Bioterrorism Agents – Plague Lesson 6

1. Bioterrorism Agents – PlagueLesson 6 Public Health Management

2. Objectives • Purposes of epidemiological investigations • Case definitions • Sentinel events indicating bioterrorism • Public health response • Natural Plague • Bio-terrorist Plague • Contact management and prophylaxis

3. Principal Purposes of Epidemiologic Investigations • Characterize cases and confirm outbreak • Identify • Causative agent • Source • Mode of Transmission • Identify • Cases • Case Contacts

4. Principal Purposes of Epidemiologic Investigations • Person, place, time • Risk factors • Control and Prevention strategies • Monitor and evaluate response

5. Plague Case DefinitionsSuspect and Probable • Suspect Case • Clinically compatible • Clinical specimens – features of Y. pestis • Probable Case • Clinically compatible • Presumptive laboratory results • Positive DFA • PCR evidence of Y. pestis • Single elevated serum antibody titer to F1 antigen

6. Plague Case DefinitionsConfirmed • Confirmed Case • Confirmatory isolation of Y. pestis • 4-fold change in antibody titer to F1 antigen • IHC staining can be considered when isolation or serology not possible

7. Early Cases • Lab confirmation important • First cases in geographic area • Treatment and isolation • Post- or pre-exposure prophylaxis • Other controls • Call public health immediately

8. Natural Disease vs Bioterrorism • Announced, credible threat • Observed threat event • Detection • Animal cases in unusual settings • Human cases without link to endemic area

9. Natural Disease vs BioterrorismNatural Plague • Recent endemic exposure • Handling of sick cat, flea bites in endemic area • Recent travel to endemic area • Sporadic, infrequent cases • Bubonic most common presentation

10. Natural Disease vs BioterrorismBioterrorist Plague • No known endemic exposure • Point source in urban, crowded setting • Severe respiratory illness • Cluster of severe and fatal pneumonia • Plague cases that don’t respond to recommended antibiotic treatment

11. Control and ContainmentInitial Stages • Sampling of environment • Definition of dispersion • Confirmation of Y. pestis • Deploy SNS • Epidemiologic Investigation • Animal control • Communications

12. Control and ContainmentInitial Stages • Coordination of activities • Active surveillance • Assisted surveillance • Clinician Information Requests • Number of plague patients • Number of plague rule-outs • Chart review for unrecognized illness

13. Chart Reviews • ER discharges, admits, transfers • Non-lab confirmed fevers, pneumonias • Prioritize hospitalized patients • Follow-up on those transferred out • Critical for determining extent and source of outbreak

14. Symptomatic Patient Evaluation • Seek care: febrile respiratory, other plague compatible syndromes • Referral and triage hospitals • Isolation and respiratory droplet precaution • All fevers 38.5C or higher or cough presumptive pneumonic plague

15. Contact Management Contact – Within 6-7 feet, or 2 meters, of patient in prior 7 days • Evaluate contacts with fever or cough • 7 days prophylaxis and symptom monitoring

16. Contact ManagementProphylaxis Groups • Exposed to Y. pestis release • Household members of respiratory plague • HCWs with direct patient contact • First responders • Patient transporters • Co-workers, friends, others with close contact to symptomatic respiratory

17. Contact ManagementAntibiotics and Monitoring • Doxycycline is first choice • Alternatives: Tetracyclines, sulfonamides, chloramphenicol • IND for gentamicin, ciprofloxacin • Temperature twice daily • Unrestricted unless fever or cough develops

18. Contact Management • Prophylaxis refusal – monitor x 7 days • Special populations management • No vaccine with proven efficacy

19. Other Management Issues • Mass prophylaxis clinics • Monitor news announcements • Environmental sampling

20. Environmental Assessment • Goals of Assessment • Infected animals • Infectious fleas • Contaminated surfaces, soils, water supplies • Plague bacteria survive poorly externally • Short-term risk for humans

21. Environmental Testing • Plague in animals, new regions • Need for vector or rodent control • Control and prevention measures • Need for follow-up surveillance • Effectiveness of control measures

22. Review Questions – PlagueLesson 6 Public Health Management

23. Plague Review QuestionLesson 6, Question 1 • Mass casualty situation • Bioterrorist attack with plague • Public health wants you to interview patients for movement in past week Why are they doing this to you now?

24. Plague Review QuestionLesson 6, Question 1 Why are they doing this to you now? • Look like they’re doing something • Determine source of exposure • B and D • Prophylaxis recommendation development

25. Plague Review QuestionLesson 6, Question 1 Why are they doing this to you now? • B and D • Determine source of exposure • Prophylaxis recommendations

26. Plague Review QuestionLesson 6, Question 2 • You’re on hospital emergency response team • Categorizing plague cases at your hospital A confirmed case would NOT include…

27. Plague Review QuestionLesson 6, Question 2 A confirmed case would NOT include… • Confirmed isolation of Y. pestis • IHC staining of Y. pestis • Stained organisms of Y. pestis • Fourfold or greater increase in antibody titer to F1 antigen

28. Plague Review QuestionLesson 6, Question 2 A confirmed case would NOT include… C. Stained organisms of Y. pestis

29. Plague Review QuestionLesson 6, Question 3 • You’re a public health worker • State epidemiologists asks you to determine if plague case is natural or bioterrorist Which would best describe naturally occurring plague?

30. Plague Review QuestionLesson 6, Question 3 Which would best describe naturally occurring plague? • History of sporadic cases in area • 1 patient only • Patient has history of rodent exposure • All of the above

31. Plague Review QuestionLesson 6, Question 3 Which would best describe naturally occurring plague? • All of the above • History of sporadic cases • Only 1 case • History of rodent exposure

32. Plague Review QuestionLesson 6, Question 4 • Plague bioterror event • Identifying close contacts • Considering antibiotic prophylaxis Which of the following fall is not considered a close contact?

33. Plague Review QuestionLesson 6, Question 4 Which of the following fall is not considered a close contact? • Friends in another city • Patient transporters • Household members of respiratory • Co-workers within 6 feet

34. Plague Review QuestionLesson 6, Question 4 Which of the following fall is not considered a close contact? • Friends in another city

35. Review QuestionLesson 6, Question 5 • Plague bioterror event • Large number of casualties • You’re on local emergency response team What activity would you expect from response leaders?

36. Plague Review QuestionLesson 6, Question 5 What activity would you expect from response leaders? • Quarantine entire city • Drop individual investigations • Symptomatic patients stay home • Establishment of treatment centers

37. Plague Review QuestionLesson 6, Question 5 What activity would you expect from response leaders? D. Establishment of treatment centers

38. BT Agents Home 6-21. Question Plague: Lesson 6- Public Health Issues BT Agents • The best answer is B. It is important that all close contacts to a pneumonic plague case receive prophylaxis. • Correct. It is important that all close contacts to a pneumonic plague case receive prophylaxis. • The best answer is B. Even naturally-occurring cases of plague should be laboratory confirmed. It is also important that all close contacts to a pneumonic plague case receive prophylaxis. Module: Plague 6) You work at a public health department in New Mexico. Your local hospital has a positive test in their lab for a single case of suspect pneumonic plague. The patient has a documented exposure to an ill animal. How will you manage this patient? Module Introduction- Module Objectives Target Audience Continuing Education Credit Lessons-1) General Overview 2) Clinical Presentation 3) Differential Diagnosis 4) Laboratory Issues 5) Medical Management 6) Public Health Issues 7) Veterinarian Issues 8) Module Self-AssessmentAdditional Resources A. I won’t do anything. The patient is being treated. B. Look for all close contacts to the patient and begin on prophylaxis. C. Stop the referral testing at the public health lab. We know it’s plague because there was an ill animal. Plague: Lesson 6- Public Health Issues 21 of _ Back Next

39. Plague Review QuestionLesson 6, Question 6 • You work in public health in New Mexico • Local hospital with suspect plague • Documented exposure to ill animal How will you manage this patient?

40. Plague Review QuestionLesson 6, Question 6 How will you manage this patient? • Nothing. Patient is being treated. • Manage all close contacts • Stop referral testing. There was a sick animal. We know it’s plague.

41. Plague Review QuestionLesson 6, Question 6 How will you manage this patient? B. Manage all close contacts