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Script and Bibliography: Bioterrorism Responses by Health Care Professionals

Developed under Auspices of the Association of Occupational and Environmental Clinics

Royce Moser, Jr., M.D., MPHRocky Mountain Center for Occupational and Environmental Health

University of Utah School of Medicine

August, 2002

This is the presentation script for the slide session, AResponding to the Bioterrorism Threat@, prepared under auspices of the Association of Occupational and Environmental Clinics. It is followed by a bibliography with sources used in developing the presentation. Those attending the session should be provided handouts containing the slides to avoid the necessity of taking extensive notes during the session. Additionally, a Pre- and Post-Test is provided as is a patient handout. Both items may be modified as desired to meet the needs of the audience.

Notes to presenter:

If you are presenting this with slides, you will note that there are several flying text lines in slides 4 - 6 that are advanced by a click of the controller. If you are looking at this in hard copy, all of the text lines will be displayed on one slide so do not become confused as I indicate an additional slide to bring up the next line of text. This is only done in the first few slides since I find it distracting to use the technique for many slides.

If Continuing Medical Education (CME) credit is planned for the session, some agencies granting the credit may require that desired learning objectives for the session be formally presented at the start of the session. These objectives are provided in slides 2 and 3. If these are used, it is recommended that slide 7, AOverview of the Session@, not be used since it duplicates much of the material in slides 2 and 3. In pilot testing, it has proven effective to omit slides 2 and 3, start with the scenario, and then give the AOverview of the Session@. The options are presented as use of slides 2 and 3 may cause some in the audience to consider the session more Aacademic@ than practical in its orientation.

Narrative:

Slide Number and Title

1. Title Slide

2. & 3. Learning objectives for the sessionBsee discussion above

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4. The challenge (need to click the controller to bring up the title)

The recent anthrax episodes underscore the potential for bioterrorism events today and the challenge we face in responding. I would like to begin the discussion with a brief scenario that is based on actual disease outbreak.

Click to bring up first bulletBAWithin the space....@

Assume that you are at home after a days work and. at approximately 3 am, you receive calls from three families complaining that the adults and children are experiencing very significant nausea, vomiting, and diarrhea.

Click for next bulletBAIs this an epidemic?@

If an epidemic is defined as the occurrence of illnesses in excess of normal, most of us would not consider this an epidemic, given the limited information available.

Click for next bulletBAIs this reportable?@

Is this outbreak reportable according to Public Health criteria.? (Discussion) At this point, again based on the information you have, the answer is ANo@ because, obviously, we do not report gastro-intestinal disease unless there is a significant epidemic. However, it is somewhat surprising that we have three families calling in with these same symptoms within such a short period of time.

5. The challenge (continued)

Click for first bulletBAAdditional history@

What additional history would you like? (Discussion)

Click for next bulletBATwo families ate....@

On questioning the families, we find that they did not eat at the same restaurant. This might suggest that this was a naturally occurring event, such as a viral condition, but we are still left with the disturbing aspect that we had three episodes in three families in a short period of time.

Click for next bulletBAAll members ill except infants@ (Discussion)

The fact that infants were not affected could suggest that the source was food or water consumed only by adults and children. However, the fact that those involved ate at different locations argues against a single food source. Having three families experience similar illnesses within the same time period is perhaps unusual in our experience, unless

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we are in the middle of a viral gastro-enteritis outbreak. What might be your next steps? (Discussion)

Click for next bulletBAHospitals report....@

When you contact the two local hospitals, you find that they have numerous patients in their emergency rooms with significant nausea, vomiting, and diarrhea. At this point, the situation certainly meets the criteria for an epidemic. Do you report this condition? (Discussion) [States typically have reporting requirements for AAny sudden or extraordinary occurrence of infectious or communicable disease...Any disease occurrence, pattern of cases, suspect cases, or increased incidence of any illness which might indicate an outbreak, epidemic, or related public health hazard, including but not limited to suspected or confirmed outbreaks of food-borne or waterborne disease, newly recognized or re-emergent diseases or disease producing agents... (Utah R386-702-2)]

Next bulletBAOver 700 people...@

This obviously was a major event that involved large numbers of people. As with recent outbreaks due to milk, water, or food contamination, it is essential to find the source of the contamination.

6. The Challenge (continued)

First bulletBAInvestigated by epidemiologists...@

Epidemiologists did investigate the outbreak. The investigators did not find a point source. They believed that this outbreak could be attributed to poor sanitation by restaurant food handlers in the community.

Second bulletBASubsequently confirmed...@

The actual source of the illnesses was confirmed when a member of the Rajneeshee sect volunteered the information that they had spread Salmonella typhimurium over restaurants salad bars and produce sections in the grocery stores in a community called The Dalles, Or, in 1984. The members were testing the technique with plans to use it to try to influence an election by causing many people in the community to become ill just prior to the election. In this way, the Rajneeshees would have sufficient voters to obtain control of the county. This plan was never implemented, but the trial was the first confirmed bioterrorism event in the United States.

7 Overview

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In today=s session, we will look at the nature of the bioterrorism threat that we face today, consider some of the potential agents that might be used, discuss the role of health care providers in event recognition and response, consider essential aspects of response plans, and then conclude with listings of sources of assistance.

8. BioterrorismBNature of the Threat

One definition of bioterrorism is depicted on this slide:

AThe systematic use of biological agent or toxin or threat of use of an agent or toxin with the intent to induce terror and intimidation in order to achieve an end.@

Although over 700 people were infected in The Dalles, Oregon, the few actual anthrax patients impacted many times that number as people became fearful of opening mail, large numbers were placed on prophylaxis, and government activities were disrupted.

9. Nature of the Threat--Background

Bioterrorism extends back to at least the 6th century BC, when Assyrians placed rye ergot in wells used by the enemy. In the middle ages, the Tartars catapulted plague victims over the walls of the besieged city of Kaffa. Some believe that this action might have been the source of the black plague epidemic that is estimated to have killed over 25 million people. We have the tragic example in America before it became the United States of British troops providing blankets contaminated with smallpox to Indians during the French and Indian war. The disease spread rapidly throughout the Indian tribes and decimated their numbers dramatically.

10. Nature of the ThreatBRecent History

More recently, the United States, the USSR, and many other countries signed a biological and toxic weapons commission in 1972 which effectively outlawed the development of bioterrorism weapons or any biowarfare weapons. Regardless of the treaty, the USSR continued their efforts, and it was later found that one of six well-documented bioweapons facilities in the USSR could produce three hundred tons of anthrax every 220 days. Other facilities were making similar large amounts of other biological agents.

At the start of the Gulf war, Iraq had produced 5000 gallons of botulism and 2,200 gallons of anthrax. Fortunately, Iraq did not use anthrax, as far as we know, since we did not have adequate supplies of anthrax vaccine at that time to immunize the U.S. troops and those of the coalition.

11. Scope of the Problem

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With the dissolution of the Union of Soviet Socialist Republics, there is concern over possible loss of control of some of the biological agents. Adding to that concern is the fact that many terrorist groups are well financed and could hire scientists and obtain equipment to produce bioterrorism agents. Additionally, as we will discuss shortly, there are multiple potential agents, and there is no effective treatment for some of them.

12. Scope of the Problem (Continued)

Of particular concern is a change in the philosophy and doctrine of many of the terrorists groups over the past few decades. Previously, the emphasis was on destroying the military capability of a targeted country or group. More recently, however, the groups consider it justified to use terrorist agents to produce maximum civilian casualties. The quotation from the al-Qaida training manual displayed on this slide emphasizes this change in philosophy.

13. Scope of the Problem (Continued)

CDC has divided potential bioterrorism agents into Categories A, B, and C. The Category A list includes agents that are easily disseminated or transmitted from person to person, may have high mortality rates, have major public health impacts, can be expected to produce public panic and social disruption, and require special public health actions. (Criteria for the B and C categories, and a listing of those agents, is provided in the AAdditional Information@ section at the end of this presentation. Time precludes discussing them during this session.)

14. CDC Category A Agents

The category A list includes: Anthrax, Botulism, Plagues, Smallpox, Tularemia, and the Viral hemorrhagic fevers.

15. Diagnosis and Treatment of Category A Agents

We will review some aspects of the Category A agents, including overviews of diagnosis and treatment. However, I want to emphasize that the information is being updated continually. I strongly recommend consulting the resources listed in this session to obtain updated information, such as that from the AMA link depicted on this slide. Let me note that all links provided in today=s session can be accessed from the Rocky Mountain Center=s site, www.rmcoeh.utah.edu.

16. A ListBOverview

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The charts on this and the next slide summarizes the incubation periods, what the mortality rate is in untreated patients, and whether there is or is not person - to person transmission. As noted for inhalational anthrax, the lethality can be over 90% if untreated. Botulism can have over 60% mortality, and the rate for pneumonic plague approaches 100%.

17. A ListBOverview

Smallpox, although it Aonly@ has a mortality rate of 30%, produces severe scaring of the skin, may involve the eyes, and results in major disfigurements in survivors. A particular concern in smallpox is that it is highly transmissible. Tularemia has a lethality of 30-60% but is not transmissible from person to person. The viral hemorrhagic fevers death rates range from 15% to over 90%, depending on the specific virus. The illness is only moderately transmissible from person to person as compared to smallpox.

18. Anthrax

As a result of the events in September and October of 2001, anthrax is now of interest to everyone. The organism is a Gram positive rod, and symptoms include standard flu like symptoms that we are all so familiar with, with abrupt onset of fever, chills, malaise, minimally - or non-productive cough, headache, and dyspnea. Note the consensus article listed at the bottom of this page. A consensus article reference is provided for each of the Category A agents. These are available on-line at the Johns Hopkins Center for Civilian Biodefense Strategies. The URL for the Center is provided in information at the end of this session, and a link is available at the previously-mentioned Rocky Mountain Center site.

19. Inhalation AnthraxBSymptoms

It is of note that one patient who died experienced marked nausea, vomiting, and abdominal pain in addition to some respiratory symptoms. Another interesting finding is that one of the survivors complained of generalized headache that became progressively worse over a period of several days. The headache was accompanied by chills and nausea but no respiratory symptoms. However, when the patient was seen in the emergency department he was found to have rhonchi on examination.

20. Anthrax Diagnosis

A quoted diagnostic clue for anthrax is the absence of significant nasal discharge even though the patient may have other respiratory symptoms. A finding characteristic of inhalation anthrax is a widened mediastinum, either on chest x-ray or, if the x-ray is negative and the suspicion is high, on a computerized tomography scan. Gram stain and culture of blood and cerebral spinal fluid can also give evidence of the disease. A high

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pulse rate and increased white count were found in essentially all patients that have been reported to date. Of particular interest is the fact that the nasal swab was negative on one patient who became a fatality. Consequently anyone relying on nasal swabs has to recognize that they may have a chance of missing an actual anthrax exposure or patient with anthrax disease.

21. Chest radiograph

This is the x-ray showing the widened mediastinum that is characteristic of anthrax.

22. Gastrointestinal Anthrax

There is a gastrointestinal form of anthrax which produces nausea, vomiting, abdominal pain, bloody diarrhea, and sepsis. Diagnostic clues include the widened mediastinum that may be present as with the inhalation form. Gram stains and cultures may be positive as well

23. Cutaneous Anthrax

Cutaneous anthrax may have an incubation as short as a few hours. Symptoms include lesions on the face, neck or arms that progress from a papule to vesicles and depressed skin ulcers with the black escars. There may be associated leg edema. This is not a benign condition in that the mortality rate may be 20% if untreated.

24. Cutaneous AnthraxBArm

This next slide shows a cutaneous anthrax lesion at 12 days on the forearm of a young lady. It is apparent that lesions may not be the enlarged black ones often cited. This somewhat benign-appearing lesion is in contrast to the neck lesion on the next slide.

25. Cutaneous AnthraxBNeck

This photo depicts an anthrax lesion that more closely resembles the photos in some medical texts.

26. Cutaneous AnthraxBContinued

Diagnostic clues include gram stain and culture of vesicular fluid or the lesion exudate and a gram stain and culture of blood.

27. AnthraxBTreatment

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In developing a treatment protocol, it is important to check for the latest CDC or other guidelines. A consensus document published in May, 2002 (as indicated on the slide) provides treatment guidelines for inhalation anthrax in adults as: Ciprofloxacin 400 mg IV q 12 h - or - Doxycycline 100 mg IV q 12 h - plus 1 or 2 additional antibiotics.

28. Anthrax TreatmentBContinued

The next slide depicts these additional antibiotics. As indicated in the bottom bullet, two of the survivors were treated with a combination of ciprofloxacin, rifampin, and clindamycin. A vaccine for anthrax has been developed and licensed, and it may be available in the near future.

29. Botulism

Clostridium botulinum is a gram positive rod. The consensus document for this condition is listed on the slide. The symptoms from the C. botulinum toxin are almost diagnostic, with double or blurred vision, nausea, vomiting, ptosis, severe fatigue and of particular note, difficulty swallowing. The disease is characterized by an acute bilateral descending paralysis as the disease progresses.

30. BotulismBDiagnostic Clues

Both treatment and public health reporting have to be based on the clinical diagnosis. The serum and stool of a patient may be assayed for toxin, but the process requires days.

31. BotulismBTreatment

Supportive care is provided and trivalent equine antitoxin is obtained from CDC as soon as the diagnosis is made. Since the antitoxin is equine there are the usual potential hazards associated with such agents, as noted in the last bullet.

32. Pneumonic Plague

Pneumonic plague is another Category A agent that is transmissible from person to person. The condition begins again with flu-like symptoms, myalgia, fevers, weakness, and headache. These are followed by chest discomfort, cough, dyspnea, cyanosis, marked respiratory distress, and shock.

33. Pneumonic PlagueBContinued

Gram stains and cultures of the blood, cerebral spinal fluid, sputum, bronchial washings, and aspirates of lymph notes will assist in making the diagnosis. A chest x-ray demonstrates infiltrates and there is an increased white count. Additionally there are

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coagulation abnormalities.

34. Chest Radiograph

This is the radiograph of a person with pneumonic plague that shows the infiltrates.

35. Pneumonic Plague (Continued)

Additional diagnostic clues include confirmatory serological and bacteriological tests that again are available through public health agencies. However, some time will be required for these confirmatory studies.

36. Pneumonic PlagueBTreatment

Treatment is for 10 to 14 days, and the currently recommended dosages for agents used are depicted on this slide.

37. Pneumonic Plague Treatment (Continued)

However, for meningitis, chloramphenicol is the first agent of choice, unless the patient is pregnant or lactating. There is a vaccine that is has been licensed for plague, but it is not readily available. The prophylaxis for respiratory contacts include doxycycline, tetracycline, or ciprofloxacin.

38. Smallpox

Smallpox is of particular concern in view of the high transmission potential and the fact that even previously immunized individuals may have lost their immunity by this time. The human is the only reservoir for smallpox. When the disease was eradicated, two cultures were maintained for studies, one in the U.S. and one in the USSR. With the disillusion of the Soviet Union it is not clear that the virus maintained in Russia has been retained in a secure environment. Smallpox is highly contagious and is spread via direct contact, aerosolized droplets, or use of contaminated clothing or linen--as in the spread in the Native American tribes mentioned earlier. It is thought that immunity after vaccination lasts for approximately 10 tears.

39. Smallpox Symptoms and Signs

The symptoms include the abrupt onset of high fever, headache, vomiting, backache, malaise with sever prostration. The initial symptoms are followed in 2-3 days by maculopapular rash that progresses uniformly in involved areas to pustules and scabs. The rash begins on the oropharynx, on the face, on the forearms and then spreads to the trunk and legs. A diagnostic aspect is that the palms and soles may be affected.

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40. Diagnosing Smallpox

CDC lists major criteria for smallpox that include fever of 101oF or higher and at least one of the following: prostration, headache, backache, chills, vomiting, or severe abdominal pain. The classic lesions are circumscribed, deep seated, feel Ashotty@ under the skin, and may become umbilicated.

41. Diagnosing Smallpox (Continued)

As previously mentioned, the lesions on any one part of the body are in the same stage of development.

These major criteria, along with minor criteria, are depicted in a color chart prepared by CDC. The chart also provide pictures of smallpox and chickenpox patients and lists other diagnoses that may be confused with smallpox. It can be located, and downloaded, at the site listed.

42. Photo of Child with Smallpox

This slide demonstrates that all lesions in any one area have progressed to the same stage of development. This is in contrast to chickenpox where we know that the lesions may be at different maturation stages within an involved body area.

43. Smallpox Reporting, Cultures

If smallpox is suspected, it is important to notify the local and state health departments immediately. The testing for smallpox is accomplished through the Public Health Laboratory Network. Samples can include pharyngeal swabs, vesicular fluid, biopsies, and scab material.

44. Smallpox Control and Treatment

Smallpox requires strict respiratory and contact isolation. Isolation requirements recommended by CDC include use of a NIOSH N95 respirator, negative air pressure room, outside discharge or high-efficiency particulate air (HEPA) filter, closed door to the room, and use of mask/eye (or face shield) protection, clean gloves on entering the room, and gown and gloves removed on leaving. Hands are washed with an antimicrobial agent.

45. Smallpox Control and Treatment (Continued)

The patient is infectious from the time the rash appears until the scabs have separated. Typically, this process takes 2 to 4 weeks. It is important to immediately vaccinate all contacts since, if done within 4 days, vaccination may prevent or mitigate the disease.

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46. Smallpox Control and Treatment (Continued)

It has been estimated that there are approximately 12 to 15 million doses of smallpox vaccine available in the U.S.. Studies have been accomplished to ascertain whether this supply can be diluted, and it appears that a 5 to 1 dilution may result in an effective antibody response. Additionally, there is a crash program to obtain new vaccine supplies, and it is projected that we will have new vaccine available in the near future. Licensing of the new vaccine is expected in 2003. There is a polymerase inhibitor (cidofovir) under study that may be effective against the virus as well. In addition to vaccination, supportive care and treatment of secondary infections are essential.

47. Tularemia (Inhalational)

Inhalational Tularemia begins with the abrupt onset of chills, fever, weakness, dry cough, again flu-like symptoms. However, weakness, sepsis, and organ failure occur as the disease progresses.

48. Tularemia (Diagnostic Clues)

As with botulism, the tularemia diagnosis is primarily a clinical one. Chest x-rays will show infiltrates, effusions, and hilar adenopathy. There is confirmatory serological testing available through public health agencies. Culture of blood, sputum, bronchial washings and biopsies is difficult and potentially dangerous.

49. TularemiaBTreatment and Control

This slide depicts the current antibiotic therapy regime that is used for patients with the disease. Note that the antibiotic selected is used for 14 days. Prophylaxis of patients with potential exposure is with doxycycline or ciprofloxacin. A vaccine is investigational at this time.

50. Viral Hemorrhagic Fevers

Viral hemorrhagic fevers are of concern in that the viral etiology limits the treatment options. Fever, headache, and myalgia are present, as in many of the other diseases that have been discussed. However, the symptoms are accompanied by mucous membrane bleeding, periorbital edema, petechiae, and, finally, thrombocytopenia, shock and death.

51. VHFBControl and Treatment

It is important to isolate the patient in a single negative pressure room with adjoining hand washing facilities, implement strict barrier precautions (which include face shields), disinfect all body fluids, and, of course, immediately notify CDCB in this instance the Special Pathogens Office at the number shown on this slide.

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52. VHF--Treatment

Treatment is primarily supportive. Ribavarin may be effective for Lassa fever and other arena viruses, for Congo-Crimean hemorrhagic fever, and for Argentine hemorrhagic fever. Ribavarin may also be used for prophylaxis. The only vaccine available is the Yellow fever vaccine.

53. How do Heath Providers Respond?

Having consider some of the potential agents, we are left with the question of how health care providers respond to the bioterrorism threat. It is important to recognize that we will be on the Afront line@ in detecting and responding to a covert bioterrorism event. Many of us have been taught that hearing hoof-beats is much more likely to indicate a horse (common medical condition) rather than a zebra (rare medical condition). With the increase potential for bioterrorism events, it is essential all providers maintain a high level of suspicion for the symptoms or findings that may represent a bioterrorist situation.

54. How do Health Providers Respond? (Continued)

As previously mentioned, an essential aspect of our response is to accomplish priority reporting to public health agencies so that appropriate federal, state, and local agencies can be mobilized to respond to the event. We need to report the potential, presumptive, or possible diagnosis on clinical suspicion or suspicious studies. Due to the potential for dissemination and the time involved for many confirmatory laboratory studies, it is no longer appropriate to delay reporting until laboratory confirmation is obtained. Consequently, every practitioner must have public health 24 hour contact numbers readily available.

55. How do Health Providers Respond? (Continued)

We also have to provide factual threat information to our patientsBinformation that will guide them in appropriate responses. There is a patient handout that accompanies this session that may be modified as desired for your own patient population. It is particularly important that workers in your practice become aware of the bioterrorism threat and steps to take if an event is suspected. Copies of handouts could be provided to other family members to give to workers in the family if the workers are not seen regularly. Finally, we are expected, of course, to provide care to our patients as needed and to participate in medical planning to respond to bioterrorist events.

56. Recognition of AZebras@ a Challenge

Unfortunately, many of the conditions begin with non-specific symptoms that are readily

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characterized as Aflu-like conditions@. It is only when symptoms do not respond to standard treatment, or the patient has a rapid down-hill course, that we might suspect

something unusual. In today=s environment, such findings should make us consider bioterrorism. Similarly, recognizing patients are professionals or workers at high risk, e.g. first responders, mail clerks, could be particularly crucial information.

In other instances, such as botulism or smallpox, symptoms and findings are more specific. Early recognition of these conditions will permit the rapid notifications and treatment/immunizations so essential in controlling the situation.

In addition to symptom patterns and progression, there are other clues that can provide valuable information, as discussed on the next two slides.

57. Clues to Recognizing a Bioterrorist Event

There are several clues that will help us to recognize a bioterrorist event. Naturally, an important clue is the occurrence of a disease outside its typical endemic area. A rare or esoteric disease such as plague, tularemia, or other Category A disease would suggest a possible terrorist event. Similarly, Aoff season@ disease outbreaks, such as an outbreak of Aflu@ during the summer, or unusual resistance to antimicrobials are clues. Unusual age distribution may also be a clue. It is important to remember the animal sentinels, such as the crows that led to the recognition of a new disease in this country, Western Nile Encephalitis.

58. Clues to Recognizing a Bioterrorist Event (Continued)

Additional clues include having all patients present at a common event, such as a musical performance or sporting event. If all the patients were inside a particular building, the suspicion would be even higher. As mentioned earlier, a particularly important, major clue would be to have all the patients from a single worksite. The experience with the postal workers underscores the importance of obtaining information on work activities and locations from any group of patients with common symptoms that developed over a limited period of time.

59. Other Methods of Recognizing a Covert Event

Other ways of detecting a covert (unannounced) attack include detection sensors. A number are under development, such as the 15 minute polymerase chain reaction (PCR) instruments, and others are available. Unfortunately, some sensors have problems with false positives or false negatives. The newer ones should reduce these problems significantly.

Another way to detect an event is to use surveillance systems to recognize a sharp

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increase in the number of patients, especially if they have unusual or unexpected symptom complexes . It is essential that such surveillance provide reports on a Areal time@ basis. Such systems were used during the Olympics in Salt Lake City to ascertain, on a daily basis, whether there was an increase in patients with a particular condition.The system did detect an influenza outbreak, not related to terrorism, in a much shorter time than would have occurred with the more typical surveillance programs.

60. Other Methods of Recognizing a Covert Attack (Continued)

Laboratory confirmation is an additional way of recognizing a covert attack. Gram stains and similar Areal time@ procedures are of particular value in these settings. It must be recognized that culturing and accomplishing the special studies needed for some agents will result in serious delays. This delay presents obvious problems in dealing with exposed populations who would be demanding to know testing results at once.

61. Other Aspects of the Threat

There are other significant aspects of the threat that need to be considered. For example, there are multiple national, state, and local offices involved. For example, at the federal level alone, there are over 100 separate agencies and offices that the Office of Homeland Defense is to coordinate. Two recent exercises demonstrated problems in making coordinated, effective responses to a bioterrorism event. One, TOPOFF (for Top Officials involved) was in 2000 and involved the release of an aerosol of Yersinia pestis in Denver, Colorado The other was the Dark Winter exercise in 2001 that started with 20 confirmed cases of smallpox in Oklahoma and suspected cases in Georgia and Pennsylvania. Both involved current or former senior government officials as well as representatives from the media and the public. Both resulted in Aepidemics@ being out of control. These experiences underscore the importance of planning and practicing responses before the event.

62. Other Aspects of the Threat (Continued)

The most recent exercise, the Dark Winter smallpox exercise, also demonstrated that large scale quarantine is not likely to be effective. Incubation periods permit travel, and it is not clear how large numbers would be controlled. However, isolation of individual patients and contact tracing are appropriate for many of the Category A diseases. (See also Barbera J, Macintyre A, Gostin L et al. Large-scale quarantine following biological terrorism in the United StatesBscientific examination, logistic, and legal limits, and possible consequences. JAMA 2001; 286:2711-2717.)

63. The Need for Planning

A statement heard too often is ANo disaster will ever follow a plan, so why plan?@ The

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comment that no disaster will ever follow a plan is, of course, correct. However, experience in actual and simulated disasters and mass casualty exercise has repeatedly demonstrated that organizations that had planned, and practiced, responses took coordinated, effective actions. Those groups that had failed to plan made poorly-organized, uncoordinated responses that not only delayed provision of care but placed others who were not injured, including the Arescuers@, in jeopardy. The often-repeated phrase, AFailing to plan is planning to fail,@ is just as true in disasters as in other situations requiring effective planning.

64. Planning to Respond

The potential numbers involved in a bioterrorist event make effective planning essential. For example, large numbers of people may arrive at a medical facility requesting decontamination or treatment even if they were not in the area where an exposure occurred. Similarly, it is important to recognize that a hoax may produce the same result as an actual announced attack unless it can rapidly be disproved with Aproof@, for example through use of Areal time@ sensors.

65. Planning to Respond (Continued)

The threat is not limited to metropolitan medical facilities in that terrorists may want to test their agents in small communities where their chance of being detected would be very low. They could then determine whether or not their dispersal method was appropriate. In planning for large or small health care facilities, I believe it is important to pay particular attention to what I call the 4 ACs@. These are considered in the following slides.

66. Command and Control

The first two Cs are for ACommand and Control@. Although sounding like a military term, command and control is essential in any effective response to a mass casualty or other medical emergency. (The equivalent term used by federal and many state agencies is AIncident Command@.) There have been repeated demonstrations in actual disaster situations, as well as in exercises, of the need to have clear definition of who is in charge, who is next in charge, and the line of succession for these people. Such clear-cut definitions will avoid confusion if one or more leaders are away due to vacation, illness, or other cause. Effective command and control is critical in making decisions during the event. In the TOPOFF exercise, there was 50 to 100 people on conference calls making decisions which were then reversed the next hour and then an hour later reversed again. I have witnessed AWho=s in charge?@ problems at table-top exercisesBin one instance the heads of two agencies come very close to blows as they shouted at each other over who was in charge. Such examples emphasize that the responsibilities for command and control need to be defined early and defined clearly.

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67. Command and Control (Continued)

Crowd control is an important aspect of Command and Control requirements. As previously mentioned, it is essential to have planned ahead for the potential arrival, by foot or by vehicle, of large numbers of patients wanting decontamination or treatment. In the same manner, it is important to have plans for Atraffic control@ of people in the facility, including staff, patients, and visitors. Otherwise, hallways and other passageways in the medical facility will be blocked with resultant compromise of patient care.

Other aspects of command and control include clear-cut in-house assignments and who will replace assigned people if those assigned are unavailable.

68. Communication

Communication is a crucial aspect of any mass casualty response. Both exercises and real world situations, including a recent tornado in Salt Lake City, Utah, and the experiences on 9/11 have shown the importance of effective communications. Several events across the country have also documented the fact that cell phones and telephones may be rapidly overwhelmed. Communication requirements involving notification, patient care, supplies, and other aspects of the responses must be planned and practiced before the event. As noted during the TOPOFF exercise, exchanging fax and telephone phone numbers during the event is much too late. Dedicated radio channels and computer notification could help significantly during an actual event. Ideally, radio channels should be secure so that eavesdroppers do not listen in and spread incorrect or other information that would increase panic or other adverse aspects of an event. People using the communication systems must be trained and practice use of the systems, with emphasis on radio discipline and concise communication of the situation and requirements.

69. Communication (Continued)

Another aspect of communication is recall of medical facility staff. In some facilities, one or two people are responsible for notifying large numbers of people. Such effort requires inordinate amounts of time with resultant impacts on response capabilities. Of course, if one of the responsible persons is away, the task becomes even more difficult, and there is the potential for large numbers not being notified. Pyramid recall systems, or Aphone trees@, work much more effectively with many notified in shorter periods of time. Procedures must be defined so that all involved know what to do if a person cannot be contacted so that the Achain@ is not broken. That is, the person making the call takes over the notification responsibilities of any person who cannot be contacted.

Another concern is the use of an Aall-or-nothing@ recall as opposed to a Amodular@ recall. In view of the potential for extended 7/24 activities, it is necessary to recognize

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that it will not be possible to keep everybody in the facility for a prolonged number of days. Developing Amodules@, composed of portions of the staff, will avoid having everyone report and then wait to be sent home. If a mass casualty situation occurs that will require full staffing for a limited period, all modules can be recalled initially.

70. Coordination

Coordination is the final C. With the multiple agencies involved and needed by medical facilities, it is important to coordinate requirements and expectations with the agencies before an event actually occurs. For example, a call to the police department when crowds start arriving they may go unanswered if police are already committed elsewhere and did not have any coordinated plans to support the facility. The National Pharmaceutical Stockpile system will be able to assist in providing back-up treatment supplies, but it will be important to be able to meet initial requirements until the Stockpile responds.

71. Coordination (Continued)

Similarly, logistical support will need to be arranged for resupply of food, bedding, utensils, and other routine supplies. Planning should also include coordination with possible sources of assistance. Increasingly, cities are developing coordinated plans that will permit support from all hospitals in the area. Nearby military facilities may also be able to provide assistance if not otherwise involved in a response. The National Disaster Medical System coordinates access to approximately 100,000 hospital beds, but implementation of the system will take time. Local support will be essential until additional help at the federal or state level can be obtained.

As previously noted, it is essential in planning to recognize the potential need for 7/24 operations for a prolonged period of time. Thus, planning must provide for staff relief, rotations, and replacements as necessary.

72. Where to go for Help

Where do we go for help? Of course we can go to our own medical resources or county and state medical societies. Our local and state health departments and the Centers for Disease Control and Prevention can provide assistance as well. Many sources of assistance are on-line, and the Rocky Mountain Center for Occupational and Environmental Health=s web site (www.rmcoeh.utah.edu) has links to all the sites listed in this session.

73. Summary

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In summary, the bioterrorism threat is real and increasing. There is a change in the terrorists= philosophy so that civilians are now targets. All of us who are primary care providers must have a high index of suspicion and recognize, and promptly report, possible bioterrorist events.

74. Summary (Continued)

Medical facility planning must include responses to known or suspected bioterrorist events, and the planning should specifically include command and control, communication, and coordination. It also is important to recognize that no plan will be effective unless it is practiced frequently and all concerned know their duties and responsibilities. AReal time@ help resources can be particularly useful in planning as well as during an actual event.

75. Additional InformationBCDC=s Category B List

This slide lists CDC=s Category B criteria and provides examples.

76. CDC=s Category B List (Continued)

This slide completes the current listing of Category B agents.

77. Additional InformationBCDC=s Category C List

This slide provides the criteria for Category C agents and two examples.

78. For Further Information

This is the CDC=s primary bioterrorism site. Links are available for other aspects of bioterrorism, although some time may be required to do a search for information on some of the agents. The AProvider Information@ link will often prove particularly valuable.

79. For Further Information (Continued)

The first bullet is the American Medical Association=s site for the table listing diagnosis and treatment options for a number of possible bioterrorism agents. Should the need arise, it should be checked to assure currency.

The next bullet is the site for ACIP=s immunization guidance.

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The first bullet is CDC=s APink Book@ Chapters on immunizations for specific conditions can be printed as desired.

The second site is Johns Hopkins Center for Civilian Biodefense Studies. In addition to other information, it includes copies of the Consensus Documents for each of the Category A agents, as printed in the Journal of the American Medical Association. The

articles contain background information as well as diagnostic procedures and recommended treatment regimes.


This slide provides links for information from the U.S. Army Medical Research Institute of Infectious Diseases, and contains useful information on biological agents.


The National Institute for Occupational Safety and Health provides guidance for protecting building environments from airborne chemical, biological, or radioactive attacks; selection and use of respirators, guidance for supervisors at disaster rescue sites, and other helpful information.


Other medical organizations have bioterrorism sites, including the Association of Occupational and Environmental Clinics. This module as well as one dealing with workers= responses to the bioterrorism threat will be available on the Association=s web site. Similarly, the American Academy of Family Physicians provides bioterrorism information for health care providers. Of particular note is a site providing information on helping children after a terrorist incident. This site could be of help to parents as well as to providers.


The principal source used for response planning is in the referenced article, which includes multiple planning references.

The book, GermsBBiological Weapons and America=s Secret War (Miller, J, Engelberg S, Broad W, 2001), is an excellent summary of the development of biological weapons in

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this and other countries, focusing on the period since the 1950s. It is based on an extensive review of documents as well as large numbers of interviews with key Aplayers@, including former President Clinton, and appears to be authoritative. The discussion of future potentials is not reassuring.

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Bibliography

85. Consensus articles:

1. Inglesby TV, Henderson DA, Bartlett JG, et al: Anthrax as a biological weaponBmedical and public health management, JAMA 1999; 281:1735-1745. (See document 5 below.)2. Henderson DA, Inglesby TV, Bartlett JG et al: Smallpox as a (biological weaponBmedical and public health management, JAMA 1999; 281:2127-2137.3. Dennis DT, Inglesby TV, Henderson DA et al. Tularemia as a biological weaponBmedical and public health management. JAMA 2001; 285:2763-1773.4. Inglesby TV, Dennis DT, Henderson DA et al. Plague as a biological weaponBmedical and public health management. JAMA 2002; 283:2281-2290.5. Inglesby TV, O=Toole T, Henderson DA et al. Anthrax as a biological weapon 2002: Updated recommendations for management. JAMA 2002; 287:2236-2252.6. Borio L, Inglesby TV, Peters CJ et al. Hemorrhagic fever viruses as biological weaponsBmedical and public health management. JAMA 2002; 287:2391-2405.

2. Other

3. Henderson DA: Bioterrorism as a public health threat, Emerg Infect Dis 1998;4(3):448-492.

4. Macintyre AG, Christopher GW, Eitzen E Jr, et al: Weapons of mass destruction events with contaminated casualtiesBeffective planning for health care facilities, JAMA 2000; 283:242-249.

5. Guidotti TL: Bioterrorism and the public health response, Am J Prev Med 2000; 18:178-180.

6. Siegrist DW: The threat of biological attack: why concern now? Emerg Infect Dis 1999; 5(4):505-508.

7. Stern J: The prospect of domestic bioterrorism, Emerg Infect Dis 1999; 5(4):517-522.8. Tucker JB: Historical trends related to bioterrorism: an empirical analysis, Emerg Infect

Dis 1999; 5(4):498-504.9. Kortepeter MG, Parker GW: Potential biological weapons threats, Emerg Infect Dis

1999; 5(4):523-527.10. Friedlander AM, Pittman PR, Parker GW: Anthrax vaccineBevidence for safety and

efficacy against inhalation anthrax, JAMA 1999; 282:2104-2106.11. O=Toole T: Smallpox: an attack scenario, Emerg Infect Dis 1999; 5(4):540-546.12. Moran GJ: Biological terrorism: are we prepared?Bpart II, Emergency Medicine 2000;

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13. Booz-Allen & Hamilton Inc.(contractor to U.S. Army Edgewood Research, Development, and Engineering Center): CBDCOM Domestic PreparednessBDefense

Against Weapons of Mass Destruction: Hospital Provider Course, 1998.14. U.S. Army Medical Research Institute of Infectious Diseases: Medical Management of

Biological Casualties Handbook, Second Edition, 1996, Fort Detrick, Frederick, MD.15. Bardi J: Aftermath of a hypothetical smallpox disaster, Emerg Infect Dis 1999; 5(4):547-

551.16. National Association of County and City Health Officials: Study of electronic

communication capacity of local health departments, 1996, National Association of County and City Health Officials, Washington, D.C.

17. Hamburg MA: Addressing bioterrorist threats: where do we go from here?, Emerg Infect Dis 1999; 5(4):564-565.

18. Gerberding JL, Hughes JM, Koplan JP. Bioterrorism preparedness and responseBclinicians and public health agencies as essential partners. JAMA 2002; 287:898-901.

19. Mina B, Dym JP, Kuepper F et al. Fatal inhalational anthrax with unknown source of exposure in a 61-year-old woman in New York City. JAMA 2002; 287:858-868.

20. Freedmank a, Alonja O, Chang MW et al. Cutaneous anthrax associated with microangiopathic hemolytic anemia and coagulopathy in a 7-month-old infant. JAMA 2002; 287:869-874.

21. Mayer TA, Bersoff-Matcha S, Murphy C et al. Clinical presentation of inhalational anthrax following bioterrorism exposureBreport of two surviving patients. JAMA 2001; 286:2549-2553.

22. Borio L, Frank D, Mani V et al. Death due to bioterrorism-related inhalational anthraxBreport of 2 patients. JAMA 2001; 286:2554-2559.

23. Lane BC, Fauci AS. Bioterrorism on the home frontBa new challenge for American medicine. JAMA 2001; 286:2595-2597.

24. Barbera J, Macintyre A, Gostin L et al. Large-scale quarantine following biological terrorism in the United StatesBscientific examination, logistic and legal limits, and possible consequences. JAMA 2001; 286:2711-2717.

25. O=Toole T, Inglesby T. Shining light on Dark Winter. Biodefense Quarterly 2002 3(2):1-3 Johns Hopkins Center for Civilian Biodefense Studies. (See on-line Dark Winter site at www.hopkins-biodefense.org)

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