Plague, Pestilence, and Forensic Pathology gy by oyc99684

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									Plague, Pestilence,
   and Forensic
    Pathology
            gy

  Michelle Barry, MD
   Office of the Medical
        Investigator
  UNM School of Medicine
Outline
    • NM Death investigation
           py
    • Autopsy cases
    • Forensic Pathology and
      public health
      – Med-X
            a
Office Medical Investigator

              • Hospital Autopsy Service
                – UNM
                – VA
              • State of NM
              • Consultation
                – Navajo Nation
                – Other states
                – Family consults
       MI
      OM
          Death 2007
Manner of D

                       Natural
                       Accident
                       Suicide
                       Homicide
                       Undetermined
              e
Medical Examiner – Major Duties
                •   Cause of Death
                •   Manner of Death
                •   Identity
                •   Testimonyy
                •   Organ/tissue procurement
                •   Public Health
   o
Autopsy
    • OMI autopsy
      –   External
      –   Internal
      –   Lab tests
      –   Histology
      –   Radiology
      xample
Case Ex
          y
     • 10 y/o male
     • h/o not feeling well x 3d
        –   Sore throat
        –   Fever
        –   Positive rapid strep
        –   Antibiotics
        days l t
     • 3d    later
        –   Fever
        –   Lethargic
        –   Unresponsive
        –   Hospital
             • Elevated WBC
             • GI bleed
             • Died
   o
Autopsy
      •   Anasarca
          A
      •   Diffuse macular rash
      •   No source GI bleed
      •   Histology
          – Thrombi
          – organisms
         m
Postmortem Cultures
               • Yersinia Pestis
                  – Culture
                  – Fluorescence
                  – CDC
               • Contacted
                  – State epidemiologist
                  – Site visit scheduled
                  – 1d later sister
                    hospitalized
               • 1d later sister
                 hospitalized
   g
   gue
Plague

   • 100 million deaths Middle
     ages ¼ population
   • 1860’s China
   • Early 20th century 10
     million deaths India
   • Worldwide distribution
   g
Plague


   • Gram negative rod
   • Transmission
     – Rodents and fleas
   • Morbidity 50%
Plague Clinical
           • Bubonic
               – Chills, fever, HA
               – Painful lymph nodes
           •   Meningeal
           •   Pharyngeal
           •   Pneumonic
           •   Septicemic
     m
Epidemiology
           • 10 per yr in SW
                 y
           • <20 yrs
           • World wide
               – 12,998
           • Prime candidate for
             bioterrorism
          u
Plague – Public Health

                      p y
                • Prophylactic
                  antibiotics
                • Environmental
                  sanitation
                • Patient education
                • Public education
                    4
                    4,
               May 14 1993



Little Water
                           Deaths,
            NM Unexplained Deaths 1993
                                         C ID,
                                         C,
                                     CDC ID         Families
OMI                     IHS          toxic
                                         cology     interviewed.   Physician
reports 3               reports 5    expeerts       CO, AZ, UT     information
deaths                  deaths       conssulted     called         letter sent
May 14                  May 17       May 18         May 19         May 24


             Family and          CDC              CDC team         CDC:
Notification community           requesteed;      arrives
                                                  arrives.         hantavirus
sent to all  contacts            Placitas         Clinical         antibody in
states       interviewed         meeting          conference       3 patients
May 25           May 26          May 27           May 29           June 4
State of NM Dept of Health
Pedestrians- Rt 666, Gallup
                  y
              • 5 years
                – 22 pedestrians struck
              • Blood ethanol .259%,
                (.115-.381%)
              • Scene:
                – Night
                – Dark clothes
                – Invisible to drivers
   666
Rt 666
Pedestrians – Epidemiology
             • Annual Estimates
               –   5,000 ped deaths
               –   85,000 nonfatal injury
               –   1 of 5 hit and run
               –   1/3 intoxicated
Pedestrians – Public Health

                       g      g
              • Investigate high risk areas
              • Understand community
                characteristics
              • Community education
                 – alcohol
OMI Med-X Surveillance

             rorism
       Bioterr
                      al
Definition of Biologica Terrorism


                        d
 The use or threatened use of biological
 agents or biologically-related toxins
         civilians,
 against civilians with the objective of
 causing fear, illness, or death.
                  rorism:
            Bioterr
                  es
    Potential Route of Exposure

•   Aerosol
•   Food
•   W t
    Water
•                    blood
    Medicine/devices/b
•   Vector
              g       rrorism Agents
         Biological Ter        g
Category A
    B. anthracis Y pestis F.      rensis smallpox virus
                                  rensis,
  – B anthracis, Y. pestis, F tular               virus,
    C. botulinum toxin, VHF virusees


Category B
  – Brucella sp, VEE, C. burnetti, B. mallei,
     i i toxin, Staphylococcus ent t i B
    ricin t i St h l               terotoxin
                                   t


  *CDC. MMWR 49(RR-4), 2000




                                                Smallpox
               Why These Agents?


•   Aerosol spread and stabi ility
•   Susceptible civilian populations
•   Morbidity and mortality
•   Person-to-person t
    P       t               mission Difficult to diagnose
                       transmi i Diffi lt t di
•                           cal
    Development for biologic warfare
  Medical Examinners/Coroners &
                 rorism
           Bioterr
• Sudden, unexplained deaths
  – homicides
  – unapparent causes
                           ectious agents
  – Eg. drugs, toxins & infe
• Respond to a known terrorist event
• Surveillance
                   to
         Response t a Known
                   st
            Terroris Event
  Homicides fall d ME/C j i di i
• H i id - f ll under M       jurisdiction
                        g
• Evidence (Murrah Bldg bombing)
                        on
• Mass disasters (aviatio accidents, heat
  wave deaths))              Anthrax
• ME/Cs part of complex x
  response team

                                             CDC
      Surveillance for a Covert
                 st
          Terroris Attack
• Sentinel fatalities
• Die at home
• Hospitalized might die precipitously or
      p             g  ep     p      y
  unexpectedly without cclear diagnosis
                    ntially Resulting
      Illnesses Poten
             from Bioterrorism
Biological threat agents
  Encephalitis             Descending paralysis
  Papulopustular rash      Hemorrhagic fever
  Hemorrhagic pneumonia    Mediastinitis
  Pneumonia
  Gastroenteritis                      Anthrax



                        aths
Unexplained illnesses/dea
       u
Med-X Surveillance
          Identify new agents
               g        q
          Recognize unique
            presentations of known
            pathogens
          Detect bioterrorism
    OMI?
Why O
 •     ntavirus
     Han
 •     eumococcal dz in daycare
     Pne
 •     ningococcal outbreak
     Men
 •   TB, plague and hepatitis C virus
             -
             -X
Designing Med-X Surveillance
               eillance System
Steps in a Surve
       Occurrence of health-related event


         Health related vent recognized
         Health-related ev
                         ng
               by reportin source


                         vent reported to
         Health-related ev
                         lic
        responsible publ health agency


     Control and         Feedback to stake holders
 prevention activities
                    tality Surveillance
    Bioterrorism Mort
                    d
                    d-X)
                 (Med X)
•   Symptoms
•   Pathology-based report
                         ting standards
•   Organism & toxin specific diagnoses
•   CDC consultation                  Anthrax
                   pt
   Symptoms to Accep Case for Autopsy
       Symptoms                  Pathologic Syndrome
           p      y y p
Fever & respiratory symptoms                  ,         g
                               Pneumonia & DAD, hemorrhagic
                               mediastinitis
Flu-like symptoms              Pneumonia & DAD, sepsis,
                               encephalitis/meningitis,
                               encephalitis/meningitis myocarditis
Descending paralysis,          Botulinum toxin, nerve agents,
polyneuropathy
p y      p y                   organophosphates
New fatal rash                 Diffuse rash, sepsis & DIC
New jaundice                   Hepatitis & hepatic necrosis
Encephalopathy or new-onset    Meningitis, encephalitis, toxins
seizures
Bloody diarrhea w/o melena     Hemorrhagic colitis
Unexplained death
                  ndromic Surveillance
Pathology-based Syn
Autopsy Syndrome                       BT
                             Potential B Illness          Public Health Benefit
Community-acquired                        emia, Q fever,
                             Plague, tulare               Flu, HPS, pneumococcal &
pneumonia, Diff    l   l
        i Diffuse alveolar   i h l d staph enterotoxin B, other b t i l viral
                             inhaled t h t t i B           th bacterial, i l
damage (ARDS)                ricin, phosgen Cl, other
                                          ne,             pneumonias
                             gases
Diffuse rash                      p
                             Smallpox, VHFs, T-2          Varicella, measles,
                             mycotoxins                   rickettsial, enterovirus,
                                                          meningococcal infections,
                                                          dengue, staph TSS
                 ie.
Sepsis syndromes ie DIC      Plague tulare
                             Plague,     emia, anthrax,
                                         emia anthrax           strep, meningococcal,
                                                          Gp A strep meningococcal
                             VHFs, T-2 myycotoxins        pneumococcal, leptospiral,
                                                          yellow fever, rickettsial
                                                          infect.
H      h i
Hemorrhagic mediastinitis
              di ti iti      A th
                             Anthrax                      P l        leptospirosis &
                                                          Pulmonary l t     i i
or meningitis                                             H. simplex encephalitis


Encephalitis,
Encephalitis meningitis                 er
                             VEE and othe equine          Viral, bacterial,
                                                          Viral bacterial fungal
                             encephalomyeelitis agents    encephalitides &
                                                          meningitides
                      ic
           OMI Syndromi Surveillance
                                                       DOH
                                                      notified

                                                                 Potential
                Symptoms                 Syndrome                BT case


Investigator
                                   y
                             Autopsy            Lab-specific Dx
  notified

               No symptoms              No syndrome          Not potential
                                                              BT case

                                    y
                           No autopsy
                     of
            Registry o Deaths
                         ts
• Infectious & toxic agent potentially used in BT
                         xic
• Infectious disease & tox syndromes w/o
  causative agent
           serum,       and
• Banked serum blood a tissue specimens
                   s
          Infectious Disease
         Death Rev view Team
• Monthly examine auto opsies w/ demonstrated or
  suspected infections
                       c
• Members: ID, forensic & clinical pathology,
    i bi l         id iology, public h l h
  microbiology, epidemiol        bli health
                        gens, unusual clinical or
• Identify notable pathog
  pathologic syndromes, epidemiologic settings
• Monitor sentinel popul
                   p p lations
Med-X Surveillance Data – 1 Year

                      otal
• 150 (4.7%) of 3196 to cases met entry
  criteria including:
  – 4.3% OMI jurisdiction cases (2910)
  – 11.7% UNM hospital c consent autopsies (77)
  – 8.0% VA hospital conssent autopsies (25)
  – 6.0% Navajo Nation cconsultation autopsies (184)
• 100 (67%) had pathologic syndrome
                    Categories
            Disease C
•   Infectious disease 95 (63%)
•   Toxin-related 14 (9%)
    Toxin related
•   Other 31 (21%)
•   Undetermined 10 (7%)
    U d t     i d
                       sease Deaths
          Infectious Dis
                               2
Organism-specific diagnosis- 72 (76%) cases
                               M-
   – Notifiable conditions in NM 34 (47%) cases
      •   S. pneumoniae               18
      •   H. influenzae                4
      •   Group A streptococcus
                p        p             7
      •   M. tuberculosis              1
      •   Botulism                     1
      •   AIDS                         1
      •   S. enteriditis               1
      •   Hepatitis C virus            1
                     f
   Predictive Value of Med-X Symptoms
                 Number           us
                          Infectiou    Toxin     Other      Undetermined
                           Diseasee
Flu like
Flu-like           68             %)
                            49 (72%     2 (4%)   16 (24%)      1 (1%)
symptoms

Fever &            48          ( %)
                            36 (75%)    2 (4%)
                                          ( )       (   )
                                                  9 (19%)        ( )
                                                               1 (2%)
Respiratory

Unexpected         28             %)
                             6 (21%    6 (21%)    8 (29%)     8 (29%)
Death

Encephalopathy     12             %)
                             6 (50%    2 (17%)    3 (25%)      1 (8%)
   Seizures
or S i
                                                    ic
                                            Pathologi Syndrome
                         PN-
                         PN    Rash   Sepsis   Hepatitis      eph-
                                                              eph
                                                           Ence      Pharyn
                                                                     Pharyn-   Myocard
                                                                               Myocard-   Bronch-
                                                                                          Bronch    STI   None   Total
                         DAD                                   tis
                                                            alit      gitis      itis       itis
           Flu-like      36     3       4         2          1         3          0         5       7      22     83

           Fever +       32     2       1         3          1         3          0         5       2      12     61
           Respiratory
      ms




           Seizures       3     0       2         0          1         0          0         1       0      6      13
 ymptom




           Encephalo.
           Paralysis      1     0       0         0          0         0          1         0       1      0      3
           Polyneuro.
           Rash           1     1       1         0          0         0          0         0       1      0      4
Sy




           Jaundice       0     0       1         2          0         0          0         0       0      0      3


           Bloody         0     0       0         0          0         0          0         0       0      1      1
           Diarrhea
           Unexpected     4     0       0         0          0         0          1         0       1      23     29
           Death
           Total
           T t l         77     6       9         7          3         6          2         11      12     64
                ce:
   ME Surveillanc Conclusions
                        ver
• Flu-like symptoms, fev & respiratory
   y p       ,
  symptoms, and encep  p      p y
                       phalopathy/new-onset
  seizures highly predicttive of infections
• Sudden unexpected death less likely to
  represent an infection
  Organism-specific
• Organism specific diag gnoses are possible in
                        ths
  the majority of ID deat
                 ase
  Infectious Disea Emergence
                      within past 20 years
• Increased incidence w
• Threatened increase in near future

        g
• Changes/evolution of e       g g
                        existing organisms
• Spread of known orga anisms to new areas or
  p p
  populations
                       usly
• Occurrence of previou unrecognized
                    g environments
  infections in changed e
          c
Surveillance Systems
          • DAWN
          • ME and Coroner’s Alert
            Project
          • FDA MedWatch Medical
            Products
          • FARS
          • MECISP
          • OSHA
          • Pediatric toxicology registry
          • Med-X
                 y
Forensic Pathology and Public Health
                  • Epidemiology
                     – Death Certificate
                  • Front lines for
                     –   Emerging epidemics
                     –   Bioterrorism
                     –   Safety issues
                     –   Prevention
                         P       i
   s
Questions

								
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