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NURSING IN THE ERA NURSING IN THE ERA OF OF BIOTERRORISM BIOTERRORISM

NURSING IN THE ERA OF BIOTERRORISM NURSING IN THE ERA OF BIOTERRORISM

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Page 1: NURSING IN THE ERA OF BIOTERRORISM NURSING IN THE ERA OF BIOTERRORISM

NURSING IN THE ERA OF NURSING IN THE ERA OF BIOTERRORISMBIOTERRORISM

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Accurate informationAccurate information

is the best defense againstis the best defense against

panic and confusionpanic and confusion

in the event of a crisis.in the event of a crisis.

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Definition of Definition of BioterrorismBioterrorism

Premeditated Premeditated threatthreat or actual use of or actual use of biological weapons to produce disease or biological weapons to produce disease or death in people, animals, or plants.death in people, animals, or plants.

Biological weapons: microbes or their toxins.Biological weapons: microbes or their toxins.

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Biological WeaponsBiological Weapons

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Bioterrorism OverviewBioterrorism Overview

Microorganisms or their toxins can be in liquid Microorganisms or their toxins can be in liquid or powder form.or powder form.

Various delivery methods are possible:Various delivery methods are possible: aerosolaerosol envelope or packageenvelope or package food or water contaminationfood or water contamination

Exposure can be isolated to a single area or Exposure can be isolated to a single area or can be more widespread.can be more widespread.

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BioterrorismBioterrorism

Microorganisms as biologic weapons Microorganisms as biologic weapons would most likely result in illness would most likely result in illness occurring days to weeks after attack occurring days to weeks after attack and would affect persons dispersed and would affect persons dispersed from the site.from the site.

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Biological Agents:Biological Agents:Types and Types and

CharacteristicsCharacteristics

BacteriaBacteria

VirusesViruses

Biological ToxinsBiological Toxins

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CDC CategoriesCDC Categories

Category A:Category A: easily disseminated OR transmitted easily disseminated OR transmitted

person to personperson to person susceptible populationsusceptible population potential for panic / disruptionpotential for panic / disruption requires special action for treatmentrequires special action for treatment high morbidity and mortalityhigh morbidity and mortality examples: examples: anthraxanthrax, , smallpoxsmallpox, , plagueplague, ,

botulismbotulism, , viral hemorrhagic feversviral hemorrhagic fevers

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CDC CategoriesCDC Categories Category B:Category B: moderately easy to disseminatemoderately easy to disseminate

moderate morbidity, low mortalitymoderate morbidity, low mortality examples: Q fever, brucellosis, glanders, examples: Q fever, brucellosis, glanders,

some toxinssome toxins

Category C:Category C: emerging pathogens that could be engineered emerging pathogens that could be engineered

for mass dissemination in the futurefor mass dissemination in the future potential for high morbidity and mortalitypotential for high morbidity and mortality examples: hantavirus, tickborne viruses, MDR examples: hantavirus, tickborne viruses, MDR

TBTB

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Isolation PrecautionsIsolation Precautions

StandardStandard (“blood and body fluid”): (“blood and body fluid”): glovesgloves mask with face shieldmask with face shield gowngown

Airborne:Airborne: standard plus negative pressure room and N95 mask standard plus negative pressure room and N95 mask

(“duckbill mask”)(“duckbill mask”)

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HANDWASHINGHANDWASHING

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Gram positive bacillus that forms Gram positive bacillus that forms sporesspores

Spores found in soil worldwideSpores found in soil worldwide Humans usually infected by Humans usually infected by

contact with infected animals or contact with infected animals or contaminated animal productscontaminated animal products

No person-to-person No person-to-person transmission of inhalation transmission of inhalation anthraxanthrax

Anthrax: OverviewAnthrax: Overview

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Anthrax: CutaneousAnthrax: Cutaneous

Most common form (95%)Most common form (95%)

Inoculation of spores in skinInoculation of spores in skin

Incubation: hours to daysIncubation: hours to days

Progression:Progression:11. small papule. small papule2. ulcer surrounded by vesicles2. ulcer surrounded by vesicles3. painless eschar with edema3. painless eschar with edema

Death:Death:• untreated – 20%untreated – 20%• treated – raretreated – rare

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Anthrax: Anthrax: GastrointestinalGastrointestinal

Ingestion of contaminated meatIngestion of contaminated meat

Fever, vomiting, bloody diarrheaFever, vomiting, bloody diarrhea

Intestinal eschar similar to Intestinal eschar similar to cutaneous anthrax lesioncutaneous anthrax lesion

Progression to general toxemiaProgression to general toxemia

Mortality 50% despite treatmentMortality 50% despite treatment

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Anthrax TestingAnthrax Testing Nasal Swab:Nasal Swab:

A tool for epidemiology, not diagnosisA tool for epidemiology, not diagnosis Limitations:Limitations:

positive test indicates exposure, not infectionpositive test indicates exposure, not infection false positives have been seen (positive test does not false positives have been seen (positive test does not

prove infection)prove infection) false negatives (negative test does not rule out false negatives (negative test does not rule out

anthrax infection)anthrax infection)

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Anthrax TestingAnthrax Testing Nasal Swab:Nasal Swab:

A tool for epidemiology, A tool for epidemiology, not diagnosisnot diagnosis Limitations:Limitations:

positive test indicates exposure, not infectionpositive test indicates exposure, not infection false positives have been seen (positive test false positives have been seen (positive test

does not prove infection)does not prove infection) false negatives (negative test does not rule out false negatives (negative test does not rule out

anthrax infection)anthrax infection)

Serologic tests:Serologic tests: Available at special labs but not used for routine Available at special labs but not used for routine

screeningscreening

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Anthrax TestingAnthrax Testing Nasal Swab:Nasal Swab:

A tool for epidemiology, not diagnosisA tool for epidemiology, not diagnosis Limitations:Limitations:

positive test indicates exposure, not infectionpositive test indicates exposure, not infection false positives have been seenfalse positives have been seen negative test does not rule out anthrax infectionnegative test does not rule out anthrax infection

Serologic tests:Serologic tests: Available at special labs but not used for routine screeningAvailable at special labs but not used for routine screening

Blood cultures:Blood cultures: Probably best test for symptomatic individual at riskProbably best test for symptomatic individual at risk

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ANTHRAX: TreatmentANTHRAX: Treatment Inhalation anthrax Inhalation anthrax oror cutaneous anthrax with systemic cutaneous anthrax with systemic

involvement:involvement:

ciprofloxacin (400mg, IV, q12h) ciprofloxacin (400mg, IV, q12h) oror doxycycline (100 mg, doxycycline (100 mg, IV, q12h)IV, q12h)

combine with one of the following:combine with one of the following:

rifampin, vancomycin, penicillin, ampicillin, clindamycin, rifampin, vancomycin, penicillin, ampicillin, clindamycin, clarithromycinclarithromycin

Treat for 60 daysTreat for 60 days

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Anthrax: Other TreatmentAnthrax: Other Treatment

Uncomplicated cutaneous anthrax:Uncomplicated cutaneous anthrax: Cipro (500 mg, po, bid) or doxycycline (100 Cipro (500 mg, po, bid) or doxycycline (100

mg, po,mg, po, bid) bid)

Prophylaxis for exposure:Prophylaxis for exposure: Cipro (500 mg, po, bid) or doxycycline (100 Cipro (500 mg, po, bid) or doxycycline (100

mg, po, bid)mg, po, bid) Children or breastfeeding mothers: Children or breastfeeding mothers:

amoxicillinamoxicillin Levoquin- adults 18 and olderLevoquin- adults 18 and older

Treat for 60 daysTreat for 60 days

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2.2 KG’S OF ANTHRAX SPRINKLED 2.2 KG’S OF ANTHRAX SPRINKLED FROM A 20FROM A 20THTH FLOOR HIGH RISE IN FLOOR HIGH RISE IN NEW YORK CITY WOULD KILL / NEW YORK CITY WOULD KILL / INFECT OVER 120,000 PEOPLEINFECT OVER 120,000 PEOPLE

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Plague: OverviewPlague: Overview

Yersinia pestis (gram-Yersinia pestis (gram-

negative coccobacillus)negative coccobacillus)

About 10 U.S. cases/yr (SW)About 10 U.S. cases/yr (SW)

Two major formsTwo major forms

Very contagious via Very contagious via

respiratory dropletsrespiratory droplets

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Plague EpidemicsPlague Epidemics

3 major recorded epidemics:3 major recorded epidemics: 550, 1350 (Black Death), 1850 (China)550, 1350 (Black Death), 1850 (China)

30% - 60% mortality in infected 30% - 60% mortality in infected continentscontinents

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PlaguePlague

GOOD NEWS:GOOD NEWS: future epidemics unlikely due to sanitation, future epidemics unlikely due to sanitation,

public health practices, and antibiotics.public health practices, and antibiotics.

BAD NEWS:BAD NEWS: US and Russia and other countries have US and Russia and other countries have

developed techniques to aerosolize plague, developed techniques to aerosolize plague, eliminating need for fleas to spread the infection.eliminating need for fleas to spread the infection.

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Plague as a BioweaponPlague as a Bioweapon

Infected fleas could spread bubonic form (less Infected fleas could spread bubonic form (less likely scenario)likely scenario)

Aerosolized organisms would spread Aerosolized organisms would spread pneumonic form (more likely scenario)pneumonic form (more likely scenario)

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Plague: BubonicPlague: Bubonic

Bite from infected fleaBite from infected flea Sudden onset flu-like syndromeSudden onset flu-like syndrome

Buboes:Buboes: tender, enlarged lymph nodes tender, enlarged lymph nodes

(inguinal, axillary, cervical)(inguinal, axillary, cervical)

Can spread to lungs Can spread to lungs (hematogenous)(hematogenous)

Can also lead to endotoxic Can also lead to endotoxic septicemic phasesepticemic phase

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Plague: PneumonicPlague: Pneumonic

Inhalation of organisms Inhalation of organisms (aerosol)(aerosol)

Incubation: 1-3 daysIncubation: 1-3 days

Sudden onset flu-like syndrome Sudden onset flu-like syndrome

Pneumonia progresses rapidly Pneumonia progresses rapidly to hypoxemia, cyanosis, to hypoxemia, cyanosis, hemoptysishemoptysis

Endotoxin: septic shock with Endotoxin: septic shock with DIC, ARDS, deathDIC, ARDS, death

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Plague Disease Plague Disease ComplexComplex

Inhalational of plague organisms

Flu-likeSyndrome

Sudden onset

2 -3 days

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Plague Disease Plague Disease ComplexComplex

Fulminant Pneumonia

Flu-likeSyndrome

Sudden onset

productive coughbilateral infiltratescyanosis

2 -3 days

24 hrs

Inhalational of plague organisms

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Plague Disease Plague Disease ComplexComplex

ARDS DIC

Fulminant Pneumonia

Flu-likeSyndrome

Sudden onset

2 -3 days

24 hrs

Inhalational of plague organisms

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Plague Disease Plague Disease ComplexComplex

ARDS DIC

Fulminant Pneumonia

Flu-likeSyndrome

Sudden onset

2 -3 days

24 hrs

Inhalational of plague organisms

Endotoxemia

Respiratory failureCirculatory collapse

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Plague Disease Plague Disease ComplexComplex

ARDS DIC

Fulminant Pneumonia

Flu-likeSyndrome

Sudden onset

2 -3 days

24 hrs

Inhalational of plague organisms

Endotoxemia

Respiratory failureCirculatory collapse

Flu-like syndrome

Tender buboes

2 - 10 days

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Pneumonic Plague:Pneumonic Plague:Isolation precautionsIsolation precautions

SECONDARY SECONDARY TRANSMISSION IS TRANSMISSION IS POSSIBLE - EASILY POSSIBLE - EASILY

USE STANDARD AND USE STANDARD AND AIRBORNE AIRBORNE PRECAUTIONSPRECAUTIONS

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Management / Management / ProphylaxisProphylaxis

Antibiotic therapy Antibiotic therapy IV amino glycoside and IV doxycyclineIV amino glycoside and IV doxycycline Ciprofloxacin Ciprofloxacin

Antibiotic resistant strains existAntibiotic resistant strains exist

Supportive measuresSupportive measures

Prophylaxis for respiratory droplet Prophylaxis for respiratory droplet exposure:exposure: oral doxycycline or oral ciprofloxacin for 7-10 oral doxycycline or oral ciprofloxacin for 7-10

daysdays vaccine - no longer manufactured in U.S.vaccine - no longer manufactured in U.S.

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Plague:Plague:Diagnostic TestsDiagnostic Tests

No widely available rapid testsNo widely available rapid tests

Gram stain of body fluids or lymph node Gram stain of body fluids or lymph node aspirate may reveal gram-negative organismsaspirate may reveal gram-negative organisms

Blood cultures should be positive within 2 days.Blood cultures should be positive within 2 days.

Confirmatory testing via government labs Confirmatory testing via government labs (antigen detection, immunoassays, and PCR)(antigen detection, immunoassays, and PCR)

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Viruses as BioweaponsViruses as Bioweapons

Viral Hemorrhagic Viral Hemorrhagic

Fevers:Fevers: EbolaEbola

LassaLassa

MarburgMarburg

SmallpoxSmallpox

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Viral Hemorrhagic FeversViral Hemorrhagic Fevers

Group of illnesses caused by several RNA Group of illnesses caused by several RNA virusesviruses

All can be used as bioweaponsAll can be used as bioweapons

Examples: Ebola, Marburg, LassaExamples: Ebola, Marburg, Lassa

Mortality can be very high (90% for Ebola)Mortality can be very high (90% for Ebola)

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VHF: OccurrenceVHF: Occurrence Naturally occurring infections can occur via Naturally occurring infections can occur via

transmission from infected rodents and transmission from infected rodents and arthropodsarthropods

Readily transmissible from person to person Readily transmissible from person to person via body fluids:via body fluids: great risk for healthcare workersgreat risk for healthcare workers

VHF very rare in US:VHF very rare in US: usually travelers to endemic areasusually travelers to endemic areas

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CURRENT OUTBREAKCURRENT OUTBREAK

Current outbreak in AfricaCurrent outbreak in Africa

80-89% MORTALITY80-89% MORTALITY

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VHF: PathophysiologyVHF: Pathophysiology Variable incubation (2-21 days)Variable incubation (2-21 days)

Flu-like symptoms with high feverFlu-like symptoms with high fever

Increased vascular permeability causes:Increased vascular permeability causes: hemorrhage in GI tract and mucous membraneshemorrhage in GI tract and mucous membranes petechial or ecchymotic rashpetechial or ecchymotic rash edemaedema hypotensionhypotension

Rapid progression to shock and deathRapid progression to shock and death

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VHF: Lab TestingVHF: Lab Testing

No widely available rapid testsNo widely available rapid tests

Government labs can provide nucleic acid Government labs can provide nucleic acid assaysassays

Routine labs reveal clotting abnormalities:Routine labs reveal clotting abnormalities: elevated PT and PTT, decreased plateletselevated PT and PTT, decreased platelets

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VHF: TreatmentVHF: Treatment Supportive treatmentSupportive treatment IV ribavirin used occasionally for Lassa IV ribavirin used occasionally for Lassa

fever.fever. Vaccines under developmentVaccines under development Postexposure prophylaxis with oral Postexposure prophylaxis with oral

ribavirin may be usefulribavirin may be useful

Contact and respiratory Contact and respiratory precautions necessaryprecautions necessary

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SmallpoxSmallpox Variola virusVariola virus

Characteristic skin lesionsCharacteristic skin lesions

About 30% mortality in unvaccinatedAbout 30% mortality in unvaccinated

Last known natural case: Somalia in 1977Last known natural case: Somalia in 1977

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Smallpox as a Smallpox as a BioweaponBioweapon

Can be aerosolizedCan be aerosolized Highly contagiousHighly contagious No effective treatmentNo effective treatment Vaccination ceased in 70’sVaccination ceased in 70’s Stable in the environment (contamination Stable in the environment (contamination

for months)for months)

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Smallpox: PathophysiologySmallpox: Pathophysiology

Virus inhaled or deposited on mucous Virus inhaled or deposited on mucous membranesmembranes

Goes to lymph nodes, incubates for 7-17 daysGoes to lymph nodes, incubates for 7-17 days Release into blood causes flu-like symptomsRelease into blood causes flu-like symptoms Rash begins 2-3 days laterRash begins 2-3 days later Death due to toxemia of viral antigens and Death due to toxemia of viral antigens and

circulating immune complexescirculating immune complexes

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Smallpox: Skin lesionsSmallpox: Skin lesions Macular (flat, red) rash 2-3 days after flu Macular (flat, red) rash 2-3 days after flu

symptomssymptoms Starts on face, forearms, hands (+ palms Starts on face, forearms, hands (+ palms

and soles)and soles) Rash evolves synchronously in an areaRash evolves synchronously in an area Evolves into tense vesiclesEvolves into tense vesicles Scabs form in 7-10 days if patient livesScabs form in 7-10 days if patient lives Infectious until all scabs are shed.Infectious until all scabs are shed.

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Day 3 Day 5 Day 7Day 3 Day 5 Day 7

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Chickenpox with characteristic rose-colored macules, papules, vesicles, pustules, necrotic pustules, and crusted lesions occurring simultaneously.

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Herpes zoster (varicella virus) withcharacteristic grouping of vesicles

Herpes zoster showing dermatomal distribution of lesions

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ProdromeProdrome yesyes minimal or minimal or nonenone

Smallpox vs. ChickenpoxSmallpox vs. Chickenpox

Smallpox Chickenpox

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ProdromeProdrome yesyes minimal or minimal or nonenone

Distribution Distribution out to inout to in in to outin to out

Smallpox vs. ChickenpoxSmallpox vs. Chickenpox

Smallpox Chickenpox

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ProdromeProdrome yesyes minimal or noneminimal or none

Distribution Distribution out to inout to in in to outin to out

LesionsLesions painfulpainful / deep / deep pruritic / superficialpruritic / superficial

ProgressionProgression synchronoussynchronous asynchronousasynchronous

Palms / SolesPalms / Soles yesyes nono

Smallpox vs. ChickenpoxSmallpox vs. Chickenpox

Smallpox Chickenpox

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Smallpox vs. Smallpox vs. ChickenpoxChickenpox

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Smallpox: DiagnosisSmallpox: Diagnosis

CLINICAL PRESENTATION AND PATIENT CLINICAL PRESENTATION AND PATIENT HISTORY IS THE KEY TO DIAGNOSISHISTORY IS THE KEY TO DIAGNOSIS

No widely available rapid testNo widely available rapid test Electron microscopy to confirm presence of Electron microscopy to confirm presence of

variola virus particlesvariola virus particles

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Smallpox:Smallpox:Treatment and ProphylaxisTreatment and Prophylaxis

No effective treatmentNo effective treatment Animal trials with cidofovir are promisingAnimal trials with cidofovir are promising Vaccinia immune globulin may be usefulVaccinia immune globulin may be useful Vaccination within 3-4 days of Vaccination within 3-4 days of ALLALL potential potential

contacts may prevent or lessen diseasecontacts may prevent or lessen disease

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Smallpox: PrecautionsSmallpox: Precautions Airborne and Contact IsolationAirborne and Contact Isolation

Airborne Isolation:Airborne Isolation: negative pressure roomnegative pressure room anteroomanteroom closed ventilation systemclosed ventilation system N95 mask (Duckbill mask)N95 mask (Duckbill mask)

Contact Isolation:Contact Isolation: strict use of PPE and handwashingstrict use of PPE and handwashing

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Smallpox: PrecautionsSmallpox: Precautions

Patients may be cohortedPatients may be cohorted

Laundry kept separate and in Red BagLaundry kept separate and in Red Bag Limit number of personnel in contactLimit number of personnel in contact Mask patient if in-hospital transportMask patient if in-hospital transport Contacts placed under 18 day fever Contacts placed under 18 day fever

surveillance (>100.5 reportable)surveillance (>100.5 reportable)

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Smallpox VaccineSmallpox Vaccine

Vaccination in U.S. ended in 1972 except Vaccination in U.S. ended in 1972 except military personnelmilitary personnel

Not known if previous vaccination is Not known if previous vaccination is protective nowprotective now

Not a benign vaccine: side effects and Not a benign vaccine: side effects and fatalitiesfatalities

Possibly MANY deaths if given to all in USPossibly MANY deaths if given to all in US

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Smallpox VaccineSmallpox Vaccine Vaccine is for vaccinia, a closely related and more Vaccine is for vaccinia, a closely related and more

benign virusbenign virus Vaccine contraindicated in some, Vaccine contraindicated in some, unless exposure unless exposure

has occurredhas occurred: : Immunosuppressed (hiv / cancer/transplant patientsImmunosuppressed (hiv / cancer/transplant patients chronic steroid usage (eyedrops)chronic steroid usage (eyedrops) eczema or chronic exfoliative skin disorderseczema or chronic exfoliative skin disorders pregnancypregnancy age under 18age under 18 CARDIAC DISEASE- Mi’s / Myopathy / AnginaCARDIAC DISEASE- Mi’s / Myopathy / Angina

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Smallpox VaccineSmallpox Vaccine Virus sheds from vaccine site for up Virus sheds from vaccine site for up

to 6 weeksto 6 weeks Shedding can infect household Shedding can infect household

contacts with vacciniacontacts with vaccinia Some serious vaccine reactions:Some serious vaccine reactions:

encephalitis, severe vaccinia, encephalitis, severe vaccinia, anaphylaxis, Stevens-Johnsonanaphylaxis, Stevens-Johnson

Auto-inoculation of orifices can occurAuto-inoculation of orifices can occur

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AUTO-INNOCULATIONAUTO-INNOCULATION

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NEW JERSEY CLINICSNEW JERSEY CLINICS

NORTHWESTNORTHWEST- - Sussex/Passaic/Warren/MorrisSussex/Passaic/Warren/Morris St Joe’sSt Joe’s and ID Associatesand ID Associates

NORTHEASTNORTHEAST- Bergen/Essex/Hudson- Bergen/Essex/Hudson Hackensack / UMDNJ- NewarkHackensack / UMDNJ- Newark

CENTRALEAST- CENTRALEAST- Middlesex/Union/Monmouth/OceanMiddlesex/Union/Monmouth/Ocean Raritan Bay Medical CenterRaritan Bay Medical Center

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CENTRALWESTCENTRALWEST- - Somerset/Mercer/ HunterdonSomerset/Mercer/ Hunterdon Hunterdon HospitalHunterdon Hospital

South- South- Camden/Burlington/Atlantic/SalemCamden/Burlington/Atlantic/Salem Our Lady of Lourdes and Shore Our Lady of Lourdes and Shore

HospitalsHospitals

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VACCINATION REPORTVACCINATION REPORT

HEALTH CARE WORKERS HEALTH CARE WORKERS NEW JERSEY- 619NEW JERSEY- 619 NYC- 138NYC- 138 PENNSYLVANIA- 67PENNSYLVANIA- 67 NEVADA – 0NEVADA – 0 MINNESOTA- 1439MINNESOTA- 1439 TENNESSEE- 2407 TENNESSEE- 2407

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VACCINATORSVACCINATORS

NEW JERSEY - 50NEW JERSEY - 50

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FEDERAL VACCINATION PROGRAM FEDERAL VACCINATION PROGRAM IS NOW ON “HOLD”IS NOW ON “HOLD”

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BIOLOGICAL TOXINSBIOLOGICAL TOXINS

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BOTULINUM – BO-TOXBOTULINUM – BO-TOX

RICINRICIN

STAPHYLOOCCAL ENTEROTOXIN B (not STAPHYLOOCCAL ENTEROTOXIN B (not

reviewed)reviewed)

T-2 MYCOTOXINS (not reviewed)T-2 MYCOTOXINS (not reviewed)

RICINRICIN

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Botulinum ToxinBotulinum Toxin 7 neurotoxins produced by Clostridium botulinum7 neurotoxins produced by Clostridium botulinum Among the most toxic substances knownAmong the most toxic substances known May be found in naturally contaminated foodMay be found in naturally contaminated food As a bioweapon, likely to be delivered by aerosolAs a bioweapon, likely to be delivered by aerosol

No person-to-person transmissionNo person-to-person transmission Multiple cases without common food source Multiple cases without common food source

suggests bioterrorismsuggests bioterrorism

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Botulinum Toxin:Botulinum Toxin:Mechanism of ActionMechanism of Action

Site: neuromuscular junction (pre-synaptic)Site: neuromuscular junction (pre-synaptic)

Action: binds at acetylcholine release sites to Action: binds at acetylcholine release sites to prevent releaseprevent release

Effect: muscle weakness (skeletal and cranial Effect: muscle weakness (skeletal and cranial nerve distribution)nerve distribution)

Does not cross the blood-brain barrier:Does not cross the blood-brain barrier: patients remain alert and afebrilepatients remain alert and afebrile

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Botulinum Toxin:Botulinum Toxin:Clinical FindingsClinical Findings

Botulism onset: about 1-3 daysBotulism onset: about 1-3 days

Cranial nerve palsies early:Cranial nerve palsies early: Eye: blurred vision, photophobia, diplopia, ptosisEye: blurred vision, photophobia, diplopia, ptosis Throat: dysarthria, dysphagiaThroat: dysarthria, dysphagia

Skeletal muscle weakness later:Skeletal muscle weakness later: symmetrical, descending, progressivesymmetrical, descending, progressive abrupt respiratory failureabrupt respiratory failure

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Botulinum Toxin:Botulinum Toxin:Differential DiagnosisDifferential Diagnosis

Differential Diagnosis:Differential Diagnosis: tetanus, myasthenia gravis, Guillain-tetanus, myasthenia gravis, Guillain-

BarreBarre

Botulism differentiated by:Botulism differentiated by: more cranial nerve involvementmore cranial nerve involvement facial muscles more involved than facial muscles more involved than

below neckbelow neck lack of sensory changeslack of sensory changes

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Botulinum Toxin: LabBotulinum Toxin: Lab

Laboratory testing:Laboratory testing: generally not helpfulgenerally not helpful detection of toxin in serum is detection of toxin in serum is

possiblepossible

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Botulinum Toxin: TreatmentBotulinum Toxin: Treatment

Do not wait for lab confirmationDo not wait for lab confirmation Administer antitoxin:Administer antitoxin:

available from CDC but very limited suppliesavailable from CDC but very limited supplies only binds to circulating toxin to prevent progressiononly binds to circulating toxin to prevent progression will not reverse symptoms already presentwill not reverse symptoms already present anaphylaxis and serum sickness may resultanaphylaxis and serum sickness may result do not prophylax exposed but asymptomatic do not prophylax exposed but asymptomatic

patientspatients Respiratory support necessaryRespiratory support necessary Recovery takes weeks to monthsRecovery takes weeks to months

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RICINRICIN

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RicinRicin

Potent protein toxin derived from castor beansPotent protein toxin derived from castor beans

Easily produced / Recently found in FranceEasily produced / Recently found in France

Inhibits protein synthesisInhibits protein synthesis

Causes necrotizing airway lesions:Causes necrotizing airway lesions: tracheitistracheitis bronchitis and bronchiolitisbronchitis and bronchiolitis interstitial pneumonia with ARDSinterstitial pneumonia with ARDS

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RicinRicin

Inhalation as an aerosol produces Inhalation as an aerosol produces severe respiratory symptoms:severe respiratory symptoms: day 1: cough, fever, dyspneaday 1: cough, fever, dyspnea day 2-3: pulmonary edema, resp failure, deathday 2-3: pulmonary edema, resp failure, death

Specific serum test is availableSpecific serum test is available

No treatment available other than No treatment available other than supportivesupportive

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Chemical WeaponsChemical Weapons

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Chemical WeaponsChemical Weapons

Nerve agentsNerve agents Vessicants (blistering Vessicants (blistering

agents)agents) Pulmonary agentsPulmonary agents Blood agents (cyanide)Blood agents (cyanide) Riot Control agentsRiot Control agents

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Nerve AgentsNerve Agents Most toxic of all the synthetic chemical agents.Most toxic of all the synthetic chemical agents. Very similar to organophosphate insecticides.Very similar to organophosphate insecticides. Death within minutes when inhaled or absorbed Death within minutes when inhaled or absorbed

through skin.through skin. Developed in WW2 by Germany but not used.Developed in WW2 by Germany but not used. U.S. completed development after WW2.U.S. completed development after WW2.

Examples:Examples:

SARINSARIN

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Nerve Agents: EffectsNerve Agents: Effects

Smooth muscle hyper Smooth muscle hyper stimulationstimulation

Glandular hyper stimulationGlandular hyper stimulation

Skeletal muscle hyper Skeletal muscle hyper stimulationstimulation

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Nerve Agents: EffectsNerve Agents: Effects Smooth muscle hyper Smooth muscle hyper

stimulation:stimulation:

vomiting and diarrheavomiting and diarrhea urinationurination bronchospasmbronchospasm small pupils (miosis)small pupils (miosis)

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Nerve Agents: EffectsNerve Agents: Effects Glandular hyper stimulation:Glandular hyper stimulation:

salivationsalivation lacrimationlacrimation increased airway secretionsincreased airway secretions increased GI secretionsincreased GI secretions

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Nerve Agents: EffectsNerve Agents: Effects

Skeletal muscle hyper stimulation at Skeletal muscle hyper stimulation at first:first: FasciculationsFasciculations

Later, skeletal muscle exhaustion:Later, skeletal muscle exhaustion: weakness followed by flaccid paralysisweakness followed by flaccid paralysis

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Nerve Agents: EffectsNerve Agents: Effects

SLUDGESLUDGE reaction: reaction: SSalivationalivation LLacrimationacrimation UUrinationrination DDefecationefecation GGeneralized twitchingeneralized twitching EEmesismesis

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Nerve Agents:Nerve Agents:DecontaminationDecontamination

Removal of contaminated clothingRemoval of contaminated clothing Copious irrigation and washing with Copious irrigation and washing with

soap and watersoap and water

BIOSUITS- NO CONTACT WITH BIOSUITS- NO CONTACT WITH AGENTAGENT

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Mark 1Mark 1Nerve Agent Nerve Agent Antidote KitAntidote Kit

ATROPINEATROPINEPROTOPAMPROTOPAM

VALIUMVALIUM

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Sources ofSources ofRadioactive MaterialRadioactive Material

High-level sources (plutonium, uranium):High-level sources (plutonium, uranium): nuclear power plantsnuclear power plants and weapons sites and weapons sites high security; more difficult to obtain and handlehigh security; more difficult to obtain and handle

Low-level sources (cobalt-60, strontium-90, Low-level sources (cobalt-60, strontium-90, cesium-137, americium-241):cesium-137, americium-241): hospitalshospitals construction sitesconstruction sites food irradiation plantsfood irradiation plants smoke detectorssmoke detectors

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Key Point: AvoidanceKey Point: Avoidance

Avoidance prevents or minimizes effects:Avoidance prevents or minimizes effects:

TIME:TIME: decrease time near source of radiationdecrease time near source of radiation

DISTANCE:DISTANCE: increase distance from sourceincrease distance from source

SHIELDING:SHIELDING: increase barriers between you increase barriers between you and sourceand source

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DecontaminationDecontamination

Spray light water mist on clothes to Spray light water mist on clothes to decrease radioactive dustdecrease radioactive dust

Remove clothes (up to 90% decrease in Remove clothes (up to 90% decrease in radioactivity exposure)radioactivity exposure)

Washing skin and hair with soapy waterWashing skin and hair with soapy water

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TreatmentTreatment

Potassium Iodide:Potassium Iodide:

may prevent thyroid cancer after radiation may prevent thyroid cancer after radiation exposureexposure

NJ dispensed it to those who live within 10 mi. of NJ dispensed it to those who live within 10 mi. of nuclear plantnuclear plant

blocks thyroid uptake of radioactive iodineblocks thyroid uptake of radioactive iodine

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TreatmentTreatment Depends on specific radioactive substance and Depends on specific radioactive substance and

mode of exposure (inhaled, ingested, skin).mode of exposure (inhaled, ingested, skin).

Call Poison Control if available.Call Poison Control if available.

Meticulously clean contaminated wounds.Meticulously clean contaminated wounds.

For ingestions, lavage, laxatives, and ion-For ingestions, lavage, laxatives, and ion-exchange resins may be indicated.exchange resins may be indicated.

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Bombing FrequencyBombing Frequency

Worldwide, 50% of terrorist attacks are Worldwide, 50% of terrorist attacks are bombings.bombings.

In U.S., over 85% of terrorist attacks are In U.S., over 85% of terrorist attacks are bombings.bombings.

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• Dramatic, low risk, draw attentionDramatic, low risk, draw attention• Few skills neededFew skills needed• Can execute attack remotelyCan execute attack remotely• Large groups not requiredLarge groups not required• Components readily availableComponents readily available• Forensic evidence difficult to identify, collect and Forensic evidence difficult to identify, collect and

assembleassemble

Why Use Explosives?Why Use Explosives?

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BOMB COOKBOOKBOMB COOKBOOK

HUNDREDS OF SITES ON HUNDREDS OF SITES ON INTERNETINTERNET

BOOKS-BOOKS- “ “Bombs for Dummies”Bombs for Dummies”

Most supplies available in home Most supplies available in home depot and garden shopsdepot and garden shops

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““Dirty Bombs”Dirty Bombs” A type of radiological dispersion device.A type of radiological dispersion device.

Combines conventional explosives with Combines conventional explosives with radioactive materials in the form of powder radioactive materials in the form of powder or pellets.or pellets.

Disperses radioactive material.Disperses radioactive material.

Causes fear and contaminates land and Causes fear and contaminates land and buildings for prolonged periodsbuildings for prolonged periods..

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““Dirty Bombs”Dirty Bombs”

Dangers of dirty bombs:Dangers of dirty bombs: if low-level radioactive sources used, primary danger is if low-level radioactive sources used, primary danger is

blast itselfblast itself gauging degree of radioactive contamination due to gauging degree of radioactive contamination due to

fallout is difficultfallout is difficult most probable sources would not provide enough most probable sources would not provide enough

radiation to cause acute radiation sicknessradiation to cause acute radiation sickness environmental contaminationenvironmental contamination

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REMEMBER-REMEMBER-

REPORT ANY SUSPICIOUS ILLNESSESREPORT ANY SUSPICIOUS ILLNESSES CLUSTERING OF CASESCLUSTERING OF CASES UNUSUAL NUMBERS OF PATIENTS WITH UNUSUAL NUMBERS OF PATIENTS WITH

SAME COMPLAINTSSAME COMPLAINTS

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SUSPECTED BIOLOGICAL INCIDENTS- SUSPECTED BIOLOGICAL INCIDENTS- REPORTABLE: FOLLOW HANDOUTREPORTABLE: FOLLOW HANDOUT

1- LOCAL AND / OR STATE DOH1- LOCAL AND / OR STATE DOH 2- LOCAL / STATE POLICE / FBI2- LOCAL / STATE POLICE / FBI 3- BIOTERRORISM TASK FORCE3- BIOTERRORISM TASK FORCE 4- CDC – FEDERAL TASK FORCE- ETC4- CDC – FEDERAL TASK FORCE- ETC