Bioterrorism Agents – Plague
Lesson 6
Public Health Management
Objectives
• Purposes of epidemiological
investigations
• Case definitions
• Sentinel events indicating
bioterrorism
• Public health response
– Natural Plague
– Bio-terrorist Plague
• Contact management and
prophylaxis
Principal Purposes of
Epidemiologic Investigations
• Characterize cases and confirm outbreak
• Identify
– Causative agent
– Source
– Mode of Transmission
• Identify
– Cases
– Case Contacts
Principal Purposes of
Epidemiologic Investigations
•
•
•
•
Person, place, time
Risk factors
Control and Prevention strategies
Monitor and evaluate response
Plague Case Definitions
Suspect and Probable
• Suspect Case
– Clinically compatible
– Clinical specimens – features of Y. pestis
• Probable Case
– Clinically compatible
– Presumptive laboratory results
• Positive DFA
• PCR evidence of Y. pestis
• Single elevated serum antibody titer to F1 antigen
Plague Case Definitions
Confirmed
• Confirmed Case
– Confirmatory isolation of Y. pestis
– 4-fold change in antibody titer to F1
antigen
– IHC staining can be considered when
isolation or serology not possible
Early Cases
• Lab confirmation important
– First cases in geographic area
– Treatment and isolation
– Post- or pre-exposure prophylaxis
– Other controls
• Call public health
immediately
Natural Disease vs Bioterrorism
•
•
•
•
•
Announced, credible threat
Observed threat event
Detection
Animal cases in unusual settings
Human cases without link to endemic area
Natural Disease vs Bioterrorism
Natural Plague
• Recent endemic exposure
• Handling of sick cat, flea bites in endemic
area
• Recent travel to endemic area
• Sporadic, infrequent cases
• Bubonic most common
presentation
Natural Disease vs Bioterrorism
Bioterrorist Plague
• No known endemic
exposure
• Point source in urban,
crowded setting
• Severe respiratory illness
• Cluster of severe and fatal
pneumonia
• Plague cases that don’t
respond to recommended
antibiotic treatment
Control and Containment
Initial Stages
•
•
•
•
•
•
•
Sampling of environment
Definition of dispersion
Confirmation of Y. pestis
Deploy SNS
Epidemiologic Investigation
Animal control
Communications
Control and Containment
Initial Stages
•
•
•
•
Coordination of activities
Active surveillance
Assisted surveillance
Clinician Information Requests
– Number of plague patients
– Number of plague rule-outs
– Chart review for unrecognized illness
Chart Reviews
• ER discharges, admits,
transfers
• Non-lab confirmed fevers,
pneumonias
• Prioritize hospitalized patients
• Follow-up on those transferred
out
• Critical for determining extent
and source of outbreak
Symptomatic Patient Evaluation
• Seek care: febrile
respiratory, other plague
compatible syndromes
• Referral and triage
hospitals
• Isolation and respiratory
droplet precaution
• All fevers 38.5C or
higher or cough
presumptive pneumonic
Contact Management
Contact – Within 6-7
feet, or 2 meters, of
patient in prior 7 days
• Evaluate contacts with
fever or cough
• 7 days prophylaxis and
symptom monitoring
Contact Management
Prophylaxis Groups
•
•
•
•
•
•
Exposed to Y. pestis release
Household members of respiratory plague
HCWs with direct patient contact
First responders
Patient transporters
Co-workers, friends,
others with close
contact to
symptomatic respiratory
Contact Management
Antibiotics and Monitoring
• Doxycycline is first choice
• Alternatives: Tetracyclines, sulfonamides,
chloramphenicol
• IND for gentamicin,
ciprofloxacin
• Temperature twice daily
• Unrestricted unless fever or
cough develops
Contact Management
• Prophylaxis refusal –
monitor x 7 days
• Special populations
management
• No vaccine with
proven efficacy
Other Management Issues
• Mass prophylaxis clinics
• Monitor news announcements
• Environmental sampling
Environmental Assessment
• Goals of Assessment
– Infected animals
– Infectious fleas
– Contaminated surfaces, soils,
water supplies
• Plague bacteria survive
poorly externally
• Short-term risk for humans
Environmental Testing
• Plague in animals, new regions
• Need for vector or rodent control
• Control and prevention measures
• Need for follow-up surveillance
• Effectiveness of
control measures
Review Questions – Plague
Lesson 6
Public Health Management
Plague Review Question
Lesson 6, Question 1
• Mass casualty situation
• Bioterrorist attack with plague
• Public health wants you to interview
patients for movement in past week
Why are they doing this to you now?
Plague Review Question
Lesson 6, Question 1
Why are they doing this to you now?
A.
B.
C.
D.
Look like they’re doing something
Determine source of exposure
B and D
Prophylaxis recommendation
development
Plague Review Question
Lesson 6, Question 1
Why are they doing this to you now?
C. B and D
– Determine source of exposure
– Prophylaxis recommendations
Plague Review Question
Lesson 6, Question 2
• You’re on hospital emergency response
team
• Categorizing plague cases at your hospital
A confirmed case would NOT include…
Plague Review Question
Lesson 6, Question 2
A confirmed case would NOT include…
A.
B.
C.
D.
Confirmed isolation of Y. pestis
IHC staining of Y. pestis
Stained organisms of Y. pestis
Fourfold or greater increase in antibody
titer to F1 antigen
Plague Review Question
Lesson 6, Question 2
A confirmed case would NOT include…
C. Stained organisms of Y. pestis
Plague Review Question
Lesson 6, Question 3
• You’re a public health worker
• State epidemiologists asks you to
determine if plague case is natural or
bioterrorist
Which would best describe naturally
occurring plague?
Plague Review Question
Lesson 6, Question 3
Which would best describe naturally
occurring plague?
A.
B.
C.
D.
History of sporadic cases in area
1 patient only
Patient has history of rodent exposure
All of the above
Plague Review Question
Lesson 6, Question 3
Which would best describe naturally
occurring plague?
D. All of the above
– History of sporadic cases
– Only 1 case
– History of rodent exposure
Plague Review Question
Lesson 6, Question 4
• Plague bioterror event
• Identifying close contacts
• Considering antibiotic prophylaxis
Which of the following fall is not considered
a close contact?
Plague Review Question
Lesson 6, Question 4
Which of the following fall is not considered
a close contact?
A.
B.
C.
D.
Friends in another city
Patient transporters
Household members of respiratory
Co-workers within 6 feet
Plague Review Question
Lesson 6, Question 4
Which of the following fall is not considered
a close contact?
A. Friends in another city
Review Question
Lesson 6, Question 5
• Plague bioterror event
• Large number of casualties
• You’re on local emergency response team
What activity would you expect from
response leaders?
Plague Review Question
Lesson 6, Question 5
What activity would you expect from
response leaders?
A.
B.
C.
D.
Quarantine entire city
Drop individual investigations
Symptomatic patients stay home
Establishment of treatment centers
Plague Review Question
Lesson 6, Question 5
What activity would you expect from
response leaders?
D. Establishment of treatment centers
BT Agents Home
6-21. Question
Plague: Lesson 6- Public Health Issues
BT Agents
Module: Plague
A.
Module IntroductionModule Objectives
Target Audience
Continuing Education Credit
Lessons1) General Overview
2) Clinical Presentation
3) Differential Diagnosis
4) Laboratory Issues
5) Medical Management
6) You work at a public health department
in New Mexico. Your local hospital has a
positive test in their lab for a single case of
suspect pneumonic plague. The patient has
a documented exposure to an ill animal.
How will you manage this patient?
A. I won’t do anything. The patient is being
treated.
B. Look for all close contacts to the patient
and begin on prophylaxis.
C. Stop the referral testing at the public health
lab. We know it’s plague because there was an
ill animal.
B.
C.
The best answer is B. It is
important that all close
contacts to a pneumonic
plague case receive
prophylaxis.
Correct. It is important that all
close contacts to a pneumonic
plague case receive
prophylaxis.
The best answer is B. Even
naturally-occurring cases of
plague should be laboratory
confirmed. It is also important
that all close contacts to a
pneumonic plague case
receive prophylaxis.
6) Public Health Issues
7) Veterinarian Issues
Plague: Lesson 6Public Health Issues
8) Module Self-Assessment
Additional Resources
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Plague Review Question
Lesson 6, Question 6
• You work in public health in New Mexico
• Local hospital with suspect plague
• Documented exposure to ill animal
How will you manage this patient?
Plague Review Question
Lesson 6, Question 6
How will you manage this patient?
A. Nothing. Patient is being treated.
B. Manage all close contacts
C. Stop referral testing. There was a sick
animal. We know it’s plague.
Plague Review Question
Lesson 6, Question 6
How will you manage this patient?
B. Manage all close contacts