Emerging_Infections agaroolak Lecture.ppt

Emerging and Re-Emerging
Infections
Introduction to Infectious
Outbreak Reporting and
Containment
Larissa May, M.D.
Department of Emergency Medicine
The George Washington University School of Medicine

Clinical Case
 28 year old previously healthy female biologist
presents with fever and spreading rash
 Two days ago she developed a fever, sore
throat, and vomiting
 She has had several very dark bowel
movements
 Today her boyfriend noted she was drowsy
and disoriented
 She returned from Uganda 3 days ago, where
she was collecting samples from wild
monkeys for DNA analysis

Clinical Case
 Vitals: 84/52 HR 132 T 104.4 94% RA
diaphoretic
 Tachypneic with bilateral bibasilar rales
 Centripetal maculopapular rash with
hemorrhagic erythema on the palms and
soles
 Subconjunctival hemorrhages, palatal
petechiae
 Diffuse abdominal tenderness with
guarding; black stool

You are the only physician working
in the Emergency Department…
 The nurse notifies you that you have two
urgent incoming calls
 EMS is transporting a 44 year-old diplomat
with massive GI and gingival bleeding,
febrile to 102, blood pressure of 60/palp
 On the other line a concerned internist is
sending two returned travelers with fever
and rash

Objectives
 How do we recognize potential
sentinel cases for an outbreak?
 How do we report a suspected
outbreak?
 What measures can we take toward
outbreak containment in the
emergency department?
 What resources are available in the
event of an outbreak?

Workshop
 ED physician
 Local health department
 National health office (CDC)
 Hospital administration (Incident
command)
 Infection control officer
 Laboratory

Why teach outbreak recognition
and containment?
Factors favoring the emergence of
infections: (1992 IOM report)
 Change in physical environment
 Human behavorial activities
 Social/political/economic factors
 Bioterrorism
 Increased use of antimicrobials and
pesticides
1. Centers for Disease Control and Prevention. Preventing Emerging Infectious Diseases. A Strategy for the 21st
century.
2. Global Emerging Crisis in Infectious Diseases. Challenges for the 21st
century. The Pfizer Journal. V(2), 2004.

Bioterrorism
 1997: biodefense budget
$137 million
 2000: $1.5 billion for
military biodefense and
$1 billion for domestic
preparedness
 Operation Bioshield: $6
billion over 10 years for
vaccines and treatments
against potential
bioterrorism agents
David R. Franz and Russ Zajtchuk. Bioterrorism: Understanding the threat, preparation and medical
response. Disease-A-Month 48(8), August 2002.

Outbreak recognition
 Most outbreaks present as “flu-like
illness”
 Size of an outbreak related to
 Virulence
 modes of transmission
 extent/mode of dissemination
James W. Buehler et. Al. Syndromic Surveillance and Bioterrorism-related epidemics. Emerging Infectious Diseases, October 2003

Outbreak recognition
James W. Buehler et. Al. Syndromic Surveillance and Bioterrorism-related epidemics. Emerging Infectious Diseases, October 2003
Severe Gastroenteritis
Severe Gastroenteritis
Fatal pneumonia in healthy patient
Fatal pneumonia in healthy patient
Widened mediastinum with fever
Widened mediastinum with fever
Rash with synchronous vesicular/pustular lesions
Rash with synchronous vesicular/pustular lesions
Acute neurologic illness with fever
Acute neurologic illness with fever
Advancing cranial nerve palsy with weakness
Advancing cranial nerve palsy with weakness

Outbreak Detection: Epidemiologic
Criteria
 Severe disease in a healthy patient
 Increased number of patients with
fever, rash, respiratory or GI
symptoms, or sepsis
 Large number of rapidly fatal
respiratory cases
Rega. Bioterrorism: A statistical manual to identify and treat diseases of bioterrorism.
Mascap Inc, Ohio, 2000.

Outbreak Detection: Epidemiologic
Criteria
 Increasing number of ill or dead
animals
 Rapid rise and fall in the epidemic
curve
 Multiple patients presenting from a
similar location
 Endemic disease at an unusual time
of the year
Rega. Bioterrorism: A statistical manual to identify and treat diseases of bioterrorism.

Syndromic Surveillance: Clinician’s Role
 Healthy People 2010 initiative calls for
improved surveillance systems
 Syndromic Surveillance: Collection and
analysis of statistical data on health trends
 Clinicians essential for active syndromic
surveillance and reporting to public health
officials
 Determination of “credible risk”
 Information technology
1. Michael Stoto et. Al. The RAND Center for Domestic and International Health Security. Syndromic Surveillance: Is it worth the effort? Chance 17(1),
2004, 19-24. 2. Peter Katona. Bioterrorism Preparedness: A generic blueprint for health departments,Hospitals and physicians. Infectious Diseases in

Model for Outbreak Epidemiology
Susceptible
Exposed
Infective
Removed
Vaccinated
KE Nelson. Infectious Disease Epidemiology: Theory and Practice. Aspen Publishers, 2001, p. 119-69.

Who do I report an Outbreak
to?
 Call your local health department first for
advice

Department of health 24 hour hotline

Check website
 Local DOH will contact the Centers for
Disease Control and Prevention if necessary
 International reporting mechanisms exist
to detect emerging infections as they occur
in their areas of origin
century. The Pfizer Journal. V(2), 2004.

Outbreak Containment in the
Emergency Department
 Detection of sentinel case
 Activation of the Hospital Emergency
Management Plan leads to notification of
Administration, Nursing, Clinical
Departments, Radiology, Supplies, and other
departments
 Notification of Infectious Disease and
Infection Control
1.Peter Katona. Bioterrorism Preparedness: A generic blueprint for health departments, Hospitals and physicians. Infectious Diseases in Clinical Practice 11(3),
2004, March/April 2002.
2. Lynn K. Flowers et. Al. Bioterrorism Preparedness II: The Community and EMS Systems. Emergency Medicine Clinics of North America 20(2), May 2002.

 Inform local Department of Health
 Epidemiologic surveillance and investigation
 Inform Director of Laboratory
 Rapid agent detection and confirmation
 Lab specimen handling, testing and referral
 Need for outside assistance
 Establishment of a communication system:
1.Peter Katona. Bioterrorism Preparedness: A generic blueprint for health departments, Hospitals and physicians. I
nfectious Diseases in Clinical Practice 11(3), 2004, March/April 2002.
2. Lynn K. Flowers et. Al. Bioterrorism Preparedness II: The Community and EMS Systems. Emergency Medicine Clinics of North America 20(2), May 2002.

 Isolation and environmental controls
 Geographical cohorting
 Patient and healthcare worker cohorting
 Admission and expedient discharge of non-
infectious patients
1.Peter Katona. Bioterrorism Preparedness: A generic blueprint for health departments, Hospitals and physicians. Infectious Diseases in Clinical
Practice 11(3), 2004, March/April 2002.
2. Lynn K. Flowers et. Al. Bioterrorism Preparedness II: The Community and EMS Systems. Emergency Medicine Clinics of North America 20(2),
May 2002.

 Patient and staff prophylaxis:
responsibility of Infection Control and DOH
 Mass patient care: requires pre-
identification of surge capacity sites
 Staffing needs: back up/functional units
 Community and mental health needs:
involve social work and psychiatry
1.Peter Katona. Bioterrorism Preparedness: A generic blueprint for health departments, Hospitals and physicians. Infectious Diseases in Clinical Practice 11(3), 2004,
March/April 2002. 2. Lynn K. Flowers et. Al. Bioterrorism Preparedness II: The Community and EMS Systems.
Emergency Medicine Clinics of North America 20(2), May 2002.

Hospital Emergency Incident
Command System (HEICS)
 Incorporate bioterrorism/contagious outbreak
plan into existing internal operations in an “all
hazards” approach
 Incident Command Structure: Incident
Commander
 Sub-chiefs: logistics, operations, finance,
planning
 Common organizational structure to coordinate
response to mass casualty event
Peter T. Pons and Stephen V. Catrill. Mass Casualty Management: A Coordinated Response. Critical Decisions in Emergency Medicine, November 2003.

Hospital Response Plans
 CDC Bioterrorism Readiness Plan: A Template for Healthcare Facilities
 Syndrome-based criteria
 Infection Control

Isolation precautions

Patient placement

Patient Transport

Cleaning, disinfection, sterilization
 Discharge Management
 Post-mortem care
 Post-exposure management
 Triage of large scale exposures and suspected exposures
 Psychological aspects and counseling
Centers for Disease Control and Prevention. APIC Bioterrorism Task Force. CDC Hospital Infections program bioterrorism working Group.

 Activation/Notification:
 Administration, media relations, infection control
 Facility Protection: security, external triage
 Decontamination: self-decontamination
 Supplies/logistics: pharmaceuticals, PPE,
ventilators
 Alternative care sites:
 Expedient discharge of patients
 Cancellation of elective cases
Carl Shulz et. Al. Bioterrorism Preparedness I: The Emergency Department and Hospital. Emergency Medicine Clinics of North America 20(2), May 2002.

 Staff education/training:
 Mass casualty protocols and drills
 Coordination and communication:
 EMS and Fire Department

Police

Government

Media
Carl Shulz et. Al. Bioterrorism Preparedness I: The Emergency Department and Hospital. Emergency Medicine Clinics of North America 20(2), May 2002.

Outbreak Containment: State and
Federal Response
 Local and State response
 DHHS identifies and applies containment for
epidemics
 FEMA coordinates federal assistance
 NDMS (National Medical Disaster system)
 DMAT (Disaster Medical Assistance Teams)
 CDC: epidemiologic and laboratory expertise,
control measures and prophylaxis
 Strategic National Stockpile
Jerry L. Mothershead et. Al. Bioterrorism Preparedness III: State and Federal and Response. Emergency Medicine Clinics of North America 20(2), May 2002.

Resources During an Outbreak
 CDC Bioterrorism Website www.bt.cdc.gov
 Johns Hopkins Center for Civilian
Biodefense Studies
www.hopkins-defense.org
 US Army Medical Research Institute for
Infectious Diseases
www.usamriid.army.mil

HICPAC Infection Control Guidelines
 Established by CDC in 1991
 Standard precautions: exposure to blood and
body fluids. Personal protective equipment
(PPE): gown, gloves, mask with eye protection
 Contact isolation: PPE for all healthcare
worker interactions, private room, dedicated
patient equipment, limit transport
http://www.cdc.gov/ncidod/hip/HICPAC/publications.htm

HICPAC Infection Control Guidelines
 Droplet: for microbes less than 5
micrometers in diameter, transmissible at
less than 3 feet distance. PPE including
mask at all times
 Airborne: small infectious particles. PPE
including N95/PAPR, negative pressure
isolation room with 6-12 air changes per
hour
http://www.cdc.gov/ncidod/hip/HICPAC/publications.htm

EBOLA
What could have been done?
 1995 Ebola outbreak in Congo: 240 deaths in 4
months
 Delayed outbreak reporting
 Hospital-promoted transmission
 Provision of disinfectant and PPE
led to containment
 1997 Ebola outbreak in the Congo:
 19 days to outbreak awareness
 49 days to international assistance
Centers for Disease Control and Prevention. Preventing Emerging Infectious Diseases. A Strategy for the 21st
century.

Lessons from SARS
 Outbreak cost estimated at $80 billion
 Efficient response by GOARN, GPHIN
and Promed mail
 Ontario provincial emergency: creation
of SARS units
 Singapore: 10 day quarantine for all
SARS contacts, screening of all airport
and seaport arrivals for fever
Joshua Lederberg et. Al. Emerging Infections: Microbial threats to health in the United Sates. Institute of Medicine, 1992.

Lessons from SARS: Containment
 Infected patients:
 Detection
 Isolation
 Containment
Conversion of patient rooms
into isolation rooms
“hotwards”
Designated ambulance service
Back up teams/functional units
 Uninfected
patients
 Monitoring
 protection
Lessons Learned from SARS: Management of an Emerging Infectious Disease from a Military Perspective. ww.mindef.gov.sg

Emerging Infections: A Deadly
Prospect
 “When Veronica brought him back to the same
clinic, he was running a fever of 103 degrees F,
…His systolic blood pressure was
low….Although Veronica was panicked, she
tried to bear in mind what Azikiwe had told her.
American doctors weren’t like they were in
Nigeria..they knew what they were doing…
Now, after three visits to the HMO, she wasn’t
so sure…Still, no one asked him about travel.”
•From Level 4: Virus Hunters of the CDC. By Joseph B. McCormick and Susan Fisher-Hoch with Leslie Anne Horvitz. Barnes and Noble Books:
From Level 4: Virus Hunters of the CDC. By Joseph B. McCormick and Susan Fisher-Hoch with Leslie Anne Horvitz. Barnes and Noble Books:
New York, New York, 1996.
New York, New York, 1996.

Clinical Case (continued)
 A tentative diagnosis of viral hemorrhagic fever
is made
 Patients placed in airborne isolation, cohorted
with staff
 You call Infectious Disease on Call and Hospital
Administration for activation of the Contagious
Disease Outbreak Plan
 You notify the DC DOH emergency hotline and
the CDC for recommendations and assistance in
containment of the outbreak and contact tracing
 Identification and confirmation of Ebola
serotype made by USAMRIID BSL 4 laboratory

Viral Hemorrhagic Fever: Filoviruses
 Marburg and Ebola cause severe illness
 Family endemic to Central Africa
 Marburg first identified in Germany in 1967 in lab-workers
exposed to infected monkeys
 Ebola-Reston virus discovered in 1989 in imported monkeys
 Multiple outbreaks since 1977
 Ebola Zaire 88% mortality
 Long period of infectivity
 Body fluids of deceased infectious
Omar Lupi and Stephen K.. Tyring. Tropical Dermatology: viral tropical Diseases. Journal of the American Academy of Dermatology 49 (6), December 2003.

Viral Hemorrhagic Fever:
Filoviruses
 Incubation period 4-5 days
 Sudden onset high fever, sore throat,
fatigue, headache
 Nonpruritic maculopapular centripetal
rash desquamates after one week
 GI, skin and mucous membrane
hemorrhages
Omar Lupi and Stephen K.Tyring. Tropical Dermatology: viral tropical Diseases. Journal of the American Academy of Dermatology 49 (6), December 2003.

Viral Hemorrhagic Fever: Filoviruses
 Leukopenia, thrombocytopenia,
transaminitis
 Mortality from hemorrhage and
hypovolemic shock
 Differential Diagnosis: Yellow fever,
dengue, meningococcemia, leptospirosis,
ITP

Viral Hemorrhagic Fever:
Filoviruses
 Diagnosis
 Immunofluorescence or ELISA
 PCR
 Therapy
 Supportive
 No vaccine yet available

Guidelines
 Contact isolation
 Cannot rule out airborne transmission
 PAPR provides better filtration than N95
but more expensive and increases
needlestick risk
 Supportive treatment
 Experimental IND for ribavirin in
arenaviruses
Luciana Borio et. Al. Hemorrhagic Fever Viruses as Biological Weapons: Medical and Public Health Management. JAMA 287(18), May 8, 2002.

Outbreak Preparedness: Goals for
Clinicians
 Be familiar with epidemiologic criteria for
sentinel cases
 Know your hospital emergency
preparedness plans and how to report a
suspected sentinel case
 Follow basic principles of isolation,
infection control, and cohorting in an
outbreak

References
1. David R. Franz and Russ Zajtchuk. Bioterrorism: Understanding the threat,
Preparation and medical response. Disease-A-Month 48(8), August 2002.
2. Rega. Bioterrorism: A statistical manual to identify and treat diseases of bioterrorism.
3. Michael Stoto et. Al. The RAND Center for Domestic and International Health Securtiy.
Syndromic Surveillance: Is it worth the effort? Chance 17(1), 2004, 19-24.
4. Ben Y. Reise and Kenneth D. Mandl. Syndromic Surveillance: the effects of syndrome
grouping on model accuracy and outbreak detection. Annals of Emergency Medicine
44(3(), September 2004.
5. James W. Buehler et. Al. Syndromic Surveillance and Bioterrorism-related epidemics.
Emerging Infectious Diseases, October 2003
6. Edward N. Barthell et. al. Syndromic Surveillance: The Frontiers of Medicine project: a
roposal for the standardization communication of ED data for public health uses
including syndromic Surveillance. Annals of Emergency Medicine 39(4), April 2002.
7. Peter Katona. Bioterrorism Preparedness: A generic blueprint for health departments,
Hospitals and physicians. Infectious Diseases in Clinical Practice 11(3),
2004,March/April 2002.
8.Seth Foldy et. Al. Syndromic Surveillance Using Regional Emergency Medicine Internet.
Annals of Emergency Medicine 44(3), September 2004.
9.The George Washington University Contagious Disease Outbreak Plan. January 2005.

References
10. Fred M. Burkles, Jr. Mass Casualty Management of a Large Scale Bioterrorism Event: An
Epidemiologic Approach that Shapes Triage Decisions. Emergency Clinics of North America 20(2), May
2002.
11.KE Nelson. Infectious Disease Epidemiology: Theory and Practice.
Aspen Publishers, 2001, p. 119-69.
12.Centers for Disease Control and Prevention. Preventing Emerging Infectious
Diseases. A Strategy for the 21st
century.
century. The Pfizer Journal.
V(2), 2004
14. Joshua Lederberg et. Al. Emerging Infections: Microbial threats to health in the
United Sates. Institute of Medicine, 1992.
15. Lessons Learned from SARS: Management of an Emerging Infectious Disease from a
Military Perspective. www.mindef.gov.sg
16. Lynn K. Flowers et. Al. Bioterrorism Preparedness II: The Community and EMS
Systems. Emergency Medicine Clinics of North America 20(2), May 2002.
17. Fred M. Henretig. Medical Management of the Suspected Victim of Bioterrorism:An algorithmic
approach to
the undifferentiated patient. Emergency Medicine Clinics of North America 20(2), May 2002.
18. CDC Bioterrorism Website www.bt.cdc.gov
19. John Hick et. Al. Health Care Facility and Community Strategies for Patient Surge Capacity.Annals
of Emergency Medicine Volume 44 • Number 3 • September 2004
20. Jerry L. Mothershead et. Al. Bioterrorism Preparedness III: State and Federal and Response.
Emergency Medicine Clinics of North America 20(2), May 2002.
21. Centers for Disease Control and Prevention. APIC Bioterrorism Task Force.
CDC Hospital Infections program bioterrorism working Group.

References
22. Peter T. Pons and Stephen V. Catrill. Mass Casualty Management: A
CoordinatedResponse. Critical Decisions in Emergency Medicine, November 2003.
23. Carl Shulz et. Al. Bioterrorism Preparedness I: The Emergency Department and
Hospital. Emergency Medicine Clinics of North America 20(2), May 2002.
24. www.cdc.gov/ncidod/hip/HICPAC/publications.htm
25. Luciana Borio et. Al. Hemorrhagic Fever Viruses as Biological Weapons: Medical and
Public Health Management. JAMA 287(18), May 8, 2002.
27. Omar Lupi and Stephen K.Tyring. Tropical Dermatology: viral tropical Diseases.
Journal of the American Academy of Dermatology 49 (6), December 2003.
28. 21st
Century Bioterrorism and Germ Weapons—U.S. Army Field Manual for the
Treatment of Biological Warfare Agent Casualties, 2000.
29. Robert Darling et. Al. Threats in Bioterrorism I: CDC Category A agents. Emergency
Medicine Clinics of North America 20(2), May 2002.
30.The 1, 2, 3's of Biosafety Levels Jonathan Y. Richmond, Ph.D.
Director, Office of Health and Safety
Centers for Disease Control and Prevention
Atlanta, GA 30333. Adapted from the CDC/NIH 3rd edition of
Biosafety in Microbiological and Biomedical Laboratories

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