Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce
Diseases of Bioterrorist Potential: Overview
Developed by
Jennifer Brennan Braden, MD, MPH
NorthwestCenter for Public Health Practice
University of Washington
Seattle, Washington
*This manual and the accompanying MS Powerpoint slides are current as of Dec 2002. Pleaserefer to updates to the material.
Acknowledgements
This manual and the accompanying MS PowerPoint slides were prepared for the purpose of educating the public health workforce in relevant aspects of bioterrorism preparedness and response. Instructors are encouraged to freely use portions or all of the material for its intended purpose.
Project Coordinator
Patrick O’Carroll, MD, MPH
NorthwestCenter for Public Health Practice, University of Washington, Seattle, WA
Centers for Disease Control and Prevention; Atlanta, GA
Lead Developer
Jennifer Brennan Braden, MD, MPH
NorthwestCenter for Public Health Practice, University of Washington, Seattle, WA
Design and Editing
Judith Yarrow
Health Policy Analysis Program, University of Washington, Seattle, WA
The following people provided technical assistance or review of the materials:
Jeffrey S. Duchin, MD: Communicable Disease Control, Epidemiology and Immunization Section, Public Health – Seattle & KingCounty
Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA
Jane Koehler, DVM, MPH: Communicable Disease Control, Epidemiology and Immunization Section, Public Health – Seattle & KingCounty; Seattle, WA
Dennis Anderson, MA: Office of Risk and Emergency Management, Washington State Department of Health; Olympia, WA
Nancy Barros, MA: State of Alaska, Division of Public Health; Juneau, AK
Janice Boase, RN, MS, CIC: Communicable Disease Control, Epidemiology and Immunization Section Public Health – Seattle & King County, Seattle, WA
Jeanne Conner, RN, BSN: Sweet Grass Community Health; Big Timber, MT
Marcia Goldoft, MD, MPH: Communicable Disease Epidemiology, Washington State Department of Health; Shoreline, WA
Nancy Goodloe: Kittitas County Health Department; Ellensburg, WA
Sandy Kuntz, RN: University of MontanaSchool of Nursing; Missoula, MT
Mike McDowell, BSc, RM: Public Health Laboratories, Washington State Department of Health; Shoreline, WA
Patrick O’Carroll, MD, MPH: Centers for Disease Control and Prevention; Atlanta, GA
Maryann O’Garro: Grant County Health Department, Ephrata, WA
Carl Osaki, RS, MSPH: Department of Environmental Health, University of Washington; Seattle, WA
Sandy Paciotti, RN, BSN: Skagit County Health Department, Mount Vernon, WA
Eric Thompson: Public Health Laboratories, Washington State Department of Health; Shoreline, WA
Matias Valenzuela, Ph.D.: Public Health – SeattleKingCounty; Seattle, WA
Ed Walker, MD: Department of Psychiatry, University of Washington, Seattle, WA
Contact Information
NorthwestCenter for Public Health Practice
School of Public Health and Community Medicine
University of Washington
1107 NE 45th St., Suite 400
Seattle, WA98105
Phone: (206) 685-2931, Fax: (206) 616-9415
Table of Contents
About This Course...... 1
How to Use This Manual...... 3
Diseases of Bioterrorist Potential: Overview...... 4
Learning Objectives (Slide 4)...... 5
Biological Agents of Highest Concern (Slides 5-7) ...... 6
Overview of Symptoms and Treatment (Slides 8-10)...... 7
Patient Decontamination and Infection Control (Slides 11-15)...... 9
Mail Safety (Slides 16-19)...... 11
Summary of Key Points (Slides 20-21) ...... 12
Resources (Slides 22-24) ...... 12
Quick References for Health Care Providers (Slide 25)...... 13
References ...... 14
Appendix A: Modules...... 20
Appendix B: Glossary...... 21
Last Revised December 2002
1
Diseases of Bioterrorist Potential Overview
About This Course
Preparing for and Responding to Bioterrorism:Information for the Public Health Workforce is intended to provide public health employees with a basic understanding of bioterrorism preparedness and response and how their work fits into the overall response. The course was designed by the NorthwestCenter for Public Health Practice in Seattle, Washington, and Public Health – Seattle & KingCounty’s Communicable Disease, Epidemiology & Immunization section. The target audience for the course includes public health leaders and medical examiners, clinical, communicable disease, environmental health, public information, technical and support staff, and other public health professional staff. Health officers may also want to review the more detailed modules on diseases of bioterrorism in Preparing for and Responding to Bioterrorism: Information for Primary Care Clinicians: NorthwestCenter for Public Health Practice (available at Public health workers are a very heterogeneous group, and the level of detailed knowledge needed in the different aspects of bioterrorism preparedness and response will vary by job description and community. Therefore, the curriculum is divided into modules, described in Appendix A.
The course incorporates information from a variety of sources, including the Centers for Disease Control and Prevention, the United States Army Medical Research Institute in Infectious Disease (USAMRIID), the Working Group on Civilian Biodefense, the Federal Emergency Management Agency, Public Health – Seattle & King County, and the Washington State Department of Health, among others (a complete list of references is given at the end of the manual). The curriculum reflects the core competencies and capacities outlined in the following documents:
CDC. Bioterrorism preparedness and response: core capacity project 2001 (draft), August 2001.
CDC. Cooperative Agreement U90/CCUXXXXXX-03-X Public Health Preparedness and Response for Bioterrorism.
CDC. The public health response to biological and chemical terrorism: interim planning guidance for state public health officials, July 2001.
Center for Health Policy, ColumbiaUniversitySchool of Nursing. Core public health worker competencies for emergency preparedness and response, April 2001:
Center for Health Policy, ColumbiaUniversitySchool of Nursing. Bioterrorism and emergency readiness: competencies for all public health workers (preview version II), November 2002.
The course is not copyrighted and may be used freely for the education of public health employees and other biological emergency response partners.
Course materials will be updated on an as-needed basis with new information (e.g., guidelines and consensus statements, research study results) as it becomes available. For the most current version of the curriculum, please refer to:
How to Use This Manual
This manual provides the instructor with additional useful information related to the accompanying MS PowerPoint slides. The manual and slides are divided into six topic areas: Introduction to Bioterrorism, Emergency Response Planning, Diseases of Bioterrorist Potential, Health Surveillance and Epidemiologic Investigation, Consequence Management, and Communications. Links to Web sites of interest are included in the lower right-hand corner of some slides and can be accessed by clicking the link while in the “Slide Show” view. Blocks of material in the manual are periodically summarized in the “Key Point” sections, to assist the instructor in deciding what material to include in a particular presentation. A Summary of Key Points is indicated in bold, at the beginning of each module.
The level of detailed knowledge required may vary for some topics by job duties. Therefore, less detailed custom shows are included in the Emergency Response Planning and Diseases of Bioterrorist Potential: Overview modules for those workers without planning oversight or health care responsibilities, respectively. In addition, there are three Consequence Management modules: for public health leaders, for public health professionals, and for other public health staff (see Appendix A).
This module serves as an introduction to diseases of bioterrorist potential, and may be an adequate coverage of this topic for public health workers without health care, disease education, or investigation responsibilities (e.g., administrative support staff).More detailed disease-specific information is included in other modules in this section.
Diseases of Bioterrorist Potential
Summary of Key Points (Slides 20-21)
- Most of the biological agents of concern produce an initial non-specific or “flu-like” illness.
- Standard precautions should be used with all patients following a bioterrorism incident.
- Additional precautions are required with a few biological agents, where person-to-person transmission is possible.
- Notify building security and local law enforcement if a suspicious package or substance is received.
- If a suspicious substance, remove contaminated clothing, and wash with soap and water.
Slide 1: Curriculum Title
Slide 2: Acknowledgements
Slide 3: Module Title
Learning Objectives (Slide 4)
The learning objectives for this module are:
- Develop an awareness of the potential agents that might be used in a bioterrorism event
Identify contagious agents
Describe the types of illness caused by the agents
Identify agents that might require public health to provide immunizations or antibiotics to exposed persons
- Describe how to respond if a suspicious package or substance is received
Biological Agents of Highest Concern (Slides 5-7)
CDC has designated critical agents with potential for use as biological weapons and grouped them according to level of concern (Rotz et al., Emerging Infect Dis 2002;8(2):225-230).Several factors determine the classification of these agents, including previous use or development as a biological weapon, ease of dissemination, ability to cause significant mortality or morbidity (negative consequences of disease, other than death), and infectious nature.
Category A agents are designated agents of highest concern. They are listed in slide 5. Category A agents includevariola major (smallpox), Bacillus anthracis (anthrax), Yersinia pestis (plague), Francisella tularensis (tularemia), Clostridium botulinum toxin (botulism), and the filoviruses and arenaviruses (hemorrhagic fever viruses).
Category B agents are of the next highest level of concern and are listed in slides 6 and 7.These agents are moderately easy to disseminate and produce lower mortality and moderate morbidity.A subset of the Category B agents includes food- and water-borne agents.Note that these agents are also a routine cause spontaneous disease (isolated cases and outbreaks).
Overview of Symptoms and Treatment (Slides 8-10)
Most of the critical agents produce an initial nonspecific or “flu-like.” The clinical presentation and disease course of infections in the context of bioterrorism may differ from descriptions of naturally occurring infections, as was observed in the 2001 anthrax outbreak.Coughor pneumonia are potential illnesses from anthrax, plague, tularemia, Q-fever, brucellosis, glanders, ricin toxin, and Staphhlococcus enterotoxin B.Skin lesions are possible with anthrax, tularemia, and plague if contact with a break in the skin (such as a cut) has occurred.Smallpox produces a characteristic rash that progresses from macules to vesicles, pustules, and scabs.Ebola and Marburg viruses (viral hemorrhagic fevers) produce an erythematous macular rash.Botulinum toxin causes a paralysis that begins in the facial muscles and later progresses to the arms and legs (temporary, but recovery may take weeks to months). Diarrhea and vomiting are typical symptoms resulting from ingestion of food and water-borne agents and may also be present with other agents if ingested.Headache and confusion are typical with the causative agents of viral encephalitis and may also be present with other agents.
Most of the critical agents are not transmitted person-to-person.Smallpox and plague can be transmitted via respiratory secretions.Some viral hemorrhagic fevers can be transmitted via body fluids (e.g., blood, secretions, urine, feces).Food- and water-borne agents can be transmitted via the fecal-oral route (For example, insufficient hand-washing followed by food preparation can infect those subsequently eating the food).
Slide 10 lists biological agents for which prophylaxis of exposed persons with antibiotics or immunization might prevent development of disease.The anthrax vaccine has been used for post-exposure prophylaxis (under an investigational new drug protocol), but is usedonly in combination with antibiotics.
Patient Decontamination and Infection Control (Slides 11-15)
Extensive decontamination after exposure to the critical agents is not necessary; soap and water is adequate in most cases.Intact skin serves as an effective barrier for the biological agents of concern.Requirements for the decontamination of facilities and equipment varies by agent (see module on environmental sampling and decontamination) and may include disinfectant agents such as bleach, sporicidal agents such as paraformaldehyde, incineration, or autoclaving.
The causative agents of plague and botulism have short survival times in the environment, and thus, environmental decontamination may not be necessary if the area can be isolated from people for an appropriate period of time (one hour and two days, respectively).
Intact skin (cuts/breaks in the skin are a portal of entry for B. anthracis, Y. pestis, & F. tularensis) is a barrier to the Category A-C critical agents, and few agents are transmitted person-person (smallpox and pneumonic plague are transmitted person to person). Thus, Level D personal protective equipment is usually sufficient for public health workers who will have contact (i.e., for interviewing and information-gathering purposes) with potentially exposed individuals. This principle does not apply to personnel entering a suspected or confirmed site of release or dissemination (e.g., emergency workers or environmental samplers) or workers in contact with patients known to be contaminated with a biological agent (see references listed below).
CDC. Protecting investigators performing environmental sampling for Bacillus anthracis:personal protective equipment.
CDC. Interim recommendations for the selection and use of protective clothing and respirators against biological agents. (
Arnold JL & Lavonas E. CBRNE – personal protective equipment. eMedicine Journal 2001;2(10).
If the agent is known, the following precautions apply (USAMRIID, 2001 and Borio et al., JAMA 2002;287:2391-2405 ):
Smallpox and Viral Hemorrhagic Fevers – airborne and contact precautions
Pneumonic Plague – droplet precautions
Mail Safety(Slides 16-19)
Slides 16-19 address the recognition and response to suspicious pieces of mail.It is important to note all persons in the building at the time a suspicious substance was discovered.If laboratory studies confirm the presence of a biological agent of concern, exposed individuals may require antibiotic prophylaxis. Turning off the air conditioning system will help to prevent further spread of the substance to other rooms sharing the same ventilation system.
Summary of Key Points (Slides 20-21)
Resources(Slides 22-24)
Quick References for Health Care Providers
Slide 25 lists sources of quick references on the Category A-C diseases (e.g., fact sheets, PDA applications) for health care providers.
References
General Bioterrorism Information and Web Sites
AmericanCollege of Occupational and Environmental Medicine. Emergency Preparedness/Disaster Response. January 2002.
Centers for Disease Control and Prevention. Public Health Emergency Preparedness and Response. January 2002.
Center for the Study of Bioterrorism and Emerging Infections at Saint LouisUniversitySchool of Public Health. Home Page. January 2002.
Historical perspective of bioterrorism. Wyoming Epidemiology Bulletin;5(5):1-2, Sept-Oct 2000.
Journal of the American Medical Association. Bioterrorism articles. April 2002.
JohnsHopkinsCenter for Civilian Biodefense Studies. Home Page. January 2002.
Pavlin JA. Epidemiology of bioterrorism. Emerging Infect Dis [serial online] 1999 Jul-Aug; 5(4).
Tucker JB. Historical trends related to bioterrorism: an empirical analysis. Emerging Infect Dis [serial online] 1999 Jul-Aug; 5(4).
Washington State Department of Health. Home Page. January 2002.
Emergency Response Planning
Bioterrorism and emergency response plan clearinghouse.
Butler JC, Mitchell LC, Friedman CR, Scripp RM, Watz CG. Collaboration between public health and law enforcement: new paradigms and partnerships for bioterrorism planning and response. Emerging Infect Dis [serial online] 2002 Oct; 8(10):1152-55.
CDC. Biological and chemical terrorism: strategic plan for preparedness and response. MMWR Recommendations and Reports 2000 April 21;49(RR-4):1-14.
CDC. Bioterrorism preparedness and response: core capacity project 2001 (draft), August 8, 2001.
CDC. Cooperative agreement U90/CCUXXXXXX-03-Xpublic health preparedness and response for bioterrorism.
CDC. The public health response to biological and chemical terrorism: interim planning guidance for state public health officials, July 2001.
Center for Health Policy, ColumbiaUniversitySchool of Nursing. Bioterrorism and emergency readiness: competencies for all public health workers (preview version II), November 2002.
Center for Health Policy, ColumbiaUniversitySchool of Nursing. Core public health worker competencies for emergency preparedness and response, April 2001.
Environmental Protection Agency. Emergency planning and community right-to-know act overview.
Federal Emergency Management Agency. Emergency management guide for business & industry.
FederalEmergencyManagementAgency & United StatesFireAdministration-NationalFireAcademy. Emergency response to terrorism: self-study (ERT:SS) (Q534), June 1999.
Federal Emergency Management Agency. Independent study course on the incident command system.
Medical response in emergencies: HHS role.
Public Health Program Office, Centers for Disease Control and Prevention. Local emergency preparedness and response inventory, April 2002.
Washington state comprehensive emergency management plan.
Health Surveillance and Epidemiologic Investigation
CDC. Case definitions under public health surveillance. MMWR; 1997:46(RR-10):1-55.
CDC. Updated guidelines for evaluating public health surveillance systems: recommendations from the Guidelines Working Group. MMWR. 2001; 50(RR13):1-35.
CDC Epidemiology Program Office. Excellence in curriculum integration through teaching epidemiology (Web-based curriculum).
Koehler J, Communicable Disease Control, Epidemiology & Immunization Section, Public Health – Seattle & KingCounty. Surveillance and Preparedness for Agents of Biological Terrorism (presentation). 2001.
Koo, D. Public health surveillance (slide set).
List of nationally notifiable infectious diseases.
Lober WB, Karras BT, Wagner MM, Overhage JM, Davidson AJ, Fraser H, et al.Roundtable on bioterrorism detection: information system–based surveillance. JAMIA 2002;9:105-115.
Diseases of Bioterrorist Potential
Advisory Committee on Immunization Practices (ACIP). Use of smallpox (vaccinia vaccine), June 2002: supplemental recommendation of the ACIP.
Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deithman SD. HICPAC. Guideline for infection control in health care personnel, 1998. Am J Infect Control 1998;26:289-354.
Breman JG & Henderson DA. Diagnosis and management of smallpox. N Engl J Med 2002;346(17):1300-1308.
CDC. CDC Responds: Smallpox: What Every Clinician Should Know, Dec. 13th, 2001.
Webcast:
CDC. CDC Responds: Update on Options for Preventive Treatment for Persons at Risk for Inhalational Anthrax, Dec 21, 2001.
Webcast:
CDC. Considerations for distinguishing influenza-like illness from inhalational anthrax. MMWR 2001;50(44):984-986.
CDC. Notice to readers update: management of patients with suspected viral hemorrhagic fever – United States. MMWR. 1995;44(25):475-79.
CDC. The use of anthrax vaccine in the United States. MMWR 2000;49(RR-15):1-20.