Endemic: rhinovirus, Epidemic: pertussis several years ago Pandemic: H1N1 in was a pandemic just not as severe as originally feared

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4 Endemic: rhinovirus, Epidemic: pertussis several years ago Pandemic: H1N1 in was a pandemic just not as severe as originally feared 4

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6 Endemic, Epidemic 6

7 Endemic, Epidemic 7

8 H5N1 H7N9 8

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14 Point out that MRC response would be similar in many BT/PHP emergencies 14

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19 Nipah virus causes encephalitis or respiratory inflammation Animal-to-human and human-to-human transmission. Fruit bats are the natural host. First recognized in Pigs are a common source of human disease and outbreaks. 19

20 These are examples of the highest-risk agents for BT according to the CDC. Category A agents are easily disseminated or transmitted, have high mortality and/or potential for considerable social disruption. 20

21 The name Variola is derived from a practice termed "variolation," which was the first effective, preventative method developed to provide protection from an infectious disease. Variolation is the practice of inhaling material from the dried pox scabs or inoculating this material directly beneath the skin. This method was effective, but had the disadvantage of producing smallpox when the material was active and not providing full immunological protection in some recipients. Nevertheless, this practice of variolation was practiced in the 18 th century in China, India, western Asia, and Europe. Smallpox is a highly communicable severe rash illness. There are different strains of the virus: one set causing more severe disease called variola major and other strains causing a more mild illness called variola minor. Historically there were 3 serious and 2 less serious forms of variola major. The most common form, ordinary smallpox, occurred in 90% of cases and had case-fatality rates of 15-45%. Other severe types of variola major were flat-type smallpox aka malignant smallpox and hemorrhagic smallpox. The milder forms of variola major were modified smallpox and variola without eruption. These occurred in persons with some immmunity from past infection or vaccination. Variola minor was less severe, was caused by different strains of variola virus and in the 20 th century was the most prevalent form of smallpox in the USA. 21

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23 After a global 12-year international campaign involving mass vaccination programs combined with surveillance and containment of outbreaks, Smallpox became the first (and only) infectious human disease to be eradicated from the world! Efforts to vaccinate and contain the spread of this disease had been made ever since the 18 th century with variolation techniques. Then came along Jenner, who used the cowpox virus to give the worldís first vaccination against smallpox. This was highly effective, but could cause later neurological sequealae, and so the standard vaccine that was used to eradicate smallpox was the vaccinia virus. Vaccinia virus either had its origins from a recombinational event between the cowpox or variola virus through serial passage or could be the representative of a long-since extinct virus. Now only laboratory workers that handle the variola virus and continue to be vaccinated. 23

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25 These are examples of the highest-risk agents for BT according to the CDC. Category A agents are easily disseminated or transmitted, have high mortality and/or potential for considerable social disruption. 25

26 Bacillus anthracis is a large spore forming aerobic encapsulated bacteria. In an environment rich in nutrients, the spores germinate and form bacteria. When nutrients in the environment are exhausted, the bacteria form spores. Anthrax spores are resistant to drying, heat, ultraviolet light, gamma radiation, and some disinfectants. Spores can persist in soli for years, wheras anthrax bacteria survive poorly outside of mammalian hosts. Anthrax spores are found in soil in many parts of the world, including Bay Area counties with grazing cattle (in 2001, an outbreak of bovine anthrax caused death of 21 beef cattle in Santa Clara county). ANTHRAX: Depending upon the route of exposure Bacillus anthraces can cause: Cutaneous Anthrax, Inhalational Anthrax, gastrointestinal anthrax, anthrax meningitis Cutaneous: initial lesion is small, pruritic papule or vesicle, papule then ulerates with central drying and necrosis. Painless, localized non-pitting edema, black eschar which sloughs off after days. Can have painful lymphadenopathy. Fever and maliase common. Lesions resolve without complications in 80-90% patients. Treatment is aimed at preventing systemic dissemination which occurs in 10-20% of cases. Inhalational:inhaled spores go to aveoli, get phagocytosed and travel to regional lymph 26

27 nodes, then germinate to become bacterial cells, which multiply in the lymphatic system and cause lymphadenitis of the mediastinal and peribronchial lymph nodes. The bacteria cause focal hemorrhagic necrosis in the lungs. Baceria entering the bloodstream lead to septicemia, shock, death. Illness is biphasic, initial phase is flulike, with progression after a few days to acute severe respiratory distress, high fever, shock, death. CXR notable for widened mediastinum. NOT CONTAGIOUS. Anthrax meningitis: can occur as a complication of cutaneous, inhalational or gi anthrax. 26

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30 These are examples of the highest-risk agents for BT according to the CDC. Category A agents are easily disseminated or transmitted, have high mortality and/or potential for considerable social disruption. 29

31 Y. pestis can enter Bioterrorism: aerosolized Y. pestis => contagious Pneumonic Plague (without bubonic plague features) Environmental Cycle: Flea (infected) bite => Bubonic Plague => septicemia => Pneumonic Plague => contagious respiratory droplets 30

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33 These are examples of the highest-risk agents for BT according to the CDC. Category A agents are easily disseminated or transmitted, have high mortality and/or potential for considerable social disruption. 32

34 Botulism is an intoxication caused by botulinum toxin, which is produced by Clostridium botulinum and rarely other species. C. Botulinum is a large, strictly anaerobic, spore-forming bacteria commonly isolated from soil and from marine and lake sediments. There are several strains, all of which make toxins. C. botulinum bacteria, are not, in and of themselves, toxic to humans. Disease is caused by exposure to the bacterial toxin. Food borne botulism cased by ingesting of food contaminated with toxin. Dispersion of aerosolized toxin would cause inhalational botulism Wound caused by infection of a contaminated wound with C. botulinum organisms, and subsequent absortpion in the the circulation of locally produced toxin. Most cases related to injection drug use. In California, associated with black tar heroin. Infant is caused by ingestion of C. Botulinum spores. The spores colonize the gi tract, germinate and produce toxin which is absorbed into the circulation. Regardless of exposure, the same neurologic syndrome occurs: WHICH IS NOT CONTAGIOUS 33

35 Symptoms start hours after ingestion/inhalation/contamination profound muscle paralysis respiratory failure (< 24 hrs after onset of sx s) most toxic biological compounds known to man 10, ,000X more toxic than nerve agents 33

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37 These are examples of the highest-risk agents for BT according to the CDC. Category A agents are easily disseminated or transmitted, have high mortality and/or potential for considerable social disruption. 35

38 Caused by bacteria Francisella tularensis Cultured 1912 in Tulare County (CA) Spread via direct contact with contaminated meat, inhalation and insect vectors Historical illnesses: rabbit fever, deer fly fever, market men s disease Organism of warfare research since

39 60 s Natural disease of Northern Hemisphere North America, Europe, Asia True pneumonia looks same as many pneumonias Not contagious human to human Standard precautions 36

40 Treatment Pre or Post exposure Prophylaxis: ciprofloxacin or doxycycline Live Vaccine Strain (LVS) investigational 37

41 These are examples of the highest-risk agents for BT according to the CDC. Category A agents are easily disseminated or transmitted, have high mortality and/or potential for considerable social disruption. 38

42 These viruses each are characterized by an acute generalized febrile illness that includes malaise, prostration, increased vascular permeability, and abnormalities of circulatory regulation. All agents are highly infectious via the aerosol route, most are stable as respiratory aerosols, and they can be replicated in cell culture. Thus, they possess characteristics ideal for use by terrorists. 4 families of viruses, which include the Arenaviridae (Lassa, Argentine, Bolivian, Brazilian, Venezuelan hemorrhagic fevers), Bunyaviridae (Rift Valley, Crimean Congo, Hantavirus), Filoviridae (Marburg, Ebola hemorrhagic fevers), and Flaviviridae (yellow, dengue, Kyasanur Forest, Omsk hemorrhagic fevers). Filoviridae family 39

43 highly contagious body fluids high mortality Ebola virus Sudan, Zaire, Gabon, Ivory Coast 50 90% mortality Marburg virus Africa, Germany, Yugoslavia African Green Monkey vector 39

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46 Pose question to participants. Record responses on white board. 42

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48 Something like a virus, bacteria, parasite or fungus can get Someone, usually a susceptible host, which will be discussed in more detail shortly, sick. That Someone however needs to be exposed to that Something Somehow, like through the mouth or broken skin, and lack of basic precautions can cause us to pick up that Something from Somewhere. So if we do not take basic precautions to protect ourselves we may get sick. 44

49 Water contaminated water can cause GI illness and wound infections. Giardia is a parasite that causes gastrointestinal illness and has often been linked with contaminated water. Outbreaks of bacterial illnesses like Salmonella and E. coli and also norovirus have also been associated with fecally contaminated water. A type of bacteria called Vibrio can be present in coastal waters and is capable of causing infection if an open wound is exposed to contaminated water. Air there were over 200 cases of coccidioidomycosis or valley fever after the 1994 northridge earthquake. Coccidioidomycosis is a fungus that exists naturally in the soil and can become airborne when a lot of dust is stirred up. People in dust clouds following the earthquake were at higher risk for infection. Can cause a flu-like illness (~60% asymptomatic). Some people can develop chronic pulmonary infection or widespread disseminated infection. Air can also contain infectious droplets that cause respiratory illnesses (influenza, TB, etc). Food food contaminated with human or animal fecal matter can cause a wide range of GI illnesses. Salmonella, E. coli, Campy, norovirus, etc Soil Clostridium tetani, which causes tetanus is present in soil. Clostridium sp. are 45

50 also capable of causing gangrene when they enter an open wound. Gangrene is characterized by tissue death and can occur when a body part loses its blood supply. This may happen from, for example, injury or infection. People are sources for many respiratory illnesses. Also many vaccine preventable illnesses such as measles, chickenpox, whooping cough etc. Skin infections such as those caused by Staphylococcus may occur due to close contact with infected individuals or sharing personal items like towels. Animals are natural reservoirs for many infectious agents that can cause human illness. Rabies, Salmonella, E. coli, leptospirosis are just a few examples. Vectors transmit diseases to people that are usually from an animal reservoir. Examples would be ticks which can transmit Lyme disease and have a mouse reservoir. Mosquitoes that can transmit WNV, which has a bird reservoir. There usually isn t an immediate risk for increase in vector-borne diseases following a disaster unless, for example, people are suddenly outside a lot more than previously and are therefore much more likely to be bitten (say by mosquitoes during the summer). What you might be more likely to encounter in a shelter setting would be nuisance vectors, such as head lice, mites, and bed bugs. They do not transmit diseases to humans, but they are still a public health concern because they can spread from person to person and cause rashes and discomfort. 45

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52 Direct contact sexual transmission, diarrhea Indirect contact surface contamination Droplets cold, flu, meningitis Airborne dust, droplets, aerosol from medical procedures Vehicle-borne ingestion contaminated food/water, injection drug use Vector-borne WNV/mosquitoes Vertical mother to child at birth 47

53 Nurses will be familiar with these principals of infection control already, but will need to remind patients and the public of the importance of basic sanitation following a disaster. 48

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