Preparing for and Responding to Bioterrorism: Information for Primary Care Clinicians

1. Preparing for and Responding to Bioterrorism: Information for Primary Care Clinicians

2. Acknowledgements This presentation, and the accompanying instructor’s manual (current as of 7/02), were prepared by Jennifer Brennan Braden, MD, MPH, at the Northwest Center for Public Health Practice in Seattle, WA, and Jeff Duchin, MD with Public Health – Seattle & King County and the Division of Allergy & Infectious Diseases, University of WA, for the purpose of educating primary care clinicians in relevant aspects of bioterrorism preparedness and response. Instructors are encouraged to freely use all or portions of the material for its intended purpose. The following people and organizations provided information and/or support in the development of this curriculum. A complete list of resources can be found in the accompanying instructor’s guide. Jane Koehler, DVM, MPH Communicable Disease Control, Epidemiology and Immunization section, Public Health - Seattle & King County Ed Walker, MD; University of WA Department of Psychiatry Patrick O’Carroll, MD, MPH The Centers for Disease Control and Prevention Project Coordinator Judith Yarrow Health Policy & Analysis, University of WA Design and Editing

3. Bioterrorism Preparedness and Response CDC

4. Bioterrorism Preparedness & ResponseLearning Objectives • Be familiar with: • The role of the clinician in bioterrorism preparedness and response • The roles of local and national agencies involved in bioterrorism preparedness and response

5. Bioterrorism Preparedness & ResponseLearning Objectives • Be familiar with: • The purpose and functions of the Health Alert Network (HAN) and the National Pharmaceutical Stockpile (NPS) • How to contact the appropriate local agency to report potential bioterrorism or other public health concerns

6. Bioterrorism Preparedness & ResponseCrisis & Consequence Management • Crisis management: law enforcement response to terrorist acts • Local, state, federal law-enforcement agencies • Consequence management: response to the disaster focusing on the alleviation of damage, loss, hardship, or suffering • Public health, medical, & emergency mgt personnel • Falls under ESF-8 (public health) of Federal Disaster Response Plan PDD-39 This link will take you away from the educational site

7. National Responders • Health and Human Services (HHS) • Centers for Disease Control and Prevention (CDC) • Federal Emergency Management Agency (FEMA) • FBI • Environmental Protection Agency (EPA) • Department of Agriculture • Department of Defense

8. Health care providers & facilities Local and state health departments Emergency management agencies Search & Rescue, EMS, & HAZMAT teams Volunteers Law enforcement, National Guard State emergency management agency Political leaders Community service organizations State and Local Responders

9. National Preparedness1999 Initiative • National Bioterrorism Preparedness and Response Initiative • 1999 DHHS Initiative to prepare the nation to respond to potential BT activity • CDC designated lead in upgrading nation’s public health capacity and in developing a BT preparedness & response plan More on 1999 Initiative... This link will take you away from the educational site

10. National PreparednessCDC Activities • CDC bioterrorism preparedness & response activities • Preparedness and prevention • Detection and surveillance • Diagnosis and characterization of biological and chemical agents • Response More on CDC program... This link will take you away from the educational site

11. National PreparednessCDC Activities, cont. • CDC bioterrorism preparedness & response activities • Education and training • Improved communication systems –HAN, LRN • National Pharmaceutical Stockpile

12. National PreparednessOther DHHS activities • Medical Consequence Management: HHS Office of Emergency Preparedness (OEP), expanding efforts to develop medical response capabilities at local and national levels

13. National Pharmaceutical StockpilePurpose • Provides resources to respond to both biological and chemical attacks • Requested by governor • Managed by the Centers for Disease Control and Prevention More on NPS... This link will take you away from the educational site

14. National Pharmaceutical StockpilePush Packages • 12-hour “Push Packages” in cargo-sized containers weighing approximately 37 tons each • Located around the country at strategic locations • Held in environmentally controlled and secured warehouses • Can reach its destination within 12 hours of being requested

15. National Pharmaceutical StockpilePush Packages • Contain color-coded inventory • Pharmaceuticals - stock rotated before expiration • IV supplies, airway supplies, ventilators • Bandages & personal protective equipment

16. National Pharmaceutical StockpilePush Packages • Materials pre-packaged for immediate dispensing • Support staff will accompany the package • Receiving state responsible for logistics of repackaging and distribution

17. National Pharmaceutical StockpileVendor-Managed Inventory • Agreements with pharmaceutical manufacturers to make large stocks available on demand • Shipped to arrive within 24-36 hours after requested • VA hospitals have an agreement with CDC to assist in the procurement & maintenance of NPS

18. Health Alert Network Definition • A nationwide, integrated information and communications system designed to: • Ensure communications capacity at all local and state health departments • Ensure capacity to receive distance-learning offerings from CDC, et al. • Ensure capacity to broadcast and receive health alerts at every level More on HAN... This link will take you away from the educational site

19. Health Alert Network How It Works • Links local health departments to one another and to other organizations critical for preparedness and response: • Community first-responders • Hospital and private laboratories • State health departments • CDC • Other federal agencies

20. Health Alert Network National Electronic Disease Surveillance • Information system “highway” for the National Electronic Disease Surveillance System (NEDSS) • NEDSS supports automated collection and transmission of disease reports from clinicians’ offices, laboratories, & hospitals to local & state health departments and CDC

21. Community PreparednessA Coordination of Efforts • Partnerships between public health and: • Clinicians and health care facilities • Public safety: law enforcement, fire, HAZMAT • Emergency management • Coordinate response across agencies at the local, state, and federal levels

22. Community PreparednessKnow Whom to Contact • Know how to activate the biological disaster response plan in your practice setting • Who’s in charge? • Communication • Know the 24/7 contact number for your local health department

23. Community Preparedness Role of Public Health • Coordinate preparedness & response activities • Requires collaboration with medical professionals, first responders, and other partners • Provide information to health professionals, government leaders, and the public

24. Community Preparedness Role of Public Health • Detection and evaluation of biological disaster • Requires robust surveillance, epidemiology, and disease investigation infrastructure plus new detection methods • Facilitate medical management of exposed persons • Provide information on diagnosis, treatment, prophylaxis, and infection control issues

25. Community PreparednessRole of Public Health • Coordinate and engage state and federal resources • Education, training, and information • Surveillance, disease case and outbreak investigation

26. Community PreparednessRole of Public Health • Inventory and address deficiencies in regional resources • Hospital response capacity/preparedness • EMS/first responder capacity/preparedness • Mass treatment and prophylaxis • Mortuary capacity/preparedness • Law enforcement/security

27. Bioterrorism Preparedness & Response Role of the Clinician as “First Responder” • Prompt recognition, evaluation, and management of suspicious cases • Recognize clinical presentations consistent with potential BT agents • Be familiar with the “epidemiological clues” • Requires thorough, targeted history • Occupation, travel, contacts, recent “exposures,” threats • Differentiating the “worried well” from the ill

28. Bioterrorism Preparedness & Response Role of the Clinician as “First Responder” • Prompt recognition, evaluation, and management of suspicious cases, continued • Know how to access current resources and information on infection control, treatment, and post-exposure prophylaxis • Local and state public health, CDC • Infectious disease consultants, hospital epidemiologist, or infection control professionals • Be familiar with procedures for obtaining & submitting clinical specimens for testing by clinical & health dept labs

29. Bioterrorism Preparedness & Response Role of the Clinician as “First Responder” • Report confirmed or suspicious cases to public health • Be familiar with 24/7 reporting procedures for suspected cases or potential outbreak • Know how to engage local emergency responders • Be familiar with the disaster response plan for your hospital or practice setting • Know the immunization status and eligibility of your staff for vaccine preventable diseases

30. Bioterrorism Preparedness & Response Role of the Clinician - Preparedness Planning • Long-term consequence management and remediation • Identify and manage late-onset cases • Monitor for and manage adverse effects of treatment or prophylaxis • Identify and manage psychological sequelae • Be familiar with local procedures for evaluation of suspicious substances (“white powder”): role of law enforcement & public health

31. Bioterrorism Preparedness & Response Role of the Clinician - Preparedness Planning • Participate in preparedness planning • Identify resources needed for biological mass casualty event • Medical, nursing, other professional, and support staff • Antibiotics and other pharmaceuticals • Supplies for mass treatment/vaccination • Ventilators and related respiratory support equipment

32. Bioterrorism Preparedness & Response Role of the Clinician - Preparedness Planning • Identify resources needed for biological mass casualty event, continued • Hospital ICU and isolation beds • Mental health resources • Post-mortem management • Triage, security and crowd control • Communication – internal, external, public relations/media

33. Bioterrorism Preparedness and Response Role of the Clinician • To report a potential BT incident or threat in King County • Notify Public Health – Seattle & King County: 206-296-4774 (24hr number) • If no one available, call the Washington State Department of Health: 1-877-539-4344 • Notify your hospital epidemiologist or infection control practitioner • Notify other partners as identified on your facility’s biological disaster response plan • Consider activating your site disaster response plan

34. Hoaxes and Evaluation of Suspicious Powders • If a suspicious package or substance is received • Cover package/substance (do not try to clean up any spilled contents) • Leave the room and close the door • Turn off air conditioning system • Wash hands with soap & water • Report to local law enforcement (call 911) • Notify building security

35. Hoaxes and Evaluation of Suspicious Powders, cont. • Additional steps to take, if exposed to a suspicious powder or substance • Remove contaminated clothing & place in plastic bag or other sealed container • Shower with soap & water (bleach is not necessary) • Contact local health jurisdiction • Symptom monitoring and/or prophylaxis may be needed for others in the room/area

36. Bioterrorism Preparedness and Response Summary of Key Points • BT preparedness and response requires coordination between clinicians, public health, emergency first responders, and law enforcement.

37. Bioterrorism Preparedness and Response Summary of Key Points • BT preparedness for clinicians involves • Ability to recognize unusual clinical presentations and clusters of cases • Knowledge of diagnosis and management of diseases of BT origin • Awareness of their health care facility or practice’s disaster response plan • Knowledge of disease reporting requirements, and how and when to contact local public health authorities

38. ResourcesNational These links will take you away from the educational site Strategic Plan for Preparedness & Response MMWR 49(RR-4) • Centers for Disease Control and Prevention • Emergency Preparedness & Response branch 24-hour notification telephone number: (770) 488-7100 • CDC Public Inquiry HotlinesEnglish (888) 246-2675Español (888) 246-2857 • National Domestic Preparedness Office: (202) 324-9026 M-F 8am-5pm EST Bioterrorism Web site: http://www.bt.cdc.gov

39. Resources Washington State These links will take you away from the educational site • Washington State Department of Health • Communicable Disease Epidemiology • (206) 361-2914 • 1-877-539-4344 - 24-hour emergency number • Julie Wicklund, BT Surveillance Epidemiologist (206) 361-2881 • Washington State Emergency Management Division http://www.doh.wa.gov http://www.wa.gov/wsem/

40. ResourcesLocal This link will take you away from the educational site • Public Health – Seattle & King County • To report illness or discuss suspicious substances (206) 296-4774 (24 hr) http://www.metrokc.gov/health/bioterrorism

41. Resources Emergency Management This link will take you away from the educational site • State Emergency Management duty officer (800)258-5990 • Regional Emergency Coordinator,Region X (206) 615-2266 • FBI • Western WA and after hrs, Statewide: (206) 622-0460 • Eastern WA: (509) 747-5195 • Federal Emergency Management Agency (FEMA) - includes links to emergency management courses http://www.fema.gov

42. Resources Health Care Facility Preparedness These links will take you away from the educational site • American Hospital Association Disaster Readiness site • Association of Professionals in Infection Control and Epidemiology (APIC) • APIC & CDC BT readiness plan template for health care facilities http://www.aha.org/Emergency/EmIndex.asp http://www.apic.org http://www.cdc.gov/ncidod/hip/Bio/13apr99APIC-CDCBioterrorism.PDF

43. In Case of An Event…Web Sites with Up-to-Date Information and Instructions These links will take you away from the educational site • Centers for Disease Control and Prevention • Saint Louis University, CSB & EI • WA State Local Health Departments/Districts • Level A Lab Protocols: Presumptive Agent ID http://www.bt.cdc.gov/EmContact/index.asp http://bioterrorism.slu.edu/hotline.htm http://www.doh.wa.gov/LHJMap/LHJMap.htm http://www.bt.cdc.gov/LabIssues/index.asp

44. In Case of An Event…Web Sites with Up-to-Date Information and Instructions These links will take you away from the educational site http://www.fbi.gov/terrorism/terrorism.htm • FBI Terrorism Web Page • WA State Emergency Mgt Division – Hazard Analysis Update • Mail Security • Links to your state health department • NIOSH – Worker Safety and Use of PPE http://www.wa.gov/wsem http://www.usps.com/news/2001/press/serviceupdates.htm http://www.astho.org/state.html http://www.cdc.gov/niosh/emres01.html