological and chemical attacks n Requested by governor n Managed by the Centers for Disease Control and Prevention More on NPS. . . This link will take you away from the educational site

National Pharmaceutical Stockpile Push Packages n 12 -hour “Push Packages” in cargo-sized containers weighing approximately 37 tons each n Located around the country at strategic locations n Held in environmentally controlled and secured warehouses n Can reach its destination within 12 hours of being requested

National Pharmaceutical Stockpile Push Packages n Contain color-coded inventory n Pharmaceuticals - stock rotated before expiration n IV supplies, airway supplies, ventilators n Bandages & personal protective equipment

National Pharmaceutical Stockpile Push Packages n Materials pre-packaged for immediate dispensing n Support staff will accompany the package n Receiving state responsible for logistics of repackaging and distribution

National Pharmaceutical Stockpile Vendor-Managed Inventory n Agreements with pharmaceutical manufacturers to make large stocks available on demand n Shipped to arrive within 24 -36 hours after requested n VA hospitals have an agreement with CDC to assist in the procurement & maintenance of NPS

Health Alert Network Definition n A nationwide, integrated information and communications system designed to: n Ensure communications capacity at all local and state health departments n Ensure capacity to receive distance-learning offerings from CDC, et al. n Ensure capacity to broadcast and receive health alerts at every level More on HAN. . . UW Northwest Center for Public Health Practice This link will take you away from the educational site

Health Alert Network How It Works n Links local health departments to one another and to other organizations critical for preparedness and response: n Community first-responders n Hospital and private laboratories n State health departments n CDC n Other federal agencies UW Northwest Center for Public Health Practice

Health Alert Network National Electronic Disease Surveillance n Information system “highway” for the National Electronic Disease Surveillance System (NEDSS) n NEDSS supports automated collection and transmission of disease reports from clinicians’ offices, laboratories, & hospitals to local & state health departments and CDC UW Northwest Center for Public Health Practice

Community Preparedness A Coordination of Efforts n Partnerships between public health and: n Clinicians and health care facilities n Public safety: law enforcement, fire, HAZMAT n Emergency management n Coordinate response across agencies at the local, state, and federal levels

Community Preparedness Know Whom to Contact n Know how to activate the biological disaster response plan in your practice setting n Who’s in charge? n Communication n Know the 24/7 contact number for your local health department

Community Preparedness Role of Public Health n Coordinate preparedness & response activities n Requires collaboration with medical professionals, first responders, and other partners n Provide information to health professionals, government leaders, and the public

Community Preparedness Role of Public Health n Detection and evaluation of biological disaster n Requires robust surveillance, epidemiology, and disease investigation infrastructure plus new detection methods n Facilitate medical management of exposed persons n Provide information on diagnosis, treatment, prophylaxis, and infection control issues

Community Preparedness Role of Public Health n Coordinate and engage state and federal resources n Education, training, and information n Surveillance, disease case and outbreak investigation

Community Preparedness Role of Public Health n Inventory and address deficiencies in regional resources n Hospital response capacity/preparedness n EMS/first responder capacity/preparedness n Mass treatment and prophylaxis n Mortuary capacity/preparedness n Law enforcement/security

Bioterrorism Preparedness & Response Role of the Clinician as “First Responder” n Prompt recognition, evaluation, and management of suspicious cases n Recognize clinical presentations consistent with potential BT agents n Be familiar with the “epidemiological clues” n Requires thorough, targeted history n Occupation, travel, contacts, recent “exposures, ” threats n Differentiating the “worried well” from the ill

Bioterrorism Preparedness & Response Role of the Clinician as “First Responder” n Prompt recognition, evaluation, and management of suspicious cases, continued n Know how to access current resources and information on infection control, treatment, and post-exposure prophylaxis n Local and state public health, CDC n Infectious disease consultants, hospital epidemiologist, or infection control professionals n Be familiar with procedures for obtaining & submitting clinical specimens for testing by clinical & health dept labs

Bioterrorism Preparedness & Response Role of the Clinician as “First Responder” Report confirmed or suspicious cases to public health n Be familiar with 24/7 reporting procedures for suspected cases or potential outbreak n Know how to engage local emergency responders n Be familiar with the disaster response plan for your hospital or practice setting n Know the immunization status and eligibility of your staff for vaccine preventable diseases n UW Northwest Center for Public Health Practice

Bioterrorism Preparedness & Response Role of the Clinician - Preparedness Planning Long-term consequence management and remediation n Identify and manage late-onset cases n Monitor for and manage adverse effects of treatment or prophylaxis n Identify and manage psychological sequelae n Be familiar with local procedures for evaluation of suspicious substances (“white powder”): role of law enforcement & public health n UW Northwest Center for Public Health Practice

Bioterrorism Preparedness & Response Role of the Clinician - Preparedness Planning n Participate in preparedness planning n Identify resources needed for biological mass casualty event n Medical, nursing, other professional, and support staff n Antibiotics and other pharmaceuticals n Supplies for mass treatment/vaccination n Ventilators and related respiratory support equipment UW Northwest Center for Public Health Practice

Bioterrorism Preparedness & Response Role of the Clinician - Preparedness Planning n Identify resources needed for biological mass casualty event, continued n Hospital ICU and isolation beds n Mental health resources n Post-mortem management n Triage, security and crowd control n Communication – internal, external, public relations/media UW Northwest Center for Public Health Practice

Bioterrorism Preparedness and Response Role of the Clinician n To report a potential BT incident or threat in King County n Notify Public Health – Seattle & King County: 206 -296 -4774 (24 hr number) n If no one available, call the Washington State Department of Health: 1 -877 -539 -4344 n Notify your hospital epidemiologist or infection control practitioner n Notify other partners as identified on your facility’s biological disaster response plan n Consider activating your site disaster response plan UW Northwest Center for Public Health Practice

Hoaxes and Evaluation of Suspicious Powders n If a suspicious package or substance is received n Cover package/substance (do not try to clean up any spilled contents) n Leave the room and close the door n Turn off air conditioning system n Wash hands with soap & water n Report to local law enforcement (call 911) n Notify building security UW Northwest Center for Public Health Practice

Hoaxes and Evaluation of Suspicious Powders, cont. n Additional steps to take, if exposed to a suspicious powder or substance n Remove contaminated clothing & place in plastic bag or other sealed container n Shower with soap & water (bleach is not necessary) n Contact local health jurisdiction n Symptom monitoring and/or prophylaxis may be needed for others in the room/area UW Northwest Center for Public Health Practice

Bioterrorism Preparedness and Response Summary of Key Points n BT preparedness and response requires coordination between clinicians, public health, emergency first responders, and law enforcement. UW Northwest Center for Public Health Practice

Bioterrorism Preparedness and Response Summary of Key Points n BT preparedness for clinicians involves n Ability to recognize unusual clinical presentations and clusters of cases n Knowledge of diagnosis and management of diseases of BT origin n Awareness of their health care facility or practice’s disaster response plan n Knowledge of disease reporting requirements, and how and when to contact local public health authorities UW Northwest Center for Public Health Practice

Resources National These links will take you away from the educational site n Centers for Disease Control and Prevention Strategic Plan for Preparedness & Response MMWR 49(RR-4) Bioterrorism Web site: http: //www. bt. cdc. gov Emergency Preparedness & Response branch 24 -hour notification telephone number: (770) 488 -7100 n CDC Public Inquiry Hotlines English (888) 246 -2675 Español (888) 246 -2857 n National Domestic Preparedness Office: (202) 324 -9026 M-F 8 am-5 pm EST n UW Northwest Center for Public Health Practice

Resources Washington State These links will take you away from the educational site n Washington State Department of Health http: //www. doh. wa. gov n Communicable Disease Epidemiology n (206) 361 -2914 n 1 -877 -539 -4344 - 24 -hour emergency number n Julie Wicklund, BT Surveillance Epidemiologist (206) 361 -2881 n Washington State Emergency Management Division http: //www. wa. gov/wsem/ UW Northwest Center for Public Health Practice

Resources Local This link will take you away from the educational site n Public Health – Seattle & King County n To report illness or discuss suspicious substances (206) 296 -4774 (24 hr) http: //www. metrokc. gov/health/bioterrorism UW Northwest Center for Public Health Practice

Resources Emergency Management This link will take you away from the educational site State Emergency Management duty officer (800)258 -5990 n Regional Emergency Coordinator, Region X (206) 615 -2266 n FBI n Western WA and after hrs, Statewide: (206) 622 -0460 n Eastern WA: (509) 747 -5195 n Federal Emergency Management Agency (FEMA) http: //www. fema. gov- includes links to n emergency management courses UW Northwest Center for Public Health Practice

Resources Health Care Facility Preparedness These links will take you away from the educational site n American Hospital Association Disaster Readiness site http: //www. aha. org/Emergency/Em. Index. asp n Association of Professionals in Infection Control and Epidemiology (APIC) http: //www. apic. org n APIC & CDC BT readiness plan template for health care facilities http: //www. cdc. gov/ncidod/hip/Bio/13 apr 99 APIC-CDCBioterrorism. PDF UW Northwest Center for Public Health Practice

In Case of An Event… Web Sites with Up-to-Date Information and Instructions These links will take you away from the educational site n Centers for Disease Control and Prevention http: //www. bt. cdc. gov/Em. Contact/index. asp n Saint Louis University, CSB & EI http: //bioterrorism. slu. edu/hotline. htm n WA State Local Health Departments/Districts http: //www. doh. wa. gov/LHJMap. htm n Level A Lab Protocols: Presumptive Agent ID http: //www. bt. cdc. gov/Lab. Issues/index. asp UW Northwest Center for Public Health Practice

In Case of An Event… Web Sites with Up-to-Date Information and Instructions These links will take you away from the educational site n FBI Terrorism Web Page http: //www. fbi. gov/terrorism. htm WA State Emergency Mgt Division – Hazard Analysis Update http: //www. wa. gov/wsem n Mail Security http: //www. usps. com/news/2001/press/serviceupdates. htm n n Links to your state health department http: //www. astho. org/state. html n NIOSH – Worker Safety and Use of PPE http: //www. cdc. gov/niosh/emres 01. html UW Northwest Center for Public Health Practice