Disease Control Bulletin: October 2001
- Special Issue: Bioterrorism: Detection and Response
- Vermont Department of Health Plans for Emergency Response to Public Health Threats
- Vermont Hospitals: Partners in Emergency Response
Bioterrorism: Detection and Response
Following the tragic eventes in New York City , Washington, DC, and Pennsylvania on September 11, 2001, the Editorial Board of the Disease Control Bulletin initially conceived of this special issue as an opportunity to 1) inform health care providers about the response of the Vermont Department of Health and other state agencies to terrorist events in general and 2) raise awareness about the potential for biological terrorism. In the interim, several cases of apparently intentionally-caused anthrax have occurred, and biological terrorism is no longera potential threat buta reality. In this issue of the Disease Control Bulletin, we are providing an overview of the issues involved in emergency response and biological threats, with references to other resources you can access for additional information.
Role of the Health Care Provider
Health care providers, including physicians, nurses, physician assistants, laboratory technologists, and EMTs and paramedics, are essential for the early detection of biological events.A biological event can be naturally occurring, such as an influenza outbreak, or the result of an intentional release of an infectious, disease-producing biological agent. Working together with public health professionals, providers can greatly limit morbidity and mortality from such an event with early detection, treatment, and implementation of prevention and control strategies.
Vermont regulations require that physicians, laboratories, and others report specified diseases and organisms. The regulations, revised in 2001 and published in the previous edition of the Disease Control Bulletin, also mandate reporting of “any unexpected pattern of cases, suspected cases, deaths or increased incidence of any other illness of major public health concern, because of the severity of illness or potential for epidemic spread, which may indicate a newly recognized infectious agent, an outbreak, epidemic, related public health hazard or act of bioterrorism.” The regulations are also available at the Department of Health website: www.state.vt.us/ health/regulations/commdis.pdf.
By developing an awareness of epidemiologic principles and maintaininga high index of suspicion for unusual etiologies of disease, providers will be able to identify biological events and work with public health effectively, especially during a biological/bioterrorism event.
Principles of Syndromic Surveillance
Public health epidemiologists track the occurrence of disease in populations and use the descriptive factors of person, time, and place to determine if an outbreak or unusual occurrence of disease is happening. Health care providers in the field can use similar information to detect trends indicating that an intentional release ofa biological agent has occurred. If you suspect an unusual trend, please contact Infectious Disease Epidemiology at the Vermont Department of Health and we’ll conduct an evaluation.
Some illnesses typically occur in certain people, and those people can be described by various characteristics such as age, sex, ethnic origin, tobacco use, occupation, and immune status. For example, chickenpox is generallya disease of children, and complications of influenza are more likely to occur in the elderly.A pox-like rash ina large number of adults is an unusual occurrence and, while it might indeed be due to varicella, the potentially fatal diagnosis that needs to be considered is smallpox.
A large number of otherwise healthy young adults presenting with flu-like symptoms, especially with the complications of pneumonia, respiratory distress, or death, is also unusual. Providers need to considera new virulent influenza strain and agents of bioterrorism (inhalation anthrax, pneu-monic plague, tularemia) in their differential diagnosis. Information such as this was used to raise suspicions when a newspaper photographer with no history, either by occupation or hobby, of exposure to animals infected with anthrax came down with the inhalational form of the disease in early October, 2001.
Epidemiologists are alerted when an unexpected number of illnesses occurs ina geographic area or among people who were grouped geographically at the time ofa potential exposure. This commonly occurs when a contaminated food is served at a meal and many of the people who ate at the event become ill. Ifa biological weapon can be aerosolized and is released at a specific location, the people exposed at that location who become ill could, by history, be identified as being present at the release. Investigators following up on the Florida case of inhalational anthrax used the principle of “place” to seek out other potentially exposed persons in the news media building.
An unusual incidence of disease might present as a group of people with similar symptoms seen in a relatively narrow time period. This could indicate a common-source exposure to a pathogen with similar incubation periods in the involved people. Time also refers to the time of year that a disease occurs. Influenza, for example, occurs in late fall and winter in the Northern Hemisphere. If there is an outbreak of influenza-like illness in the summer, possible explanations might include an unusual naturally-occurring strain of influenza virus with potential for epidemic or pandemic spread, or an intentional release ofa biological agent that causes this type of illness, such as plague or anthrax.
By considering person, place, and time in the evaluation of each patient, providers can detect trends that indicate unusual disease incidence and some of the more unusual diseases in their differential diagnoses.
Principles of Syndromic Surveillance
Several agents have been “weaponized” by the United States and other countries and could potentially be used as agents of bioterrorism (see accompanying table). The presenting symptoms of the diseases that these agents can cause are generally nonspecific and could be symptoms of other much more common and less severe illnesses. Providers need to be aware of this possibility, and should consider these uncommon diseases in their differential diagnosis, obtaining appropriate laboratory and radiological testing to rule out agents of bioterrorism. Although events throughout Octo-ber have focused on Bacillus anthracis as the agent being intentionally released through the mail, other agents need to be considered in any suspicious circumstance.
The need for a high index of suspicion and diagnostic acumen is especially important as we enter into the influenza season. Nonspecific symptoms of flu-like illness (fever, headache, malaise, weakness, myalgias) occur with a number of common illnesses, including influenza, nonspecific viral syndrome, and early upper respiratory infection. These nonspe-cific symptoms might also be the first symptoms of anthrax, plague, or tularemia.
Rapid direct antigen tests for influenza can tell you if you are dealing witha case of influenza (please follow-up with a viral culture for differentiating influenzaA andB and identifying the strain). Contact your hospital laboratory or the Vermont Public Health Laboratory for information on testing for influenza. An elevated white blood cell count will give clues ofa bacterial etiology. Cultures of sputum, cere-brospinal fluid and/or blood (with gram stain) might provide clues to the identity of the organism.
Other presenting syndromes that could represent intentional biological releases:
Flu-like symptoms with cough
Common: Upper respiratory infection (various viruses), bronchitis (viral, mycoplasmal), community acquired pneumonia (viral [including influenza, RSV, others], mycoplasma, bacteria [pneumococcus]) Less common: legionellosis
Unusual, possibly related toa bioterrorist event: Inhalational anthrax, pneumonic plague, tularemia Use rapid direct antigen tests for influenza and gram stain and subsequent culture of appropriate specimens,e.g., sputum and/or blood, for diagnosis. Chest Xray might identify some typical findings of unusual organisms (anthrax).
Common: Congestive heart failure, pulmonary edema, acute asthma, severe pneumonia (viral, bacterial, other)
Uncommon, naturally occurring: hantavirus
Unusual, possibly related toa bioterrorist event: Inhalational anthrax, pneumonic plague
Flu-like illness with evidence of bleeding
Usually considered: meningococcal disease, DIC secondary to sepsis
Uncommon, naturally occurring: dengue hemorrhagic fever (ina patient with an appropriate travel history)
Unusual, possibly related to a bioterrorist event: Ebola, hemorrhagic smallpox
Flu-like illness with rash
Common: varicella and other viral exanthems (especially in children)
Unusual, possibly related toa bioterrorist event: smallpox
Common: gram negative sepsis secondary to urinary tract infection in an elderly person
Unusual, possibly related toa bioterrorist event: septic plague
Cranial nerve palsy, symmetrical descending flaccid paralysis
Relatively common: stroke, myasthenia gravis, Guillain-Barre syndrome Less common: tick paralysis, atropine poisoning, paralytic shellfish/puffer fish poisoning
Unusual, possibly related toa bioterrorist event: botulism
Common: subarachnoid hemorrhage
Unusual, possibly related toa bioterrorist event: anthrax
Common: viral gastroenteritis, Shigella, Salmonella, staph enterotoxin
Less common: E. coli O157:H7
Unusual, possibly related to a bioterrorist event: similar organisms but in an unusual or unexpected outbreak setting.
Vermont Department of Health
Plans for Emergency Response to Public Health Threats
Over the past several years, programs within the Vermont Department of Health have developed plans for addressing emergency situations that threaten the health of Vermonters. Presented here briefly are descriptions of those plans.
Ann R. Fingar, MD, MPH, State Epidemiologist
The Infectious Disease Epidemiology Section in the Division of Health Surveillance has participated in planning for department and state emergency responses, especially regarding events involving biological agents. These events might be related to naturally-occurring diseases (e.g., an influenza pandemic); accidents (e.g., risk of tetanus followinga mass-casualty event); natural disasters (e.g., risk of waterborne infection followinga flood); or bioterrorist events (e.g., intentional release of an infectious biological agent). Planning has included:
- establishing guidelines for working cooperatively with other divisions in the Vermont Department of Health and other departments of state government as well as with statewide Emergency Response agencies and organizations
- establishing effective and reliable communication channels with hospitals and other health care facilities, infectious disease specialists, emergency departments, and other health care providers
- creating protocols for standard information gathering, analysis, management of, and dissemination of information about infectious diseases and potential agents of bioterrorism
- increasing skills of public health staff in the central and district offices to better investigate and manage such an event
- planning dissemination of information to providers to help them identify unusual disease incidence, interact effectively with public health, and limit morbidity and mortality
Whatever the inciting event, our actions will reflect well-established epidemiologic methods of responding to an emergency event and include:
- establishing active surveillance to detect cases of the disease or condition
- maintaining open, timely, and complete communication with and providing information to partners in the field (physicians, hospitals, laboratories), other departments and agencies of state government, other state’s health departments and emergency management associations, the CDC and other federal partners, and the public
- acquiring data about the affected persons and the involved organism(s); analyzing the data; and using the derived information to institute measures to limit or eliminate exposure, prevent spread, and minimize morbidity and mortality.
Raymond N. McCandless, Chief, Occupational and Radiological Health
Occupational and Radiological Health staff have been extensively involved in many phases of the Vermont Radiological Emergency Response Plan for the Vermont Yankee Nuclear Power Plant in Vernon. The plan has been in effect for about 30 years and has expanded greatly in scope and content during that period. Participation has been in two broad areas:
- providing detailed technical guidance and processes to Vermont Emergency Management, which authors the plan
- providing technically trained first responders who can generate probable patterns of radioactive contamination during a release from the nuclear plant, carry out field measurements to verify the projected release patterns and dose rates, and conduct sampling of vegetation, water, milk, direct Gamma radiation and other media as necessary.
Results from the field team activities are used to determine if the general public must be evacuated from certain areas and, if they are, when the contaminated area is considered safe for reentry.
In addition, staff provide technical advice concerning matters such as respirator use and emergency response to hazardous substances incidents. The Occupational Health Program is part of the Vermont Occupational Safety and Health Agency (VOSHA) and enforces the regulation 1910.120 “Hazardous Waste Operations and Emergency Response” (HAZWOPER), which applies to first responders to incidents involving hazardous substances such as chemical, biological, and radiological materials. This combination of providing technical assistance and enforcing the regulation keeps us in close touch with fire, police, and emergency medical services statewide.
Bill Bress, PhD, State Toxicologist
The Environmental Health Office in the Division of Health Protection has been involved in planning for statewide emergency responses, especially in relation to events involving chemical agents. These events include accidental spills (e.g., overturned tankers); natural disasters (e.g., floods resulting in contaminated wells, basements and crops); and terrorist events (e.g., intentional release ofa chemical agent). Planning has included:
- establishing ongoing dialog and guidelines for working with other divisions in the Vermont Department of Health and other departments in state government, as well as statewide Emergency Response agencies and organizations
- training in medical identification of and treatment for exposure to chemical agents.
- participating in tabletop and field training exercises with state and federal agencies.
- researching existing toxicity and exposure information of potential terrorism chemicals
- participating on a National Advisory Committee for establishing short-term air health advisories for chemical terrorism agents
During a chemical terrorism event the Vermont Department of Health will:
- maintain open, timely, and complete communication and provide information to the Hazardous Materials (HAZMAT) Response Team; partners in the field (e.g., physicians, hospitals, fire chiefs, first responders and laboratories); other state of Vermont departments and agencies; other state’s health departments and emergency management associations; the Environmental Protection Agency and the Agency for Toxic Substances and Disease Registry; and the public
- acquire data about the affected persons and agent(s) involved and recommend decontamination procedures to minimize morbidity and mortality
- after the event, establish clean up and re-entry levels for homes and businesses, respond to food and water contamination issues, and make recommendations as to use or the need for disposal.
Eunice Froeliger, PhD, Microbiology Chief, VT Public Health Laboratory
A central goal guiding the CDC bioterrorism response effort has been to establisha nationwide, four-tiered Laboratory Response Network (LRN) capable of providing an organized response for the detection and diagnosis of biological agents. As part of this network, Vermont laboratories will be prepared for any infectious disease outbreak, not just a bioterrorism event. Recent activities of the Vermont Department of Health Laboratory have included:
- increasing the skill level of staff to conduct rapid and accurate diagnostic testing aimed at excluding or identifying, at a minimum, the priority biologic threat agents Bacillus anthra-cis, Yersinia pestis, Brucella species, and Francisella tularensis; establishing operational and laboratory protocols for the identification of priority biologic threat agents
- maintaining BSL-2 and BLS-3 facilities and practices and ensuring worker safety; maintaining critical reagents, equipment and supplies
- assuring proper chain of custody, adequate security, transport and storage of specimens
- establishing procedures for effective and secure communication of laboratory results to key partners such as statewide emergency response agencies, the LRN, and the CDC
- participating in ongoing collaborative efforts with the national LRN and the State Emergency Task Force
- responding to numerous events in Vermont where items or substances are suspected of containing anthrax
An important next step for enhancing laboratory capacity is to work with local LevelA hospital/clinical laboratories to develop their capabilities for using clinical data and standard microbiological tests to decide which specimens and isolates should be forwarded higher level laboratories such as the Vermont Department of Health laboratory. We are currently organizinga LevelA laboratory training to be held during early December and staff members receive training from CDC in the laboratory procedures for rapid detection of the agents of bioterrorism.
Incidents Involving Deaths
Paul Morrow, MD, Chief Medical Examiner
The Office of the Chief Medical Examiner (OCME) is responsible for the investigation of certain types of statutorily defined deaths including:
- deaths suspected to be due to non-natural circumstances
- sudden deaths when in apparent good health
- deaths considered a hazard to public health, welfare or safety.
By law, there isa law enforcement investigation in every medical examiner case, and the state’s attorney has jurisdiction of the body. Either the state’s attorney or the chief medical examiner authorizes autopsies.
Initial medical investigations are performed by Assistant Medical Examiners (AME), who are paramedical death investigators trained by the Office of the Chief Medical Examiner. AMEs either refer the case to the chief medical examiner for autopsy and further investigation or to a regional medical examiner who signs the death certificate if no further investigation is required. AMEs may also waive jurisdiction to the decedent’s physician when appropriate. The local AME on call may be contacted through the local police department or the Vermont State Police.
Vermont Health Alert Network
Corbett Sionainn, Distance Learning Coordinator
The Vermont Health Alert Network (Vermont HAN) is funded by a grant from CDC to improve communications with medical personnel, first responders, veterinary personnel, mental health and social service providers, and policymakers in the event of an emerging public health threat. The Vermont HAN is connected to a national Health Alert Network coordinated by the CDC. Through this national network, Vermont receives up-to-date information concerning bioterrorism and other potential health threats.
The Vermont HAN is being developed to provide timely information ina variety of ways, including:
- a website for the general public and media so they can be updated regularly about an event
- a website for responders including medical personnel, first responders, veterinarians, and mental health providers that enables sharing information such as treatment protocols, health alerts, surveillance data, and other information
- coordinated training and distance learning opportunities, for continuous upgrading of skills in preparedness for biot-errorism, infectious disease, and other threats
- support for local planning efforts to strengthen prepared-ness in Vermont municipalities
- an early warning system including broadcast fax to alert local, state, and federal authorities about urgent health threats and necessary response actions to be taken The Vermont Health Alert Network can be accessed through the Vermont Department of Health website: www.vdh.state.vt.us/health.
Vermont Hospitals: Partners in Emergency Response
The Vermont Association of Hospitals and Health Systems, Inc. (VAHHS), has participated in planning for hospital and health systems and state emergency responses by coordinating the hospital portion of an event. Association staff are qualified representatives at Vermont Emergency Management and are called into the Emergency Operations Center during an event to work under the Operations Section in the patient coordination unit.
VAHHS has been working with all Vermont hospitals over the last four years to develop and implement an Inter-Hospital Mutual Aid Agreement. Medical facilities across the state have supplied emergency contact numbers, resource lists and facility-specific information, and this information has been compiled in this agreement. The purpose is to provide an efficient way to share critical assets duringa catastrophic event, whether it is an isolated incident or one that encompasses the entire State. The effectiveness has been tested and proven both in Vermont Yankee drills and real life emergencies such as the Summit of the Americas and the terrorist attack on September 11, 2001.
Activities that the VAHHS and the Agreement perform duringa response are:
- Contacting all medical facilities to assess resources such as physicians, nurses, available beds and pharmaceuticals
- Determining the best receiving facility for various types of patients needing transfer
- Implementing the Partner Hospital Concept, in which each hospital is linked to designated partners as the “first calls for help” duringa disaster or event
- Notifying facilities to implement their individual emergency preparedness plans
- Identifying resources from out-of-state facilities
- Using Interrogatories to catalogue hospital resources that could be available for other hospitals duringa disaster
In an event, the impacted facility will open a command post. The command post is responsible for informing the state communication center of its situation and of any needs that cannot be accommodated by the partner hospital.
The senior administrator or designee is responsible for requesting personnel, pharmaceuticals, supplies, equipment, or authorizing the evacuation of patients. He or she will coordinate both internally, and with the donor or patient-accepting hospital, all of the logistics involved in implementing this disaster aid services agreement. Logistics include identifying the number and specific location where personnel, pharmaceuticals, supplies, equipment, or patients should be sent, how to enter the security perimeter, estimated time interval to arrival and estimated return date of borrowed supplies, etc. The State Emergency Operations Center serves as an information center for recording and disseminating the type and amount of available resources at each facility.
After finalizing the plan, an issue arose regarding reciprocity of licensed personnel. To address this issue,a bill was submitted to the legislature and passed, such that in cases of emergency declared by the Governor, the issue of licensure would be waived. At the same time this bill was submitted, the Emergency Management Assistance Compact was signed by the Governor and also included a segment on licensure waiver of professionals duringa declared state of emergency. The latter bill, S.323, was signed by the Governor and enacted law in the spring of 1999.
For the past two years, the Vermont Association of Hospitals and Health Systems, Vermont Department of Health and Vermont Emergency Management, have sponsored a program on mutual aid. This joint effort continues to demonstrate the collaboration and strong bond at the state level.
Important Telephone Numbers
To report suspected unusual incidence of disease or condition:
Vermont Department of Health Infectious Disease Epidemiology
802-863-7240 or 1-800-640-4374 (in VT 8-4:30)
- Routine disease reports:
Vermont Department of Health Infectious Disease Epidemiology
802-863-7240 or 1-800-640-4374 (in VT 8-4:30) 802-951-4080 or 1-888-588-7781 (24-hour voicemail)
- To speak with an epidemiologist:
Vermont Department of Health Infectious Disease Epidemiology
802-863-7240 or 1-800-640-4374 (in VT 8-4:30)
- For information about laboratory testing:
Vermont Department of Health Public Health Laboratory
802-863-7570 or 1-800-660-9997 (in VT 8:30-4:30)
- For after hours emergency:
Vermont Department of Health Infectious Disease Epidemiology 802-863-7240 or 1-800-640-4374 (VT) The answering service will notify the on-call epidemiologist who will return your call.
REPORT DISEASE: VERMONT TOLL-FREE 1-800-640-4374 OR 1-802-863-7240
For More Information
A great deal of information on biological agents is available at multiple sources. Several Internet resources are listed here. If you do not have Internet access or are having trouble acquiring information you desire, please contact Infectious Disease Epidemiology at 802-863-7240 or 1-800-640-4374.
Vermont Department of Health website www.state.vt.us/health
Includes links to:
- Consensus statements on biological agents (JAMA)
- Vermont Department of Health recommendations
- Vermont Health Alert Network - medical provider information
USAMRIID’s Biological Casualties Handbook www.usamriid.army.mil/education/bluebook.html
Johns Hopkins Center for Civilian Biodefense Studies www.hopkins-biodefense.org
APIC/CDC Recommendations for Health Care Facilities www.apic.org/bioterror
Emerging Infectious Diseases Journal Issue www.cdc.gov/ncidod/eid/vol5no4/contents.htm
CDC Bioterrorism agents list www.bt.cdc.gov/Agent/Agentlist.asp
ACIP Smallpox Vaccine Recommendations www.cdc.gov/mmwr//preview/mmwrhtml/rr5010a1.htm
ACIP Anthrax Vaccine Recommendations www.cdc.gov/mmwr/PDF/rr/rr4915.pdf
Chemical and Biological Arms Control Institute www.cbaci.org
Toxicology Data Network, National Library of Medicine toxnet.nim.nih.gov
REPORT DISEASE : VERMONT TOLL-FREE
1-800-640-4374 OR 1-802-863-7240
Vermont Department of Health
Division of Health Surveillance P.O. Box 70 Burlington, VT 05402-0070
Agency of Human Services
Jan K. Carney, MD, MPH
THIS BULLETIN IS PRODUCED BY THE EPIDEMIOLOGY PROGRAM STAFF.
Ann R. Fingar, MD, MPH