CDC Centers for Disease Control and Prevention Bioterrorism Mass Casualty Response: Current Concepts and Controversies European Masters in Disaster Medicine Sandigliano, Italy 02 May 2005 Eric K. Noji, M.D., M.P.H., FACEP Medical Epidemiologist Centers for Disease Control & Prevention Washington, D.C.
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CDC Centers for Disease Control and Prevention Bioterrorism Mass Casualty Response: Current Concepts and Controversies European Masters in Disaster Medicine.
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CDCCenters for Disease Control
and Prevention
Bioterrorism Mass Casualty Response: Current Concepts and
Controversies
European Masters in Disaster Medicine Sandigliano, Italy
02 May 2005
Eric K. Noji, M.D., M.P.H., FACEP
Medical Epidemiologist Centers for Disease Control & Prevention
Washington, D.C.
CDCCenters for Disease Control
and Prevention
The Immediate Future The Immediate Future 2003 – 20102003 – 2010
A Revolution in A Revolution in biotechnology, genomics biotechnology, genomics and proteomics that will and proteomics that will affect all human beingsaffect all human beings
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and Prevention
““A bioterrorism attack anywhere in the A bioterrorism attack anywhere in the
world is inevitable in the 21world is inevitable in the 21stst century.” century.”
Anthony Fauci, Director, NIAIDAnthony Fauci, Director, NIAID
• Inhalational, gastrointestinal, cutaneous• NOT communicable (except maybe
cutaneous)• Vaccine not available for civilian use• 20%-80% mortality
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Anthrax: Inhalational
• Inhalation of spores• Incubation: 1 to 43 days • Initial symptoms (2-5 d)
– Fever, cough, myalgia, malaise
• Terminal symptoms (1-2d )– High fever, dyspnea, cyanosis
– Hemorrhagic mediastinitis/effusion
– Rapid progression shock/death
• Mortality rate ~ 100% w/o RX
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Varying Presentations of NYC Cutaneous Lesions
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Diagnosis
-Diagnosis difficult given diseases have been seen by few living clinicians
-Abnormal presentations of classical diseases may be present due to super infection
-Diagnosis critical for epidemiological monitoring
-Accurate data required for potential future prosecution of war crimes
-Psychogenic overlay may cloud the diagnostic process
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and Prevention
CDCCenters for Disease Control
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Small Pox (Variola major virus)
• Transmitted primarily by aerosol route, contaminated clothes & linens
• Highly communicable• Vaccine can lessen the severity of
disease if given within 4 days of exposure
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• Increasing Global Travel• Rapid access to large populations• Poor global security & awareness
...create the potential for simultaneous ...create the potential for simultaneous creation of large numbers of casualtiescreation of large numbers of casualties
Epidemiological Pattern of Epidemiological Pattern of Smallpox WeaponSmallpox Weapon
New foci of secondary infection
“Contaminated” zone
“Infected” zone
Zone of initialexplosion
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CDCCenters for Disease Control
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Pneumonic Plague
• Caused by infection with Yersinia Pestis
• Pneumonic form will occur after intentional aerosol delivery
• Roughly 6000 hospitals• 615,000 physicians and surgeons• 2.4 million registered nurses• 240,000 pharmacists• Approximately $390 billion spent on
healthcare in 2003• $15.5 billion spent on hospital
construction (2001)
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Current IssuesCurrent Issues
• The US healthcare system functions at capacity on a daily basis
• Contagious patients may render existing facilities inoperable
• Expansion (surge) capability relies on federal programs that take time to deploy
• Personnel engaged in healthcare are already functioning at maximum
• No formal process to identify who is in charge (of what) when using multi-jurisdictional assets
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WORSENING SITUATION IN US
• Many hospitals on diversion during normal times (no inpatient beds, consultants)
• Decreasing number of emergency depts, trauma centers, inpatient beds
• Not economically viable for hospitals to maintain surge capacity,
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CDCCenters for Disease Control
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CDCCenters for Disease Control
and Prevention
CDCCenters for Disease Control
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CDCCenters for Disease Control
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CDCCenters for Disease Control
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CDCCenters for Disease Control
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Enhancing existing local first responder, medical, public health and emergency planning to increase capabilities to manage the incident until Federal resources arrive (typically 48-72 hours)
Metropolitan Medical Response SystemMMRS
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Original MMRSOriginal MMRSBoston, New York, Baltimore, Philadelphia, Washington DC, Atlanta, Miami, Memphis, Jacksonville, Detroit, Chicago, Milwaukee, Indianapolis, Columbus, San Antonio, Houston, Dallas, Kansas City, Denver, Phoenix, San Jose, Honolulu, Los Angeles, San Diego, San Francisco, Anchorage, Seattle
Metropolitan Medical Response SystemsMetropolitan Medical Response Systems
MMRS 1999MMRS 1999Hampton Roads (Virginia Beach)Area, Pittsburgh, Nashville, Charlotte, Cleveland, El Paso, New Orleans, Austin, Fort Worth, Oklahoma City, Albuquerque, St. Louis, Salt Lake City, Long Beach, Tucson, Oakland, Portland (OR), Twin Cities (Minneapolis), Tulsa, Sacramento
MMRS 2001MMRS 2001Colorado Springs, Baton Rouge, Raleigh, Stockton, Richmond (VA), Shreveport, Jackson, Mobile, Des Moines, Lincoln, Madison, Grand Rapids, Yonkers, Hialeah, Montgomery, Lubbock, Greensboro, Dayton, Huntington Beach, Garland, Glendale (CA), Columbus (GA), Spokane, Tacoma, Little Rock
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MAJOR COMPONENTSMAJOR COMPONENTS
Medical ResponseMedical Response
Patient EvacuationPatient Evacuation
Definitive Medical CareDefinitive Medical Care
National Disaster Medical SystemNational Disaster Medical System
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CDCCenters for Disease Control
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Strategic National Stockpile
• Twelve push packages ready for deployment within 12 hours anywhere in the U.S.
• Vendor Managed Inventory (VMI) – specific medical supplies needed to control and contain outbreaks of infectious diseases and other emergency incidents
– ventilators, ambu-bags, ET tubes, laryngoscopes, suction devices, oxygen masks, NG tubes
• Other Emergency Medications:
– for hypotension, anaphylaxis, sedation, pain management
• Bandages and Dressings
• Vaccine
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Bad communication adds to crisis
• Mixed messages from multiple “experts”• Late information “overcome by events”• Over-reassuring messages• No reality check on recommendations• Myths, rumors, doomsayers not countered• Poor performance by spokesperson/leader• Public power struggles and confusion
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CDCCenters for Disease Control
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A Typical Day at CDC Autumn 2001
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Public Awareness
•Reliable, credible information to the public is key to keeping cooperation and minimizing panic
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Tactical response to biological weapon
exposure• Need to make life-saving decisions rapidly in
the absence of data• Access to subject matter experts will be
limited• No “textbook” experience to guide response • Need coherent, rapid process for
addressing staff and civilian safety in midst of crisis
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Top STRATEGIC Challenges to Hospital Preparedness
• Surge Capacity• Healthcare Personnel
– Relevant training– Sufficient numbers
• Materiel– Pharmaceuticals– Decontamination
equipment
• Collaboration at local, state, and federal level
Must prepare for MCI at the same time as providing “routine” healthcare to the community!
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Bottom Line
• Early, rapid recognition of unusual clinical syndromes or deaths
• Early rapid recognition of increase above “expected levels” of common syndromes, diseases, or death
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The detection and control of saboteurs are the
responsibilities of the FBI, but the recognition of
epidemics caused by sabotage is particularly an
epidemiologic function…. Therefore, any plan of
defense against biological warfare sabotage
requires trained epidemiologists, alert to all
possibilities and available for call at a moment’s