Pup biologic warfare

L 11 Epidemics and Emerging Infections 1
Epidemics and Emerging
Infections
Hospital Preparedness for Emergencies

Wars of the Future:
Biological Warfare and Chemical
Weapons
Teodoro Herbosa MD FPCS
Department of Emergency Medicine
College of Medicine
University of the Philippines, Manila

Objective
Identify the fundamentals of a
hospital preparedness and
response plan for epidemics.
Upon completion of this unit, you will
be able to:

Biological Hazards
❑ “Terrorism” / Anthrax
❑ SARS
❑ Avian Flu
❑ Dengue
❑ MERSCoV
❑ Ebola
Vulnerability emerging to infectious
diseases

Biological
Hazards
Tartars used
plague-
infected
corpses in
Kaffa, 1346.

Influenza Pandemic
Nurses work in the
Red Cross rooms of
Seattle, WA with
“influenza masks” on
their faces. December
1918 (Courtesy of the
National Archives,
165-WW-269B-10)

Basic Dictum
Safety First!

Biological Event
❑ Bacterial agents
▪ Anthrax, Brucellosis, Yersinea pestis
(Plague) & Cholera , Salmonella
❑ Viruses
▪ Smallpox, Hemorrhagic Fever Virus
❑ Biological product
▪ Botulinum toxin, Endotoxins, Mycotoxin,
SEB, ricin,

Smallpox – Bangladesh, 1976
A child stricken by smallpox is
relatively cured but his health is
still threatened by malnutrition
and secondary infection.
(Courtesy of the National
Archives, 76-845)

Biological Event
❑ Infection borne through air, food
and water
❑ Incubation period - delay from
time of exposure until clinical
symptoms arise
❑ Extensive exposure may occur
before the primary event is
appreciated.

Rare Diseases can be Overseen
Rare color
photo of Baby
with smallpox.
National
Archive film
footage from
Vietnam
(RG-428-
NPC-38594)

Biological Event
❑ Delivered with conventional
explosives
❑ Emergency care,
decontamination is necessary
(outside the hospital)
❑ Personnel must be trained in
patient decontamination

Decontamination Area
❑ Storage for decontamination equipment
and supplies
❑ Decontamination area - cooled to reduce
the heat load on personnel caused by
their protective equipment
❑ The decontamination site has 3 zones:
▪ Hot zone – incoming casualties
▪ Warm zone – decontamination area
▪ Cold zone – triage and transport

Contamination reduction
(warm) zone
Support (cold) zone
Exclusion (hot) zone
wind
CORRIDOR
amp
Access
control points
Crowd control
line
Decontamina
tion line
Hot line

❑ First responders and medical
personnel SHOULD PROTECT
THEMSELVES
❑ Personal Protective Equipment
(PPE)
▪ Protect eyes, lungs and skin

Storage for decontamination
equipment and supplies
Decontamination area
❑ cooled to reduce the heat load
on personnel caused by their
protective equipment

Hot zone
Support zone
Decontamination
zone
Patients
No special protective gear
hazmat teams with proper protective gear
gross contaminates removed here
remove victim’s contaminated clothing
wash & final rinse/soap & shampoo
wash & rinse
clean stretcher & blankets

❑ First responders (decontamination)
protect themselves through PPE.
❑ Personal Protective Equipment
(PPE) respiratory equipment
❑ Garments and barrier material

❑ Maximum protection is achieved
through use of positive pressure
respirators and total body
encapsulation.
❑ Surgical mask and a pair of latex
gloves provide minimum protection

Personal Protective Equipment
Red Cross workers of Boston,
MA removing bundles of masks
for American Soldiers from a
table where other women are
busily engaged in making
them. March 1919. (Courtesy
of the National Archives, 165-
WW-269B-37)

Medical Response
❑ Pandemic
▪ large number of
casualties with similar
symptoms
▪ dissemination device
▪ receipt of a warning
▪ hospital may receive
untreated casualties
directly from the site
Emergency Hospital at Brookline,
MA to care for influenza cases.
October 1918

Medical Response
First responders
and medical
personnel
SHOULD
PROTECT
THEMSELVES
September 11

Medical Response
Why is the level of
Epidemic
preparedness so
critical?
❑ Because the
consequences of not
being prepared are so
catastrophic
Smallpox Vaccine

Category A
The public health systems and primary health-care
providers must be prepared to address varied biological
agents, including pathogens that are rarely seen. High-
priority agents include organisms that pose a risk to
national security because they –
❑ can be easily disseminated or transmitted
person-to-person;
❑ cause high mortality, with potential for major
public health impact;
❑ might cause public panic and social disruption;
and
❑ require special action for public health
preparedness.

Category A Agents Include:
❑ Variola major (Smallpox):
❑ Bacillus anthracis (Anthrax);
❑ Yersinia pestis (Plague);
❑ Clostridium botulinium toxin
(Botulism);
❑ Francisella tullarensis
(Tularemia);

Category A Agents Include:
❑ Filoviruses
- Ebola Hemorrhagic Fever;
- Marburg Hemorrhagic Fever; and
❑ Arenaviruses
- Lassa (Lassa Fever)
- Junin (Argentine Hemorrhagic Fever)
related viruses.

Category B
Second-highest priority agents:
❑ moderately easy to disseminate
❑ cause moderate morbidity and low
mortality
❑ require specific enhancements of CDC’s
diagnostic capacity and enhanced
disease surveillance

Category B agents include:
❑ Coxiella burnetti (Q fever)
❑ Brucella species (Brucellosis)
❑ Burkholderia mallei (Glanders)
❑ Alphaviruses
▪ Venezuelan encephalomyelitis
▪ Eastern and Western equine
encephalomyelitis
❑ Rich toxin from Ricinus communis (castor beans)
❑ Epsilon toxin of Clostridium perfringens
❑ Staphylococcus enterotoxin B

Category B
A subset of List B agents include pathogens
that are food or waterborne. These pathogens
include, but are not limited to:
▪ Salmonella species
▪ Shigella dysenteriae
▪ Escherichia coli O157:H7
▪ Vibrio cholerae
▪ Cryptosporidium parvum

Category C
Third-highest priority agents include emerging
pathogens that could be engineered for mass
dissemination in the future because of:
❑ availability
❑ ease of production and dissemination
❑ potential for high morbidity and mortality
due to major health impacts

Category C agents include:
❑ Nipah virus
❑ Hantaviruses
❑ Tickbone hemorrhagic fever viruses
❑ Tickbone encephalitis viruses
❑ Yellow fever
❑ Multi-drug resistant tuberculosis

Category C
Preparedness for List C agents requires ongoing
research to improve disease detection,
diagnosis, treatment and prevention.
Linking bio-terrorism preparedness efforts with
ongoing disease surveillance and outbreak
response activities as defined in CDC’s emerging
infectious disease strategy is imperative.

❑ Cholera epidemic, Europe 1830 - 1847
intensive infectious disease diplomacy
multilateral cooperation; First International
Sanitary Conference, Paris 1851
❑ 1948 WHO Constitution
❑ 1951 WHO adopted International Sanitary
Regulations
❑ International Health Regulations, 1969
History of the IHR

IHR (1969) to monitor and control six
serious infectious diseases:
Cholera, Plague, Yellow fever,
Smallpox, Relapsing fever and Typhus
IHR (1969) - Cholera, Plague and Yellow
fever remain of concern
WHO must be informed
History of the IHR

1990's resurgence of epidemics
Cholera - South America
Plague - India
Emergence of infectious agents Ebola
(48th World Health Assembly, 1995 revision
of IHR, May 2001)
WHA 54.14, Global health security:
epidemic alert and response
History of the IHR

May 2003 resolution WHA56.28 Revision
of IHR
IGWG sessions in Nov 2004 and Feb/
May 2005
58th World Health Assembly adopted IHR
(2005) 23 May 2005 resolution WHA58.3.
History of the IHR

International Health Regulations of
2005, Article 5-1 Surveillance
Declaration of
Policies
• urges Member States to develop,
strengthen and maintain as soon as
possible, but no later than five years
from entry into force of these
regulations, and the capacity to detect,
assess, notify and report events in
accordance with these regulations.

L 11 Epidemics and Emerging Infections 41DOH – CHD, REGIONAL EPIDEMIOLOGY and SURVEILLANCE UNIT (RESU)
Priority Diseases/Syndromes And Conditions Targeted For Surveillance
Category I (Immediately
Notifiable)
1. Acute Flaccid Paralysis
2. Adverse Event Following
Immunization (AEFI)
3. Anthrax
4. Human Avian Influenza
5. Measles
6. Meningococcal Disease
7. Neonatal Tetanus
8. Paralytic Shellfish
Poisoning
9. Rabies
1.Severe Acute
Respiratory
Syndrome (SARS)
Category II (Weekly Notifiable)
1. Acute Bloody Diarrhea
2. Acute Encephalitis
Syndrome
3. Acute Hemorrhagic Fever
Syndrome
4. Acute Viral Hepatitis
5. Bacterial Meningitis
6. Cholera
7. Dengue
8. Diphtheria
9. Influenza-like Illness
10. Leptospirosis
11. Malaria
12. Non-neonatal Tetanus
13. Pertussis
•Typhoid and Paratyphoid
Fever

Medical Response
First responders must take
care that they don't become
victims themselves.

Medical Response
A 1995 NBC exercise in New York City
determined the first 100 emergency
responders to arrive on scene 'killed'
❑ not adequately prepared or trained to
deal with this incident
Los Angeles exercise
❑ doctors admitting that 'victims' have
seriously contaminated hospitals

Why is the level of epidemic  
preparedness so critical?
Because the
consequences of not
being prepared are so
catastrophic!

L 10 Complex Emergencies 45
Terrorism
❑ ‘War Within Borders’
❑ Asia - a nesting place for terrorism and
lead member of the globe in terrorism
❑ Afghanistan ➔ Japan
❑ Vulnerability of non-involved population
❑ Unclear end-point for termination of
further, recurrent acts

Weapons of Mass Destruction (WMD)
❑ In warfare for 2500 years
❑ Biological - Tartars used plague-infected
corpses in Kaffa in 1346.
❑ Modern warfare (1915) - Chlorine gas
❑ Nuclear bombs - Hiroshima and Nagasaki,
1945.
❑ Nerve and vesicant agents against Iran
❑ Cyanide against the Kurds

Nuclear Agents
❑ Nuclear detonation through
conventional explosives
❑ Activation of Radioactive material
❑ Dissemination through
▪ Food
▪ Water
▪ Direct environmental spread

Injury Profile – Nuclear Agents
❑ Thermal injury - burns
❑ Eye injuries - blindness due to blast
flash
❑ Ear injuries - deafness rupture of ear
drums
❑ Penetrating wounds/orthopedic
injuries/head injuries

Radiation Sickness
❑ Irradiation injuries do not make
the patient radioactive!
❑ Decontamination before
transport
❑ Removal of all clothing
❑ Tepid bathing of skin surface

Biological agents
❑ Infectious disease or toxin that can be
used in bioterrorism or biological
warfare
❑ Viruses, microorganisms (bacteria and
fungi) and their associated toxins
❑ Can be delivered with conventional
explosives, air, food and water

❑ Incubation period: delay in time of
exposure until clinical symptoms
❑ Some are rapidly fatal
❑ Others are severely incapacitating
❑ Extensive exposure may occur
before the primary event is revealed
Biological Agents

Biological agents
❑ Bacteria - Anthrax, Brucellosis,
Plague & Cholera
❑ Viruses - smallpox / hemorrhagic
fever
❑ Biological products - Botulinum
toxin, endotoxins, mycotoxin

Anthrax
❑

Plague
❑ Bubonic Plague –
Enlarged Lymph nodes
❑
“Black Death” – Peripheral
gangrene

Smallpox
❑

Chemical Agents
Chlorine gas dispersion during World War I

❑ About 70 chemicals are documented
in history as WMD which include:
Chlorine, Phosgene, Cyanide
and Vesicants (‘Nitrogen Mustard’)
❑ Exposure may not be revealed until
chemical injuries are recognized
❑ On-site decontamination
Chemical Agents

Nerve Gas  
(Sarin Gas Attack - Japan)
❑ Sarin - fluorinated phosphinate
❑ Similar to Insecticide - malathion
❑ Attacks the  
nervous system

NBC incident –  
Characteristics
❑ Mass casualties with similar symptoms
❑ Dissemination device
❑ Receipt of warning
❑ Hospital may receive untreated casualties
direct from the site
❑ Rescue personnel could become victims
due to unavailability of information
Fill in the Blank

Hospital Preparedness for  
NBC Events
❑ Management system for mass NBC
casualties
❑ HAZMAT suits and PPE for staff
❑ Education of staff and community
regarding local and regional risks
❑ Training in patient decontamination
Fill in the Blank

Decontamination Protocols
❑ Patients could arrive at hospital
prior to decontamination
❑ Risk to health care professionals
who would subsequently require
decontamination.
❑ Designated Decontamination areas
in the Hospital
Fill in the Blank

Review of Objectives
As a result of this session, you should be able
to:
❑ Describe the characteristics and
challenges of Complex Disasters.
❑ Identify the salient features of NBC
incidents and the response required.
❑ Outline major health effects and hospital
preparedness for complex disasters.

Summary
❑ Epidemics pose challenges for medical
personnel.
❑ Preparedness for an appropriate hospital
response activated is essential, while
ensuring the safety of personnel.
❑ EMS may not provide the most effective
and immediate medical response.
❑ Successful outcome of the medical care
requires adequate preparedness.

Summary
❑ Planning, disciplined & coordinated
behavior by personnel, mobilization
ability, availability of medical
resources, and communication are
essential in effective care.
Continue…

Objectives
❑ Identify the fundamentals of a
hospital preparedness and
response plan for epidemics.
Upon completion of this unit you will be
able to:

Exercise
❑ What resources does your hospital have
which can be applied to a CBR incident?
❑ What training is required for EM
personnel in order to mount a safe and
effective hospital response to a CBR
incident?
❑ With what other agencies should the
hospital be conducting joint CBR
exercises?

❑ With whom should the hospital
coordinate regularly on CBR
issues?
❑ Who should be represented on
your hospital’s CBR functional
preparedness committee?
Exercise
Continue…

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