BNICE and Tularemia

8/2/2019 BNICE and Tularemia

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Dr. Casto asked me to accomplish 6 things in this presentation- given that I have less than 30 minutes to do so, I have achallenge before me.

These are the six things he wanted me to cover (go over

them).

Through this talk I will also emphasize four essentials incombating terrorism - those are

1. Early recognition of the event

2. Early management of the event

3. Knowing whom to contact, and

4. Working together as a multidisciplinary team and

understanding your role on that team.

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An Introduction to the Bioterrorist ThreatAn Introduction to the Bioterrorist Threat

BNICE 101BNICE 101

Purposes of PresentationPurposes of Presentation Background onBackground on The Ohio Center ofThe Ohio Center of

Excellence for Bioterrorism Preparedness andExcellence for Bioterrorism Preparedness andResponseResponse

Role ofRole of Interprofessional CourseInterprofessional Course

How you can help usHow you can help us

Review the importance of collaborationReview the importance of collaboration

DiscussDiscuss Case of the Mysterious IllnessCase of the Mysterious Illness

TularemiaTularemia -- what is it?what is it? Tularemia and bioterrorismTularemia and bioterrorism


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11 September 200111 September 2001

The Attack on the USThe Attack on the US

Source: www.thaibase.com/news/wtc/imagesSource: www.thaibase.com/news/wtc/images

We all remember September 11, 2001, the day whenterrorists attacked both the World Trade Center in NewYork City and the Pentagon in Washington DC. Also, 40individuals lost their lives when United Airlines Flight 93

crashed into a Pennsylvania field.


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Threat TrendsThreat Trends

BB

NN

II

CCEE

CyberCyber

Weapons ofWeapons of

Mass DestructionMass Destruction

Terrorists such as these are not hesitant to use weaponsof mass destruction. And these weapons are not justbiological (point to the letter B in the circle above), whichwe think of when we hear the word, bioterrorism.These weapons also involve (point at each letter in thecircle above) - nuclear, incendiary, chemical, explosive,and cyber terrorism.


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The greatest threat to the United States and its citizensThe greatest threat to the United States and its citizens

in the first decade of the 21st century will not comein the first decade of the 21st century will not come

from a military confrontation. Rather, it will come fromfrom a military confrontation. Rather, it will come from

an attack within our borders from a single individual oran attack within our borders from a single individual or

group that has access to weapons of mass destruction,group that has access to weapons of mass destruction,

including large conventional explosives and nuclear,including large conventional explosives and nuclear,

chemical or biological weapons.chemical or biological weapons.COL Ed Eitzen, Senior Medical Advisor to the US Assistant SecretCOL Ed Eitzen, Senior Medical Advisor to the US Assistant Secretary for Publicary for Public

Health Emergency Preparedness.Health Emergency Preparedness.

Dr. Ed Eitzen, the Senior Medical Advisor to the USAssistant Secretary for Public Health EmergencyPreparedness, emphasized that,

The greatest threat to the US and its citizens in the firstdecade of the 21st century will not come from a militaryconfrontation. Rather, it will come from an attack withinour borders from a single individual or group that hasaccess to weapons of mass destruction, including largeconventional explosives and nuclear, chemical orbiological weapons.


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Terror Is a Weapon ItselfTerror Is a Weapon Itself

The realThe real force multiplierforce multiplier ininbioterrorism is the panic,bioterrorism is the panic,

misinformation and paranoiamisinformation and paranoiaassociated with it.associated with it.

Sidell FR, Patrick WC, Dashiell TR.Janes Chem-Bio Handbook.

Alexandria, VA, Janes Information Group, 1998.

However, the biggest threat is not the weaponsthemselves, but the terror that is associated with thatthreat. Recall what our nation went through a few yearsago when small towns across the US were trying toprepare for a potential chemical attack. Remember therun on duct tape as people were sealing their basements,often cutting off their own oxygen supply? It has beendocumented in prior attacks that for every one personwho is injured physically, there are four individuals whoare injured emotionally.


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The major purpose of terrorism is not to kill, but to createdisabling fear and panic.


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Terrorism forces us to make a choice.Terrorism forces us to make a choice.

We can be afraid. Or we can be ready.We can be afraid. Or we can be ready.Tom Ridge, U.S. Department of Homeland Security, www.ready.govTom Ridge, U.S. Department of Homeland Security, www.ready.gov

But as Tom Ridge, the Former Director of HomelandSecurity, points out, terrorism forces us to make achoice. We can be afraid. Or we can be ready.


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The Ohio Center of Excellence for BioterrorismThe Ohio Center of Excellence for Bioterrorism

Preparedness and ResponsePreparedness and Response

RationaleRationale

A need exists to train healthcareA need exists to train healthcare

professional students to beprofessional students to be

prepared to respond to terroristprepared to respond to terrorist

acts and other public healthacts and other public health

emergenciesemergencies

Which brings to our Center. Todays talk has beenpossible through the efforts of over 50 healthcareproviders who have come together, thanks to a grantfrom HRSA, to develop The Ohio Center of Excellencefor Bioterrorism Preparedness and Response. Thiscenter was created because a need exists to trainhealthcare professional students to be prepared torespond to terrorist attacks and other public healthemergencies and major natural disasters.

This center is a collaborative effort of The Ohio StateUniversity, the University of Cincinnati, Ohio University,

and Northeastern Ohio Universities College of Medicinein the disciplines of allied medical professions, medicine,nursing, and public health.


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What Every Health CareWhat Every Health Care

Provider Should KnowProvider Should Know1.1. Early recognitionEarly recognition

2.2. Early managementEarly management

3.3. Whom to notifyWhom to notify

4.4. How to work together as a teamHow to work together as a team

The Centers goal is that each health care professional student,prior to graduation, will be able to

1. Recognize early a potential bioterrorist attack. Nuclear andconventional explosions are easy to detect. However,

biological and chemical attacks are often less obvious, andrequire a heightened sense of awareness and attention tosubtle clues.

2. Manage the early events of an attack, including what to dopersonally, what to do with your colleagues, and what to dowith your patients. This task also includes the management ofpanic and hysteria that commonly follows the attack.

3. Know who to notify if you suspect a terrorist attack. And

4. Work together in a multidisciplinary team, knowing your role onthe team, and the roles of others.


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What do we mean by prepared?What do we mean by prepared?

the right place on the continuumbetween mindless complacency and

all consuming paranoia

Dr. Irwin Redlener, Associate Dean & DirectorThe National Center for Disaster Preparedness

MindlessComplacency

All ConsumingParanoia

And when we talk about needing to be prepared for aterrorist attack, we are talking about being at the rightplace on the continuum between mindless complacency,which can easily occur when it has been a while sincethe last attack, and all consuming paranoia, which occursin the event of an attack.


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BNICE 101BNICE 101

BBiologicaliological

NNuclearuclear

IIncendiary/firencendiary/fire

CChemicalhemical

EExplosivexplosive

As mentioned earlier, bioterrorism goes beyond just abiological attack. It also includes nuclear, incendiary,

chemical, and explosive weapons. However, for tonight,I will focus on the potential biological weapons, and oneagent in particular.


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Bioterrorism DefinedBioterrorism Defined

Unlawful release of biologic agents or toxinsUnlawful release of biologic agents or toxins

IntentIntent

to intimidate or coerce a government orto intimidate or coerce a government orcivilian population to further political orcivilian population to further political orsocial objectivessocial objectives

TargetsTargets -- humans, animals, plantshumans, animals, plants

First recognized by the astute person in theFirst recognized by the astute person in thecommunitycommunity

Bioterrorism is defined as the unlawful release ofbiological agents or toxins with the intent to intimidate orcoerce a government or civilian population to furtherpolitical or social objectives.

Targets can include humans, animals, and plants.

It is highly probable that an astute person in thecommunity, not the traditional first responders such asfire fighters and law enforcement, will be the first to

recognize that a bioterrorist event has occurred.


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Biological Agents as WMDBiological Agents as WMD

Relatively easy to obtainRelatively easy to obtain

Technology easily concealedTechnology easily concealed

Terrorist organizations are interested in using biologicalagents as weapons of mass destruction for a number ofreasons. First, these agents typically can be obtainedfrom soil, water, animals, clinical specimens and clinicalresearch labs. Second, technology used to produceantibiotics, vaccines, and other industrial and foodproducts can be converted to making biological agents,which can be easily concealed.


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Characteristics of a GoodCharacteristics of a Good

Biological AgentBiological Agent

Pathogenic at low dosesPathogenic at low doses

High rate of morbidity & mortalityHigh rate of morbidity & mortality

Highly infectiousHighly infectious

Difficult to diagnose and treatDifficult to diagnose and treat

Insidious at onsetInsidious at onset

Easy, fast, and cheap to produceEasy, fast, and cheap to produce Concentrated for distributionConcentrated for distribution

Adaptable to weapons systemsAdaptable to weapons systems Name causes fear and panicName causes fear and panic

Those biological agents that are ideally used forbioterrorism have these characteristics. They causedisease, which can be severe, at low doses. They resultin a high rate of morbidity and death. They are highlyinfectious, but not always contagious. They are difficultto diagnose and to treat and are insidious in onset. Theyare easy, fast, and cheap to produce, and can beconcentrated for easier distribution. They can beadaptable to weapons systems. And, their names causefear and panic among the public.


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Popular Interest in BioterrorismPopular Interest in Bioterrorism

It is quite clear that there is growing concern that the

people of the United States might be subjected tobioterrorism assaults. This manifests itself in multipleways. It shows in the growing press coverage of thethreat. It also shows up in popular culture: here arenearly two dozen novels that include incidents of the useof biological agents by criminals and terrorists as acentral theme. It also shows up in the increasing numberof comments about the threat by non-US government

experts and by senior US officials.


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Biological AttackBiological Attack

TransmissionTransmission

AerosolAerosol

GastrointestinalGastrointestinal

TranscutaneousTranscutaneous

The three major ways in which biological agents can betransmitted are through aerosol, through the GI tract, andthrough the skin.


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Biological AttackBiological Attack -- AerosolAerosol

Effectively delivered as anEffectively delivered as anaerosolaerosol

ProtectionProtection

Protective maskProtective mask

2 to 3 layers of cotton2 to 3 layers of cotton

Several layers of tissue orSeveral layers of tissue orpaper towelspaper towels

Explosives are inefficientExplosives are inefficient

delivery systemsdelivery systems

Many biological agents are effectively delivered as anaerosol. If a protective mask is not readily available,cover your mouth and nose with layers of fabric that canfilter the air but still allow for breathing. Examples include2 to 3 layers of cotton such as a T-shirt, handkerchief, ortowel. Otherwise, several layers of tissue or papertowels may help.

Explosives are inefficient delivery systems becausethe heat generated by the explosion will inactivate mostof the biological agents.


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Biological AttackBiological AttackContamination of MilkContamination of Milk

Botulinum toxinBotulinum toxin

Another concern is possibly the contamination of our milksupply with a pathogen such as botulinum toxin. Easy tofind and easy to produce, botulinum toxin is the mostpoisonous natural substance on earth. In the hands of abioterrorist, a single gram - the weight of a paper clip -could kill more than one million people.


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Category A Biological AgentsCategory A Biological Agents

HighHigh -- p r i o r i t y a g e n t sp r i o r i t y a g e n t s Risk to n a t i ona l secu r i t yRisk to na t i ona l secu r i t y

Charac ter is t i csCharac ter is t i cs

Eas i l y d issem inat ed orEas i l y d issem inat ed ort r a n sm i t t e d f r o m p e r so n t ot r a n sm i t t e d f r o m p er s on t opersonperson

Hi g h m o r t a l it y r a t e sH i g h m o r t a li t y r a t e s

Majo r pu b l i c hea l th im pactMa jo r pub l i c hea l th im pact

Publ ic pan ic and socia lPub l i c pan ic and soc iald i s ru p t i o nd i s rup t i on

Requ i re spec ia l ac t ion fo rRequ i r e specia l act io n fo rpub l i c hea l th p r eparednesspub l i c hea lth p reparedness

Although there are hundreds of thousands of biologicalagents in this world, only a dozen or so could potentiallybe used as a biological weapon. Of these, the Centersfor Disease Control have classified them according totheir potential threat. Category A agents are those high-priority organisms that have the following characteristics:

First, they pose a risk to national security because theycan be easily disseminated or transmitted from person toperson.

Second, they can result in high mortality rates and havethe potential for a major public health impact.

Third, they cause public panic and social disruption.

And, fourth, they require special action for public healthpreparedness.


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Category A Biological AgentsCategory A Biological Agents

An th ra xAn th ra x

Baci l lus anth rac is Baci l lus anth rac is

Smal lpoxSmal lpox

v a r i o la m a j o r v a r i o la m a j o r

Botu l i smBotu l i sm

Clos t r i d ium bo tu l i numC los t r i d ium bo tu l i num

t o x i n t o x i n

PlaguePlague

Yers in ia pes t is Yers in ia pest is

Tu la remiaTu la remia

Fran c ise l la tu la rens is Fran c ise l la tu la rens is

V ira l h e m o r rh a g i cV ir a l h e m o r rh a g i cfeve rsfeve rs

f i l ov i ruses [ e .g . ,f i l ov i ruses [ e .g . ,Ebo la , Marbur g ] Ebo la , Marb ur g ]

arenav i ruses [ e .g . ,a renav i ruses [ e .g . ,

Lassa, Machupo] )Lassa, Machupo] )

The CDC has listed these six agents as Category A

Anthrax,

Smallpox,

Botulism,

Plague,

Tularemia, and

Viral hemorrhagic fevers, the most famous of which isprobably Ebola virus.


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TularemiaTularemiaFrancisella tularensisFrancisella tularensis

GramGram -- nega t i ve bact e r ianega t i ve bact e r ia

Found in roden t sFound in r oden ts

One o f th e m os tOne o f th e m os ti n fe ct i o u s a g en ts k n o w nin fe ct i o u s a g en t s k n o w n

Few o rgan ism s canFew o rgan ism s cancause d i seasecause disease

Up to 95% of naturally occurring anthrax infectionsdevelop when the bacterium enters a cut or abrasion ofthe skin, such as when handling contaminated wool,hides, leather or hair products, especially goat hair, ofinfected animals.

In this slide we see Berlin electoral workers equippedwith protective masks and gloves as they open mailedvotes during the regional elections in October 2001. Theprotection is used as a precaution against a possibleanthrax threat.


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TularemiaTularemiaFrancisella tularensisFrancisella tularensis

NonNon -- speci f ic ,speci f ic , f l u f l u -- l i ke l i ke s y m p t o m ss y m p t o m s

Fever , ch i l lsFever , ch i l ls

HeadacheHeadache

Muscle achesMuscle aches

NonNon -- p rodu c t i ve coughprodu c t i ve cough

Dead ly i f no t t rea ted !Dead ly i f no t t r ea ted !

Diagnosed byDiagnosed by index o fi ndex o fsusp i cion and con f i rm ed bysusp i c ion and con f i rm ed byl a b o ra to r yl a b o ra to r y

Up to 95% of naturally occurring anthrax infectionsdevelop when the bacterium enters a cut or abrasion ofthe skin, such as when handling contaminated wool,hides, leather or hair products, especially goat hair, ofinfected animals.

In this slide we see Berlin electoral workers equippedwith protective masks and gloves as they open mailedvotes during the regional elections in October 2001. Theprotection is used as a precaution against a possibleanthrax threat.


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Whom to Contact for SuspectedWhom to Contact for Suspected

Biological Threat?Biological Threat?

Your Local Health Department!Your Local Health Department!

If you suspect a biological threat, the best resource tocontact immediately is your local health department. Thestate and local public health departments play anextremely important role in all-hazards emergencypreparedness and response. Public health professionalswithin these departments have immediate access toguidance and information that will assist them in rapidlyestablishing priorities and undertaking necessary actionsduring the response to an emergency or disaster.


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Working Together as a TeamWorking Together as a Team

Health CareHealth Care

ProvidersProvidersFirst RespondersFirst Responders

Fire, Police, EMTFire, Police, EMT

FBIFBI

Public HealthPublic Health

OfficialsOfficials

IncidentIncidentCommanderCommander

Regardless of the cause of the disaster, whether it be natural, such as atornado or flood, or whether it be man-made, such as what we have talkedabout today, a critical skill that health care providers need to have is theability to work together in a multi-disciplinary team.

Click to bring forth next image - The team consists of these threemajor groups. Health Care Providers include physicians, nurses, allied healthsuch as lab, respiratory and x-ray technicians, veterinarians, dentists andpsychologists. Public Health Officials include the local and state healthdepartments and the Centers for Disease Control. First Responders includemembers of the fire and police department, emergency personnel, and,depending upon the disaster, the FBI, Homeland Security, and the FederalEmergency Management Agency. Each have an important role and mustwork together.

Click to bring forth next image - It is also important to know that mostdisaster plans call for an Incident Commander, who is responsible for

coordinating the effort of all three groups. The Incident Commander isdetermined by the agent and delivery mechanisms. Typically, the PublicHealth Commissioner would be the Incident Commander for biologicalevents, while the Fire Chief would oversee the other events.

It is important that you know what your role would be in this team.


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Be PreparedBe Prepared

Review your local Disaster/Bioterrorism Safety PlanReview your local Disaster/Bioterrorism Safety Plan

Review the Ohio Department of Health DisasterReview the Ohio Department of Health Disaster

Preparedness & Response PlanPreparedness & Response Plan

http://www.odh.state.oh.us/alerts/alertmain.asphttp://www.odh.state.oh.us/alerts/alertmain.asp

To be prepared, review your local Disaster andBioterrorism Safety Plan. Also, review the OhioDepartment of Health Disaster Preparedness andResponse Plan, which can be found at this website.


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http://www.ready.gov/http://www.ready.gov/

http://www.redcross.org/services/disaster/beprepared/hsas.htmlhttp://www.redcross.org/services/disaster/beprepared/hsas.html

http://www.cdc.govhttp://www.cdc.gov

Be PreparedBe Prepared

Three great websites that will help you to getprepared are presented here. First, the CDC is awonderful, rich resource for health care providers.Almost everything you wanted to know about what wehave touched on today is found at this site.

Both Homeland Security and the American Red Crosshave excellent web sites that provide advice on personaland family safety during a disaster.

I would recommend that you become familiar with allthree sites.


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How You Can HelpHow You Can Help

Be preparedBe prepared

Help us with this caseHelp us with this case

Working together as a teamWorking together as a team

The Ohio Center of Excellence forThe Ohio Center of Excellence forBioterrorism Preparedness and ResponseBioterrorism Preparedness and Response

So, in summary, it is essential that we as health careproviders be prepared for a new generation of potentialthreats to our health. Be alert for subtle warning signsthat may be due to a terrorist event. Be ready to managenot only the physical but also the mental healthcasualties. Become familiar with your local public healthdepartment, and know how to contact them quickly.Develop skills on how to work together in a multi-disciplinary team during a disaster, and know your roleon that team. And finally, know the web sites where youcan go to quickly to learn more about what we discussed

today.


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SummarySummary

Be preparedBe prepared

Be alertBe alert

Manage initial casualtiesManage initial casualties

Know whom to contactKnow whom to contact

Know yourKnow your team roleteam role

Have ready referencesHave ready references

The Ohio Center of Excellence forThe Ohio Center of Excellence forBioterrorism Preparedness and ResponseBioterrorism Preparedness and Response

So, in summary, it is essential that we as health careproviders be prepared for a new generation of potentialthreats to our health. Be alert for subtle warning signsthat may be due to a terrorist event. Be ready to managenot only the physical but also the mental healthcasualties. Become familiar with your local public healthdepartment, and know how to contact them quickly.Develop skills on how to work together in a multi-disciplinary team during a disaster, and know your roleon that team. And finally, know the web sites where youcan go to quickly to learn more about what we discussed

today.


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Thank You!Thank You!Questions?Questions?

The Ohio Center ofThe Ohio Center of

Excellence forExcellence for

BioterrorismBioterrorism

Preparedness andPreparedness and

ResponseResponse

Thank you for your attention. Please take a few minutesto complete the evaluation.

If you have any questions, I will be able to answer them

once your evaluations are completed.

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BNICE and Tularemia