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  • Introduction and Objectives In this lesson you will learn about the clinical presentation of plague. Because it is likely that it will be an astute clinician who recognizes bioterrorism, it is important for you to understand and recognize the presentation of naturally occurring disease. We will look at the three major forms of plague- bubonic, pneumonic and septicemic, in more detail. At the end of this lesson you should be able to: Identify the distinctions between bubonic, pneumonic and septicemic plague with regard to symptoms and disease course.
  • Pharyngeal Plague Uncommon. Can resemble tonsillitis with peritonsillar abscess and cervical lymphadenopathy. There can be asymptomatic carriers of pharyngeal plague in close contacts of patients with other forms of plague. Plague Meningitis This form of plague is most common in children and is usually the end result of ineffective treatment for other forms of plague. Symptoms often mimic other forms of bacterial meningitis, such as headache, neck stiffness, and photophobia.
  • Infection Control In advanced stages, the sputum of pneumonic plague patients contains large numbers of plague bacilli, and the coughing patient can spread infection via respiratory droplets to persons in close direct contact. Therefore, respiratory droplet precautions should be taken with any suspect case. If you have reason to suspect you have a plague case, even in endemic areas, your health department should be contacted immediately so that control measures can begin
  • Medical Chart – Gary Indiana Hospital Patient – 12 month old from Gary Symptoms – Parents report acute onset fever, malaise and body aches x 2 days. Presenting with extremely tender lymph node under arm that has swollen to 2 inches in diameter. Patient is exhibiting some neurologic symptoms. You’re suspecting plague meningitis. What is your first step?
  • You suspect your patient has plague meningitis. What is your first step after thinking this? Call your local health department Rule out other diseases that could have the same symptoms Place the patient in isolation
  • The UCLA Center for Public Health and Disasters first developed this training for physicians in October of 2001. Since then, the fund of knowledge has grown considerably. We have attempted to incorporate these advances in this updated version of this presentation. Updated by: Gregory J. Moran, MD, Associate Professor of Clinical Medicine, David Geffen School of Medicine; Dept. of Emergency Medicine and Division of Infectious Diseases, Olive View-UCLA Medical Center ; Steven J. Rottman, MD, FACEP, Director, UCLA Center for Public Health and Disasters, Adjunct Professor, David Geffen School of Medicine, and UCLA School of Public Health; and Tamiza Z. Teja, MPH, Project Coordinator, Bioterrorism and Public Health Preparedness, UCLA Center for Public Health and Disasters Goal: To prepare physicians and other health providers for a bioterrorist incident in order to reduce morbidity and mortality. Learning Objectives: 1) Discuss why bioterrorism is a special concern to the health community 2) Identify key biological agents that could be used in a bioterrorism attack, and for each agent describe: Potential presenting symptoms Appropriate treatment of a patient Appropriate precautions to protect self and others from secondary infection 3) Describe the policy as well as the mechanism for reporting suspected cases 4) Describe the relationship between physicians in hospitals and private practice, the local public health department, state public health department, and federal agencies in the context of real or suspected cases of bioterrorism 5) Identify bioterrorism-related information and support resources for physicians and other health care providers Target Audience: This slide presentation was designed specifically for internists, family physicians, pediatricians, emergency physicians, and other clinical practitioners who would be most likely to encounter symptomatic patients presenting for evaluation and treatment in a bioterrorism incident. Time Required: Presenting the entire slide show to a group will take approximately 1-1/2 -2 hours. Please note: this estimated presentation time does not include time for questions and answers, or detailed discussion.
  • Bioterrorism definition of the Centers for Disease Control and Prevention. Even the threat, not just the actual use, is considered terrorism. Note the variety of agents that can be used: viruses, bacteria, fungi, and the toxins they may produce.
  • This slide summarizes a diagnostic approach to people with suspected inhalation anthrax. Note that this is for those with a history of suspected exposure or believed to be at significant risk for exposure. Blood culture is the test most likely to confirm anthrax. May see organism on gram stain of blood. Notify lab if suspected. Serologic testing is available through CDC, but not available in most labs.
  • Terrorists using botulism would probably not be spreading the bacterium itself. It is more likely they would be using the purified toxin. The most potent toxin known, botulinum is 100,000 times more toxic than sarin, the agent that was used in the Tokyo subway attacks by the Aum Shinrikyo cult in 1995 (Franz, 1997). The endospores of C. botulinum, when stained using the Malachite Green staining method, will appear as green spheres, while the bacilli themselves will turn purple in color. Article References: Arnon SS, et al. Botulinum toxin as a biological weapon. JAMA 2001; 285:1059-1070. Franz DR et al . Clinical recognition and management of patients exposed to biological warfare agents. JAMA . 1997;278(5):399-411. Photo Reference: CDC Public Health Image Library, Clostridium botulinum spores stained with Malachite Green Stain. Photo by: CDC/Courtesy of Larry Stauffer, Oregon State Public Health Laboratory.
  • Many of us have seen similar cases and probably didn’t think of bioterrorism as the causative agent. We would perhaps suspect sepsis, meningitis, or maybe Streptococcus pneumoniae . The first clue of a possible outbreak is that there is a similar case from the same building – this is a signal to call infection control and the local public health department immediately. Contact the local health department anytime there is an unusual or suspicious illness. When the lab returns the results days later, blood cultures are positive for? ( Bacillus anthracis) This scenario is used for FBI trainings: an anthrax attack on the New York Stock Exchange.
  • Transcript

    • 1. Preparing Physicians for Recognizing and Responding to Bioterrorism: A Needs-based Approach Stephen C. Alder, Ph.D. Melissa Vellinga October 20, 2004 Countering Bioterrorism 2004 Preparedness through Partnerships
    • 2. Presentation Overview
      • Bioterrorism Recognition and Response
        • What is expected of physicians?
        • How do physicians perceive their own role?
        • Training physicians: What is needed and wanted?
        • Are we over-reacting?
        • Creating balance in BT preparedness
        • Developing training for physicians
        • Summary
    • 3. BIOTERRORISM What are Physicians Expected to Do?
    • 4. What the CDC Recommends Physicians Do
      • Have basic information about clinical manifestations of infections caused by the select agents of bioterrorism
      • Know how to diagnose these conditions
      • Know when and how to report confirmed or suspected conditions of importance to local public health and law enforcement officials
      • Able to obtain necessary information from patients suspected to have conditions caused by bioterrorism for further investigation
      • Bioterrorism Preparedness and Response
            • Julie L. Gerberding, MD, MPH; James M. Hughes, MD; Jeffrey P, Koplan, MD, MPH
    • 5. Role Physicians See for Themselves
      • Primary Care Physicians
        • Link to emergency response/public health infrastructure
        • Calm persons who are well but worried
        • Prevent secondary
        • exposures
    • 6. Role Physicians See for Themselves
      • Emergency Medicine Physicians
        • Identify index case
        • Provide primary medical response
        • Care for affected patients
    • 7. Role Physicians See for Themselves
      • Infectious Disease Physicians
        • Alert health department
        • Provide expertise to medical community
        • Act as a regional resource
    • 8. Role Physicians See for Themselves
      • Dermatology and Radiology Physicians
        • Aid in diagnosis
        • Identify specific signs of tularemia, smallpox, and anthrax
        • Support response efforts
        • of other physicians
    • 9. How Should Training be Provided to Physicians?
    • 10. Principles of Adult Learning
      • Adults are motivated to learn as they experience needs and interests that learning will satisfy
      • Adults are motivated to learn when they need the education to effectively cope with real-life situations
      • Adult orientation to learning is life centered – it deals more with their actual experience than with theoretical considerations
      • Experience is the richest source for adult learning
      Knowles, Holton, Swanson, 1998
    • 11. Principles of Adult Learning
      • Adults have a deep need to be self-directed in the learning process
      • Individual differences in learning among adults increases with age
      • Adults are motivated to engage in education that will enable them to perform tasks or deal with problems with which they will be confronted in everyday life
      Knowles, Holton, Swanson, 1998
    • 12. What Primary Care Physicians Want
      • Information about disease surveillance and response that is applicable to both ongoing health concerns and potential bioterrorism events
      • To be taught by a physician with expertise in bioterrorism recognition and response
      • Hands-on oriented training that includes use of reference materials
    • 13. What Emergency Medicine Physicians Want
      • Ongoing education for identification of and initial response to diseases for specific bioterrorism agents
      • To be taught by someone with specific training in bioterrorism who is sensitive to the role of emergency medicine physicians
      • Quick reference materials, web-based training, disaster drills and exercises
    • 14. What Infectious Disease Physicians Want
      • The latest training on BT agents and other newly emerging infectious diseases
      • Improve channels by which they can interact with the medical and public health community
      • To be taught by someone with expertise in BT and emerging infectious disease
      • Ongoing updates of the latest information regarding BT
    • 15. What Dermatology and Radiology Physicians Want
      • Better capacity to provide consultation to physicians with patients that may be victims of a bioterrorism event
      • To be taught by experts in BT and BT recognition within their specialty
      • Grand rounds, general presentations on BT at existing meetings
    • 16. Needs Assessment Summary
      • The medical community feels a need to be prepared to recognize and respond to bioterrorism events.
      • The needs assessment conducted among Utah physicians provided insights into their perceived training needs and preferred methods of learning.
      • Physicians have many competing demands on their time and a tailored educational offering can increase the intended audience’s acceptance and learning .
    • 17. Are We Over-reacting?
    • 18.
      • “The public health community should acknowledge the substantial harm that bioterrorism preparedness has already caused and develop mechanisms to increase our public health resources and to allocate them to address the world’s real health needs”
      Cohen HW, Gould RM, Sidel VW. The Pitfalls of Bioterrorism Preparedness: the Anthrax and Smallpox Experiences. American Journal of Public Health. 2004;94:1667-1670.
    • 19. CDC’s View
      • CDC's Health Alert Network has upgraded the capacity of state and local health agencies to detect and communicate different health threats—including bioterrorism, emerging infectious diseases, chronic diseases, and environmental hazards. This means that we reap the benefits of these investments every day, not just in the event of a bioterrorist attack.
      CDC Programs in Brief: Bioterrorism and Public Health Preparedness
    • 20. CDC’s View
      • … these [BT preparedness] measures strengthen the existing public health system while preparing for bioterrorism, infectious disease outbreaks, and other public health threats and emergencies.
      CDC Programs in Brief: Bioterrorism and Public Health Preparedness
    • 21.
      • “Terrorism presents many new challenges to the nation’s public health infrastructure. ……It is urgent that we now change and reinvest in our public health system to establish and maintain a strong disease-defense system- nationwide, competent, and modern.”
      Levy BS, Sidel VW. Terrorism and Public Health: A Balanced Approach to Strengthening Systems and Protecting People. Oxford University Press; New York: 2003.
    • 22. All-Hazards Preparedness
      • The all-hazard preparedness concept is simple in that how you prepare for one disaster or emergency situation is the same for any other disaster
      • Preparedness can be achieved through thoughtful planning before a disaster
      Federal Emergency Management Agency (FEMA) All-Hazards Preparedness
    • 23. Developing Bioterrorism Training Programs Example: Developing Training for Primary Care Physicians
    • 24. Example: How to Develop a Program
      • Develop Learning Objectives
        • Use Information from needs assessment on physicians’ perceived strengths and weaknesses
        • Combine with role identified by the CDC
      • Look at physician’s learning preferences
      • Design training to meet learning objectives
      • Evaluate training based on learning objectives
    • 25.
      • Review of Results from the Utah-based Needs Assessment
    • 26. Primary Care Physicians: Current Strengths in Preparation
      • Ongoing contact with patients within the local population
      • Ability to watch for possible effects of bioterrorism event if alerted
      • Ability to detect unusual disease patterns in the population
      • Ability to link into hierarchy of medical specialists
    • 27. Primary Care Physicians: Current Weaknesses in Preparation
      • Inadequately prepared to recognize diseases caused by bioterrorism agents
      • Inadequately prepared to treat diseases caused by all possible bioterrorism agents
      • Time constraints and ongoing priorities do not allow for substantial bioterrorism focus
    • 28. CDC Recommendations for Physician’s Role
      • Have basic information about infections caused by BT agents
      • Know how to diagnose these conditions
      • Know when and how to report these conditions
      • Be able to obtain all necessary information from the patient for further investigation
    • 29. Learning Objectives
      • Physicians able to identify indications of a BT event
      • Physicians familiar with general signs and symptoms of diseases caused by class A BT agents
      • Link this preparation to their ability to identify disease outbreaks from non-BT sources
    • 30. Primary Care Physicians: Preferred Methods to Learn
        • Training on use of reference materials
        • Short ongoing monthly training with accompanying reference materials
        • Hands-on oriented training
        • Incorporation of training into existing activities, such as regular meetings, CME activities and professional meetings
    • 31. Example: Reference guide for recognition and response to bioterrorism
    • 32. Examples of short presentations that can be made at regularly scheduled meetings for Primary Care Physicians
    • 33. What would you look for as indication of unusual disease occurrence? What would specifically indicate a BT event?
    • 34. Let’s check your responses
    • 35. Indications of Intentional Release of a Biologic Agent
        • An unusual temporal or geographic clustering of illness
        • Patients presenting with clinical signs and symptoms that suggest an infectious disease outbreak
        • An unusual age distribution for common diseases
        • a large number of cases of acute flaccid paralysis with prominent bulbar palsies, suggestive of a release of botulinum toxin.
      CDC MMWR 50(41);893-7
    • 36. Key Indicators of a BT Event
      • Sudden increase in severity or incidence of illness
      • Appearance of unusual (non-endemic) illness or syndrome in your community
      • Geographic and/or temporal pattern of illness
      • Occurrence of vector-borne disease where there is no vector
      UCLA Center for Public Health and Disasters, Bioterrorism: Are you prepared slideshow presentation
    • 37. Key Indicators of a BT Event
      • Cluster of sick or dead animals
      • Atypical seasonality
      • Unusual expression of endemic disease
      • Multi drug-resistant pathogens
      UCLA Center for Public Health and Disasters, Bioterrorism: Are you prepared slideshow presentation
    • 38. Example of training resources from CDC for small group presentations to enable Primary Care physicians to recognize signs and symptoms of diseases caused by class A BT agents (learning objective 2)
    • 39. Bioterrorism Agents – Plague Lesson 2 Clinical Presentation
    • 40. Objectives
      • Identify distinctions between
        • Bubonic Plague
        • Pneumonic Plague
        • Septicemic Plague
    • 41. Other Plague Presentations
      • Pharyngeal Plague
        • Uncommon
        • Resembles tonsillitis with
        • peritonsillar abcess
        • Cervical lymphadenopathy
      • Plague Meningitis
        • Most common in children
        • Usually end result of ineffective treatment of other forms
        • Symptoms mimic other forms of acute plague
    • 42. Infection Control
      • Large numbers of plague bacilli
      • Respiratory droplet spread in close direct contact
      • Respiratory droplet precautions with suspect cases
      • Contact public health
    • 43. Plague Review Questions Lesson 2, Question 1
      • Gary, Indiana hospital
      • 12 month old from Gary
      • Acute onset fever, malaise, body aches x 2 days
      • Extremely tender lymph node under arm, 2 inches
      • Exhibiting neurologic symptoms
      • Suspect plague meningitis. First step?
    • 44. Plague Review Questions Lesson 2, Question 1
      • What is your first step?
      • Call local health department
      • Rule out other diseases
      • Place in isolation
    • 45. Example of training resources from UCLA for small group presentations to enable Primary Care physicians to recognize signs and symptoms of diseases caused by class A BT agents (learning objective 2)
    • 46. UCLA Center for Public Health and Disasters Bioterrorism Training for Physicians Updated March 2003 Over 1700 Downloads Since Going Online October 2001 Available at:
    • 47. Biological Terrorism
      • Intentional or threatened use of viruses, bacteria, fungi or toxins from living organisms to produce death or disease in humans, animals or plants
    • 48. Evaluation of Possible Inhalation Anthrax
      • History of exposure or risk + Symptoms:
        • WBC (bandemia), Blood culture – highest yield
        • CXR – wide mediastinum, effusion, or infiltrate Consider CT if CXR normal
      • If results abnormal or pt. seriously ill:
      • Multi-drug treatment
      • If results normal and pt mildly ill:
      • Observe and initiate single-drug prophylaxis
    • 49. Botulism
      • Source:
      • Clostridium botulinum
      • neurotoxin
      • Types A, B, E, and F
      • Most potent toxin known
        • Lethal dose 1 ng/kg
        • 100,000 times more toxic than sarin
    • 50. Case 1 - Dyspnea, Hypotension
      • Patient admitted to ICU:
        • Fluids, Intubation, Ceftriaxone, Vanco., Gent.
      • Later the same day a similar patient presents
        • Also a stock trader in the same building
      • Both patients deteriorate and die the next day
    • 51. Websites for training materials
    • 52. Evaluation
      • Many presentations have review questions at the end to assess knowledge of training participants
      • Evaluation should assess whether learning objectives have been met
      • Evaluation should also serve as a mini needs assessment to help identify directions for future training
    • 53. Summary
      • Physicians need to be prepared to play a vital role in the recognition and response to bioterrorism
      • Physicians see themselves as having distinct roles depending on their specialty
      • Learning objectives can be developed by utilizing the identified role of targeted physicians and data obtained from needs assessment activities
      • Efficiency of resources may be gained by utilizing an all-hazards approach to preparedness
      • Resources are available for training physicians to recognize and respond to bioterrorism
      • Evaluation can serve to assess training activities and inform future training directions
    • 54. Acknowledgements
      • Co-authors:
        • Jamie D. Clark, MSPH
        • George L. White Jr., PhD, MSPH
        • Sharon Talboys, MPH
        • Susan Mottice, PhD
      • The Utah Department of Health
      • The Center for Disease Control & Prevention
      • Physician participants in needs assessment
    • 55. Go UTES