outbreak

					   OUTBREAK!
RECOGNIZING THE THREAT
          and
  SOUNDING THE ALARM

      Ralph M. Shealy, M.D., FACEP
  Co-Director, Bioterrorism Training Network
            South Carolina AHEC


          Francis Marion University
                Florence, S.C.
              August 12, 2005
    “Why should I
      learn about
    bioterrorism?”

“There will never be a
terrorist attack here!”
What we should really be
   concerned about
What we should really be
   concerned about
         is an

 OUTBREAK
           of
Infectious Disease!
       Remember the
Influenza Pandemic of 1917?
       Remember the
Influenza Pandemic of 1917?

Twenty to forty million deaths
  from respiratory failure.
Surely it would be different now!
Surely it would be different now!

      Modern technology.
Surely it would be different now!

       Modern technology.

   Advances in critical care.
Surely it would be different now!

       Modern technology.

    Advances in critical care.

          ICU beds.
Surely it would be different now!

       Modern technology.

    Advances in critical care.

           ICU beds.

          Ventilators.
   How many
vacant ICU beds
  do you have
in your hospital?
       In an era of
   rapid global travel,
 an infectious disease
   outbreak can be a
global catastrophe.
Do you live and work with
      people who …
Visit relatives in Brooklyn?
Visit relatives in Brooklyn?
Change planes at O’Hare?
Visit relatives in Brooklyn?
Change planes at O’Hare?
Deploy to the Middle East?
Remember the SARS
Outbreak of 2003?
Remember the SARS
Outbreak of 2003?

Came from China …
Remember the SARS
Outbreak of 2003?

Came from China …

Shut down Toronto
SARS first reported in Asia in
February 2003.

Over a few months, spread to over
two dozen countries in North America,
South America, Europe, and Asia
before it was contained.

Over 8,000 people worldwide
became sick. Almost 800 died.
Remember who died of SARS?
Remember who died of SARS?

Unprotected healthcare workers!
“The earth may be on the brink of a
worldwide epidemic from a bird flu
virus that may mutate to become as
deadly and infectious as viruses that
killed millions during three influenza
pandemics of the twentieth century.”
We haven’t even mentioned
bioterrorism yet!
          Chimera
     The Doomsday Bio-
          weapon
• Disseminated multiple simultaneous
  deadly epidemics
• Each could be spread person-to-person
• Each required a different treatment
• Each could only be treated effectively in
  the early stages
• All look like “the flu” at first
• Diagnostic features not present until
  late
Since the fall of the Soviet Union,
some of its biological arsenal and
the scientists who created it have
not been accounted for.
      Bio-Engineering
         Nightmare
Humans have
• Created drug resistant organisms
• Introduced virulence into
  organisms that are normally not
  human pathogens
Outbreaks Can Be Global
   In an age of rapid global travel, an
 outbreak that originates far from home
 can quickly arrive in your community.
 We are at risk from a
NATURAL or a MAN-
     MADE
   EPIDEMIC
      originating
  ANYWHERE!
         The
CONSEQUENCES
       could be
essentially the same.
           A Disaster:

• Threatens public health and
 safety.
          A Disaster:

• Threatens public health and
  safety.
• May destroy infrastructure.
          A Disaster:

• Threatens public health and
  safety.
• May destroy infrastructure.
• Disrupts essential services.
          A Disaster:

• Threatens public health and
  safety.
• May destroy infrastructure.
• Disrupts essential services.
• Overwhelms routine methods
 of operation.
Every DISASTER is LOCAL!
Every DISASTER is LOCAL!


It’s OURS for 72 hours!
      YOU are a
FRONT-LINE DEFENDER
 against threats to South
Carolina’s HEALTH and
       SAFETY!
  We MUST Think
“OUTSIDE THE BOX!”
  We MUST Think
“OUTSIDE THE BOX!”

Extraordinary measures
       required.
   We MUST Think
“OUTSIDE THE BOX!”

Extraordinary measures
       required.

Scope of practice changes.
    We MUST Think
“OUTSIDE THE BOX!”

 Extraordinary measures
        required.

Scope of practice changes.

Standard of care changes.
“Altered Standards of Care in Mass Casualty Events”

Office of Public Health Emergency Preparedness

U.S. Department of Health and Human Services

http://www.ahrq.gov/research/altstand/altstand.pdf
“Changes in the usual standards
of care will be required to achieve
the goal of saving the most lives in
a mass casualty event. RATHER
THAN DOING EVERYTHING
POSSIBLE TO SAVE EVERY LIFE,
it will be necessary to allocate
scarce resources in a different
manner to SAVE AS MANY LIVES
AS POSSIBLE.”
A community’s success in a
 disaster will depend on:

Effective RELATIONSHIPS
A community’s success in a
 disaster will depend on:

Effective RELATIONSHIPS
   across DISCIPLINES
A community’s success in a
 disaster will depend on:

Effective RELATIONSHIPS
   across DISCIPLINES
   and JURISDICTIONS.
Community Health Professionals
Public Health
Hospitals
Emergency Management
Law Enforcement
Fire Service
EMS
Rescue
Public Works
Business and Industry
Local, State and Federal Government
Military
Success will depend on:

Coordinated PLANNING
Success will depend on:

Coordinated PLANNING
Effective PROCEDURES
Success will depend on:

Coordinated PLANNING
Effective PROCEDURES
PRACTICE to test and refine
plans
 Natural Epidemic
        or
Man-made Epidemic?
    Natural Epidemic
           or
  Man-made Epidemic?
INITIAL course of action
          is the

       SAME!
   We must
RECOGNIZE IT
   We must
RECOGNIZE IT
 REPORT IT
   We must
RECOGNIZE IT
 REPORT IT
    and
  RESPOND
EFFECTIVELY
  Recognize an
    Outbreak
Case or a cluster of cases
        that are
  DIFFERENT
FROM THE NORM
      Disease Outbreak

• Incidence of a symptom complex
  at a rate EXCEEDING NORMAL
  BASELINE
• For a disease that is not supposed
  to occur (such as smallpox), a
  single case constitutes an outbreak.
              Red Flags


 Whenever an experienced clinician thinks,

“Hmmmm….Something ODD about this!”
   Clues to an Outbreak

• Symptoms
  – Appear in an AGE GROUP that is
    not typical
   Clues to an Outbreak

• Symptoms
  – Appear in an AGE GROUP that is
    not typical
  – Fall outside of their USUAL
    SEASON
   Clues to an Outbreak

• Symptoms
  – Appear in an AGE GROUP that is not
    typical
  – Fall outside of their USUAL
    SEASON
  – MORE SEVERE than expected
   Clues to an Outbreak

• Symptoms
  – Appear in an AGE GROUP that is
    not typical
  – Fall outside of their USUAL
    SEASON
  – MORE SEVERE than expected
  – FAIL TO RESPOND to the usual
    treatment
    Clues to an Outbreak
• A cluster of patients with
  – SYMPTOMS DEVELOPING IN
    UNISON, as though they were all
    exposed at the same time.
    Clues to an Outbreak
• A cluster of patients with
  – SYMPTOMS DEVELOPING IN
    UNISON, as though they were all
    exposed at the same time.
  – EXPOSURE TO THE SAME
    enclosed space, the same ventilation
    system, the same food or water
    source.
• Same SYMPTOMS.
• Same SYMPTOMS.
• Same TIME.
• Same SYMPTOMS.
• Same TIME.
• Same PLACE.
• Same SYMPTOMS.
• Same TIME.
• Same PLACE.


Could this be an OUTBREAK?!
       Biological Agents of
        Highest Concern
          Category A Agents
• “Easily disseminated,” infectious via aerosol
• Susceptible civilian populations
• Cause high morbidity and mortality
• Person-to-person transmission
• Unfamiliar to providers –
  difficult to diagnose/treat
• Cause panic and social disruption
• Previous development for biologic weapons
Biological Agents of
       Terror

 • Bacteria
 • Viruses
 • Biological Toxins
            Bacteria

• Anthrax

• Plague

• Tularemia
        Viruses


• Smallpox

• Viral Hemorrhagic Fevers
Biological Toxins



• Botulinum
Success in an outbreak does not depend
  on memorizing technical aspects of
  microbiology and pharmacology.
Success in an outbreak does not depend on
  memorizing technical aspects of
  microbiology and pharmacology.

Technical data and scientific understanding
  CHANGE.
Success in an outbreak does not depend on
  memorizing technical aspects of
  microbiology and pharmacology.

Technical data and scientific understanding
  CHANGE.

The MOST RECENT INFORMATION
  will quickly become available when you
  need it.
  The Ultimate
   Resource!

www.bt.cdc.go
     v
Most forms of terrorism
     are obvious.
  COVERT
  Bioterrorism
       is
NOT OBVIOUS.
Overt Biological Attack

Attack announced
Overt Biological Attack

Attack announced
Credit claimed
Overt Biological Attack

Attack announced
Credit claimed
Motive explained
Overt Biological Attack

Attack announced
Credit claimed
Motive explained
Agent identified
Overt Biological Attack

Attack announced
Credit claimed
Motive explained
Agent identified
“Lights and Sirens” response
Overt Biological Attack

Attack announced
Credit claimed
Motive explained
Agent identified
“Lights and Sirens” response
ANTHRAX LETTERS an
 example
  Covert Bioterrorism

Clandestine “sneak” attack.
  Covert Bioterrorism

Clandestine “sneak” attack.
Agent widely disseminated
  Covert Bioterrorism

Clandestine “sneak” attack.
Agent widely disseminated
Causes high morbidity and
  mortality
  Covert Bioterrorism

Clandestine “sneak” attack.
Agent widely disseminated
Causes high morbidity and
   mortality
Preferably transmitted person-
   to-person
     Covert Bioterrorism
Organisms unfamiliar to healthcare
 providers
     Covert Bioterrorism
Organisms unfamiliar to healthcare
  providers
Initial symptoms non-specific
     Covert Bioterrorism
Organisms unfamiliar to healthcare
  providers
Initial symptoms non-specific
Best treated in early stages, when difficult
  or impossible to diagnose
      Covert Bioterrorism
Organisms unfamiliar to healthcare
  providers
Initial symptoms non-specific
Best treated in early stages, when difficult or
  impossible to diagnose
Hard to treat when characteristic signs
  are apparent
    Covert Bioterrorism

• Community providers are front
  line of defense!!

• EARLY RECOGNITION AND
  APPROPRIATE RESPONSE will
  avert great loss of life.
 Syndromic Surveillance

Watches for SYMPTOM COMPLEX.
  Syndromic Surveillance

Watches for SYMPTOM COMPLEX.
Detects an unusually HIGH
 INCIDENCE of similar symptoms
 present in the community at the
 same time.
  Syndromic Surveillance
Watches for SYMPTOM COMPLEX.
Detects an unusually HIGH
 INCIDENCE of similar symptoms
 present in the community at the same
 time.
Unexplained VARIANCES FROM
 THE BASELINES can be
 recognized
  Syndromic Surveillance

• Requires seasonal BASELINE
  RATES of index symptoms
  Syndromic Surveillance

• Requires seasonal BASELINE
  RATES of index symptoms
• In order to be successful,
  reportable conditions must be
  REPORTED IN A TIMELY
  FASHION to public health
  authorities.
        During an
  Unrecognized Outbreak

• Disease is transmitted person to
  person.
        During an
  Unrecognized Outbreak

• Disease is transmitted person to
  person.
• Health providers and laboratory
  workers put at risk
        During an
  Unrecognized Outbreak

• Disease is transmitted person to
  person.
• Health providers and laboratory
  workers put at risk
• Disease progresses in the infected
Natural vs. Intentional
      Epidemic
 Many features in common.
Natural vs. Intentional
      Epidemic
  Many features in common.
    You don’t need to
 DIAGNOSE TERRORISM.
   Natural vs. Intentional
         Epidemic
      Many features in common.
         You don’t need to
     DIAGNOSE TERRORISM.
         You don’t need to
IDENTIFY A CAUSITIVE ORGANISM.
  Natural vs. Intentional
        Epidemic
     Many features in common.
         You don’t need to
     DIAGNOSE TERRORISM.
         You don’t need to
IDENTIFY A CAUSITIVE ORGANISM.
     CRITICAL TO
RECOGNIZE AND REPORT
    an OUTBREAK!
Even when we suspect something,
         we are often
RELUCTANT to REPORT
          for fear of
     BEING WRONG
             and
 LOOKING FOOLISH.
In the case of an outbreak,
       it is better to
  REPORT SUSPICIONS
     and be wrong
 than to delay reporting
    until you’re sure!
• Recognize and report
  POSSIBLE threats
• Public authorities will
  sort it out
A DHEC Epidemiology Team is on
call around the clock to investigate
potential threats to public health.

SC DHEC 24/7 Disease Reporting

     888-847-0902
If precautions are observed,
health professionals can
work safely in an
environment containing
biological agents of terror.
PERSONAL PROTECTIVE
     EQUIPMENT

PROTECT
   Eyes
   Mucous membranes
   Respiratory tract
   Skin defects
   PERSONAL PROTECTIVE
        EQUIPMENT

WEAR
   Protective Eyewear
   N 95 mask
   Gloves
   Gown or scrubs
PERSONAL PROTECTIVE
     EQUIPMENT

In other words:
     HEPA filtered air
     through fit tested mask
     with splash protection.
“SPACE SUITS”
         are
  for CHEMICALS,
for CONTAINMENT,
         and
   for the Movies!
 DECONTAMINATION OF
 EXPOSED PERSONS

Showering thoroughly with SOAP
AND WATER is adequate.

Use of bleach not necessary.
  DECONTAMINATION
Environment and Equipment

         Five percent
sodium hypochlorite solution
     for thirty minutes.
SUMMARY
An OUTBREAK of infectious disease
  ORIGINATING ANYWHERE
           on the globe
          can become a
    PUBLIC HEALTH CRISIS
      in YOUR home town.
  Whether the outbreak is of
    NATURAL ORIGIN
      or is the result of
DELIBERATE human action,
   the CONSEQUENCES
can be essentially THE SAME.
The SUCCESS of a community
in a DISASTER depends upon
  strong RELATIONSHIPS
    between DISCIPLINES
and across JURISDICTIONS.
Collaborative PLANNING,
effective PROCESSES, and
   repeated PRACTICE
     are keys to success.
PRIMARY HEALTH PROVIDERS
      are well positioned to
    DETECT an OUTBREAK
      of infectious disease.
           YOU are our
   FIRST LINE OF DEFENSE.
  Report ANY SUSPICION of
an infectious disease OUTBREAK
   to public health authorities.

     THEY will investigate.

        FEAR of making
      an unfounded report
       can COST LIVES.
         FAITHFUL use of
    ROUTINE PRECAUTIONS
offers ADEQUATE PROTECTION
 against biological agents of terror.
     SC AHEC Terrorism
           101
•   The Bacteria          • Interdisciplinary
•   The Viruses             Planning
•   The Toxins            • Pharmacological
•   Radiation               Issues
•   Explosions/Blasts     • Personal Protective
                            Equipment
•   Chemical Agents
                          • Decontamination
•   Sounding the Alarm
                          • Agricultural
•   The Forensic Proces     Bioterrorism
•   Psychosocial Issues
QUESTIONS?

				
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