Population identification processes not only help to identify the specific patient within a system, but also identifies the risk factors associated with genetic and environmental factors.. Within health care there is a strong movement to underscore awareness in cost-effective evidence based practice. Guidelines for care are being generated increasingly through peer reviewed research and literature review processes. These guidelines give weighting to the appropriateness of interventions within disease processes, and provide a guideline to the medical community as to the best practice for care in specific diseases. Within the medical community there is increasing acceptance of multidisciplinary and interdisciplinary care practices. In the old days, the physician was the dominant member of the community and nurses, physiotherapists and occupational therapists practiced under the prescription of the physician. Although this practice may still exist regionally, throughout the world there is a shift to a more collaborative model where the patient benefits from the expertise of medical specialists and allied health professionals alike while his or her family physician remains the gate keeper of care. Within the DM model too, there is strong emphasis not only on the management of existing disease but also on screening processes that can help to identify disease and the risk for disease at an earlier stage. This proactive approach and the public education processes that have partnered the process have helped the general public understand environmental risks better, and primary health prevention processes have become established norms in care.
The DMAA goes on, within its definition of to describe a disease management appraoch, that supports the patient physician relationship. It supports a plan of care for identified disease processes. The approach emphasizes prevention, both of exacerbations of established diseases, but also of undetected diseases within a primary care scenario. It shifts the locus of control of disease back to the patient, supporting a patient centered systematic approach where the patient becomes a partner in his or her care.
The Approach has built in feedback loops that are employed in continuously evaluating not only the economic and health outcomes of care, but also takes a look at the more humanistic side of care. Within that context, MedcomSoft is creating a database of outcome measures and function, which will not only help to add more personal dimension to the documentation that the physician/allied health professional user can create, but will also help to quantify dimensions meaningful to the patient. Typically the patient will seek help from their physician when they are unable to cope not only with their regular activities of daily life, but also their role in society. Functional outcome measurement provides this dimension.
Bioterror Slide Show
Playthings ofBioterroristsBioweapons of Mass Destruction James Chrosniak, MHS, PA-C
Overview Definition Characteristics Major Players History of BioWarfare Indications of a Bioweapons Attack What is being done?
Definition Bioterrorism is the intentional use of any living organisms, such as bacteria or viruses, as a weapon
Characteristics What is an effective Bioterror Agent?. High mortality rate agents are the best choice Designed to kill a large number of people quickly More than one route of infection High rate of person-to –person transmission An aerosol route is the most probable Public panic and social disruption
History of BioWarfare 1346 As Tartars launched a siege of Caffa, a port on the Black Sea, they suffered an outbreak of plague. Tartars sent the infected bodies of their comrades over the walls of the city. 1422 At Karlstein in Bohemia, attacking forces launched the decaying cadavers of men killed in battle over the castle walls. 1763 During the French and Indian War, British Gen. Jeffery Amherst ordered that blankets and handkerchiefs be taken from smallpox patients in the forts infirmary and given to Delaware Indians at a peace- making parley. (Jenner discovered in 1798 that people could be vaccinated against smallpox by using the closely-related cowpox)
History cont. In occupied Manchuria, starting around 1936, Japanese scientists (Imperial Army Unit 731) used scores of human subjects to test the lethality of various disease agents, including anthrax, cholera, typhoid, and plague. As many as 10,000 people were killed Japanese airplanes dropped paper bags filled with plague- infested fleas over the cities of Ningbo and Quzhou in Zhejiang province Iraq is known to have unleashed chemical weapons in the 1980s, both during the Iran-Iraq war and against rebellious Kurds in northern Iraq.
History cont. In 1984, the Rajneeshee cult led by the Bhagwan Shree Rajneesh contaminated with salmonella bacteria several salad bars in restaurants across Dalles, Ore., sickening 751 people in an attempt to influence the results of a local election In 1995, the apocalyptic religious sect Aum Shinrikyo released sarin gas in a Tokyo subway, killing 12 commuters and injuring thousands. The cult also had enlisted Ph.D. scientists to launch biological attacks In the fall of 2001, several deadly anthrax terrorist attacks took place in the U.S. All told, five people died and another 18 became infected, most from being in the vicinity of anthrax-laced letters, but at least two from completely unknown means Plans for airborne anthrax bombs and for attacks using botulism were found in houses that had been occupied by Al-Queda leaders in Kabul, Afghanistan
Anthrax Bacillus anthracis derives from the Greek word for coal, anthrakis, because the disease causes black, coal-like skin lesions For centuries, anthrax has caused disease in animals and, uncommonly, serious illness in humans throughout the world (Usually an occupational disease of farmers, slaughterers, tanners.) 3 types of anthrax infection occur: inhalational, cutaneous, and gastrointestinal Aerosol spraying is the gravest threat. (No cloud, colorless, tasteless) Office of Technology Assessment, estimated that up to 3 million deaths could occur following the release of 100 kilograms of aerosolized anthrax over Washington D.C., making such an attack as lethal as a hydrogen bomb
Anthrax cont Incubation period is one to six days Inhalational Anthrax Symptoms: Rapid progression of fever, malaise, cough and sub-sternal chest pain is followed by marked respiratory distress. Shock and death generally occur within 36 hours of symptom onset By the time symptoms develop, it is probably too late. Treatment of choice is Doxycycline or Ciprofloxin There is a vaccine for anthrax that requires six immunizations over 18 months plus annual boosters. It is currently available only to the military (Over 2 mil already vaccinated) Anthrax does not have person to person transmission , but watch out what you powder your nose with
Small Pox Variola major, a virus commonly known as smallpox. Through natural epidemics, smallpox has likely claimed more lives than any other infectious disease A 12-14 day incubation period after exposure to the virus (makes it difficult to track) Aerosol spreading is the common means of transmission. Symptoms include the onset of generalized rash, oral macular and papular lesions. The onset of fever, headache, backache and the oral lesions are usually exhibited within the first two days of the virus activation.
Small Pox con’t The distinction of smallpox is the involvement of the palms of the hands and soles of the feet. Generally the greatest concentrations of lesions are located on the face. An additional distinction between smallpox and chickenpox is the uniform progression of lesions from maculae to papules to vesicles then to scab formations. In chicken pox, the lesions are all at various stages of development.
Smallpox con’t Death usually occurs within day 5-7 of lesion progression with increasing fever, abdominal pain, confusion and delirium due to toxemia Outbreaks of Smallpox usually involve strict quarantine of all individuals who have come in contact with infected individuals Mortality is expected to be about 30% for the unvaccinated. Infants and the elderly historically succumbing first As with all viral agents, treatment is supportive. Vaccination given 3-5 days post-exposure can prevent the disease. Because most of North America has not been immunized in 25 years, there is a risk to the entire population
Botulism Clostridium botulinum is a bacterial agent that occurs in nature, but is commonly found in spoiled food items The bacterium produces a nerve toxin that can be fatal if not treated immediately. Botulism toxin is one of the most poisonous substances known. A single gram of crystalline toxin could theoretically kill 1 million people Three types: Food borne, wound botulism from contact with an open wound and infant botulism (from consuming the spores of botulism in items that may not be considered spoiled like natural honey)
Botulism Double vision, blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, and muscle weakness May progress to cause paralysis of the arms, legs, trunk and respiratory muscles Therapy for botulism consists of supportive care (i.e., mechanical ventilation) and passive immunization with equine antitoxin (recombinant vaccine is in development)
Plague The causative agent of pneumonic plague and black (or bubonic) plague is Yersinia Pestis, a bacteria that is commonly found in the fleas that reside on rodents like rats. In 1346, a bubonic plague pandemic known as the Black Death erupted in Europe and eventually killed 20-30 million people, a third of the population Techniques to aerosolize plague were developed in the Soviet Union, and many former Soviet scientists that have this know-how have disappeared. Transmission is by aerosol or person-to-person. Pneumonic plague is contagious through respiratory droplets. Short incubation period of two or three days
Plague Pneumonic plague symptoms include progressively worsening fever, malaise, headache, cough with bloody sputum. The pneumonia progresses over 2-4 days, without treatment, can lead to septic shock and death from respiratory and circulatory collapse Extremely swollen lymph nodes known as “bubo” Doxycycline and Cipro are the drugs of choice A vaccine was licensed in the U.S. but discontinued by its manufacturer in 1999. Does not prevent the pneumonic form of plague.
Tularemia The agent that causes tularemia, Francisella tularensis, is one of the most infectious bacteria known: inhaling as few as ten microscopic germs can trigger disease It is so infective that examining an open culture plate can cause infection. WHO has estimated that if 110 pounds of a virulent strain of the bacteria were sprayed over a city of 5 million, it could incapacitate 250,000 people and kill 19,000. Tularemia occurs naturally in small mammals such as mice, squirrels, and rabbits. Human infection, which is rare, can result from tick bites or handling infected animals
Tularemia Symptoms include high fever, malaise, severe headache, sore throat, myalgias, non-productive cough, and possibly nausea, vomiting and diarrhea Without antibiotics, the clinical course could progress to respiratory failure, shock and death Human to human transmission has not been documented The treatment is Doxycycline for 14 to up to 21 days. Ciprofloxin can also be considered No vaccine is available for the general public. The FDA is investigating a vaccine that is now available for high-risk lab workers.
Viral Hemorrhagic Fever There are a variety of viruses that cause Hemorrhagic fever, most common of which include Ebola, Marburg , and Lassa Occurs in nature either in the urine and feces of rodents or certain monkeys Hemorrhagic fever is very rare in the United States. Most cases occur in Sub-Saharan Africa (Lassa virus infections for example, claim an estimated 300,000 infected with about 5,000 deaths per year. Marburg virus has a case-fatality rate of 25%.) Japanese cult Aum Shinrikyo sent members to Zaire in 1992 to obtain Ebola for weapons development
Viral Hemorrhagic Fever Incubation period is about 1-3 weeks after being infected. Human-to-human transmission can occur by contact with infected blood or body fluids Symptoms are progressively worsening high fever, malaise, headache, myalgias, together with mucous membrane bleeding (mouth, nose, eyes) bloody diarrhea and vomiting The only treatment available is the general antiviral Ribavarin and life supportive measures available in the ER or ICU
Is this the real thing?Indications of a bioweapon attack Case numbers rapidly increase over a period of hours or days (except food poisoning outbreaks) The rapid outbreak of any disease that is not indigenous to the local area (i.e., vector-borne illness) Respiratory presentation of illnesses that usually have non- pulmonary patterns when contracted in nature (I.e., anthrax and plague) Large numbers of casualties concentrated in a certain area or with wind direction.
What is being done? National Pharmaceutical Stockpile Program (NPSP) -- This resource of medical supplies can be sent anywhere in the country within 12 hours of a biological attack. The Health Alert Network (HAN) -- The CDC and other health organizations are developing a national communication system on the Internet Health department lab preparedness -- The CDC is working with other officials to ensure that all state health departments are equipped to test suspicious substances. Health advisories -- Recent official health advisories from the CDC, available on the CDC Web site The Joint Commission on Accreditation of Healthcare Organizations recently changed its guidelines so that all hospitals must demonstrate bioterrorism preparedness to receive accreditation
References CDC Bioterrorism Section www.bt.cdc.gov Johns Hopkins Center for Civilian Biodefense Studies www.hopkins-biodefense.org/ The Maryland Institute for Emergency Medical Services Systems www.miemss.umaryland.edu Nova Online “Bioterrism” www.pbs.org “Weapons of Mass Destruction” Capt. Charles W. Reed, USAF, BSC, PA-C, MEd