cdc centers for disease control and prevention bioterrorism mass casualty response: current concepts...

CDCCenters for Disease Control

and Prevention

Bioterrorism Mass Casualty Response: Current Concepts and

Controversies

European Masters in Disaster Medicine Sandigliano, Italy

02 May 2005

Eric K. Noji, M.D., M.P.H., FACEP

Medical Epidemiologist Centers for Disease Control & Prevention

Washington, D.C.


and Prevention

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


and Prevention

““A bioterrorism attack anywhere in the A bioterrorism attack anywhere in the

world is inevitable in the 21world is inevitable in the 21stst century.” century.”

Anthony Fauci, Director, NIAIDAnthony Fauci, Director, NIAID

Clinical Infectious Diseases 2001;32:678Clinical Infectious Diseases 2001;32:678


and Prevention

Smallpox Infected People Disperse

Flights to thirty eight US cities with infected passengers


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… Life Has Changed for us all


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CBRNE Agents

Conventional (Explosive)

Chemical Biological / Radoilogic

Onset Instant Rapid Often Delayed

Source Obvious Obvious Often covert

First Victim Encounter

Prehospital Prehospital Hospital

Containment Easy Relatively Easy Difficult

Decon Helpful Usually Not Yes Usually Not*


and Prevention

Infection: Invasion of a host by an agent, with

subsequent establishment and multiplication of the agent. An infection

may or may not lead to disease.

Disease results only if and when, as a

consequence of the invasion and growth of a pathogen, tissue function

is impaired.

Thou shaltProtect Thyself


and Prevention

Protection Against BW

• Physical– Personal protective gear

• Chemical– pre- & post-exposure antibiotics

• Immunologic– passive (e.g. Botulinum antitoxin)– active (e.g. Anthrax & Vaccinia vaccines)


and Prevention

Thou shaltDecontaminate as Appropriate


and Prevention

Decontaminationafter Biological Attack

• Personnel– decon rarely needed

– less relevant than for Chem attack

– soap & water

– use common sense

• Materiel– often unnecessary

– less relevant than for Chem attack

– 5.0% bleach more than adequate

– 0.1% bleach kills anthrax spores


and Prevention

Diagnosis

• Clinical

• Epidemiological

• Laboratory


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Anthrax (Bacillus anthracis)

• Inhalational, gastrointestinal, cutaneous• NOT communicable (except maybe

cutaneous)• Vaccine not available for civilian use• 20%-80% mortality


and Prevention

Anthrax: Inhalational

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

– Fever, cough, myalgia, malaise

• Terminal symptoms (1-2d )– High fever, dyspnea, cyanosis

– Hemorrhagic mediastinitis/effusion

– Rapid progression shock/death

• Mortality rate ~ 100% w/o RX


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Varying Presentations of NYC Cutaneous Lesions


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Diagnosis

-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


and Prevention


and Prevention

Small Pox (Variola major virus)

• Transmitted primarily by aerosol route, contaminated clothes & linens

• Highly communicable• Vaccine can lessen the severity of

disease if given within 4 days of exposure


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• Increasing Global Travel• Rapid access to large populations• Poor global security & awareness

...create the potential for simultaneous ...create the potential for simultaneous creation of large numbers of casualtiescreation of large numbers of casualties

Epidemiological Pattern of Epidemiological Pattern of Smallpox WeaponSmallpox Weapon

New foci of secondary infection

“Contaminated” zone

“Infected” zone

Zone of initialexplosion


and Prevention


and Prevention

Pneumonic Plague

• Caused by infection with Yersinia Pestis

• Pneumonic form will occur after intentional aerosol delivery

• Incubation period of 1-7 days


and Prevention


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Obtaining Specimens

• CBC, ABG• Nasal Swabs (culture, PCR)• Blood for Bacterial Culture, PCR• Serology• Sputum Bacterial Culture• Toxin Assays (blood, urine)• Throat Swab (viral culture, PCR, ELISA)• Environmental Samples?


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Where to Send Specimens?

Local Local Clinical Clinical

LabLab Laboratory Laboratory ChannelsChannels

520th520th TAMLTAML

USAMRIIDUSAMRIID USAMRICDUSAMRICD


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Thou shaltRender Prompt Treatment


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Biological Warfare DiseasesNon-Specific Febrile Presentations

Agent Treatment

Tularemia Doxy or Gent

Brucellosis Doxycycline

Q-Fever Doxycycline

Prodromal Plague Doxy or Gent

Prodromal Anthrax Doxy or Cipro

VEE None


and Prevention

Smallpox: Current Vaccine

• Made from live Vaccinia virus• ID inoculation with bifurcated

needle (scarification)– Pustular lesion/induration surrounding

central scab/ulcer 6-8 days post-vaccination

– Low grade fever, axillary lymphadenopathy

– Scar (permanent) demonstrates successful vaccination

– Immunity not life-long WHO


and Prevention

Thou shaltPractice Good Infection Control


and Prevention

Isolation PrecautionsBiowarfare Diseases

• Pneumonic Plague– Droplet Precautions

• Smallpox– ? Airborne Precautions– “Strict Quarantine”

• Viral Hemorrhagic Fevers– Contact Precautions


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What is the US Health Care System?

• Roughly 6000 hospitals• 615,000 physicians and surgeons• 2.4 million registered nurses• 240,000 pharmacists• Approximately $390 billion spent on

healthcare in 2003• $15.5 billion spent on hospital

construction (2001)


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Current IssuesCurrent Issues

• The US healthcare system functions at capacity on a daily basis

• Contagious patients may render existing facilities inoperable

• Expansion (surge) capability relies on federal programs that take time to deploy

• Personnel engaged in healthcare are already functioning at maximum

• No formal process to identify who is in charge (of what) when using multi-jurisdictional assets


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WORSENING SITUATION IN US

• Many hospitals on diversion during normal times (no inpatient beds, consultants)

• Decreasing number of emergency depts, trauma centers, inpatient beds

• Not economically viable for hospitals to maintain surge capacity,


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Enhancing existing local first responder, medical, public health and emergency planning to increase capabilities to manage the incident until Federal resources arrive (typically 48-72 hours)

Metropolitan Medical Response SystemMMRS


and Prevention

Original MMRSOriginal MMRSBoston, New York, Baltimore, Philadelphia, Washington DC, Atlanta, Miami, Memphis, Jacksonville, Detroit, Chicago, Milwaukee, Indianapolis, Columbus, San Antonio, Houston, Dallas, Kansas City, Denver, Phoenix, San Jose, Honolulu, Los Angeles, San Diego, San Francisco, Anchorage, Seattle

Metropolitan Medical Response SystemsMetropolitan Medical Response Systems

MMRS 1999MMRS 1999Hampton Roads (Virginia Beach)Area, Pittsburgh, Nashville, Charlotte, Cleveland, El Paso, New Orleans, Austin, Fort Worth, Oklahoma City, Albuquerque, St. Louis, Salt Lake City, Long Beach, Tucson, Oakland, Portland (OR), Twin Cities (Minneapolis), Tulsa, Sacramento

MMRS 2000 MMRS 2000 Twin Cities (St. Paul), Hampton Roads (Norfolk),Cincinnati, Fresno, Omaha, Toledo, Buffalo, Wichita,Santa Ana, Mesa, Aurora , Tampa, Newark, Louisville, Anaheim, Birmingham, Arlington, Las Vegas,Corpus Christi, St. Petersburg, Rochester, Jersey City,Riverside, Lexington-Fayette, Akron

MMRS 2001MMRS 2001Colorado Springs, Baton Rouge, Raleigh, Stockton, Richmond (VA), Shreveport, Jackson, Mobile, Des Moines, Lincoln, Madison, Grand Rapids, Yonkers, Hialeah, Montgomery, Lubbock, Greensboro, Dayton, Huntington Beach, Garland, Glendale (CA), Columbus (GA), Spokane, Tacoma, Little Rock


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MAJOR COMPONENTSMAJOR COMPONENTS

Medical ResponseMedical Response

Patient EvacuationPatient Evacuation

Definitive Medical CareDefinitive Medical Care

National Disaster Medical SystemNational Disaster Medical System


and Prevention


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Strategic National Stockpile

• Twelve push packages ready for deployment within 12 hours anywhere in the U.S.

• Vendor Managed Inventory (VMI) – specific medical supplies needed to control and contain outbreaks of infectious diseases and other emergency incidents


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SNS Contents

• Pharmaceuticals: – Antibiotics

– Mark I kits, diazepam, atropine, pralidoxime

• IV Supplies:

– catheters, syringes, fluids, heparin-locks, administration sets

• Airway Supplies:

– ventilators, ambu-bags, ET tubes, laryngoscopes, suction devices, oxygen masks, NG tubes

• Other Emergency Medications:

– for hypotension, anaphylaxis, sedation, pain management

• Bandages and Dressings

• Vaccine


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Bad communication adds to crisis

• Mixed messages from multiple “experts”• Late information “overcome by events”• Over-reassuring messages• No reality check on recommendations• Myths, rumors, doomsayers not countered• Poor performance by spokesperson/leader• Public power struggles and confusion


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A Typical Day at CDC Autumn 2001


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Public Awareness

•Reliable, credible information to the public is key to keeping cooperation and minimizing panic


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Tactical response to biological weapon

exposure• Need to make life-saving decisions rapidly in

the absence of data• Access to subject matter experts will be

limited• No “textbook” experience to guide response • Need coherent, rapid process for

addressing staff and civilian safety in midst of crisis


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Top STRATEGIC Challenges to Hospital Preparedness

• Surge Capacity• Healthcare Personnel

– Relevant training– Sufficient numbers

• Materiel– Pharmaceuticals– Decontamination

equipment

• Collaboration at local, state, and federal level

Must prepare for MCI at the same time as providing “routine” healthcare to the community!


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Bottom Line

• Early, rapid recognition of unusual clinical syndromes or deaths

• Early rapid recognition of increase above “expected levels” of common syndromes, diseases, or death


and Prevention

The detection and control of saboteurs are the

responsibilities of the FBI, but the recognition of

epidemics caused by sabotage is particularly an

epidemiologic function…. Therefore, any plan of

defense against biological warfare sabotage

requires trained epidemiologists, alert to all

possibilities and available for call at a moment’s

notice anywhere in the country”

Alexander LangmuirFounder of CDC EIS Program1952

CDC and Biodefense


and Prevention

Questions ?

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