Epidemics and Emerging

Infections
LESSON 11
 Objective
Upon completion of this unit, you will be
able to:
1. Identify the fundamentals of a
hospital preparedness and response
plan for epidemics.
 Biological Hazards
• “Terrorism” / Anthrax
• SARS
• Avian Flu
• Dengue

Vulnerability to emerging infectious

diseases
 Biological Hazards
Tartars used plague-infected corpses in Kaffa, 1346.
 Influenza Pandemic
Nurses work in the
Red Cross rooms
of Seattle, WA
with “influenza
masks” on their
faces. December
1918 (Courtesy of
the National
Archives, 165-
WW-269B-10)
Basic EMS Dictum
 Biological Event
 Bacterial agents
 Anthrax, Brucellosis, Yersinea pestis
(Plague) and Cholera, Salmonella
 Viruses
 Smallpox, Hemorrhagic Fever Virus
 Biological product
 Botulinum toxin, Endotoxins, Mycotoxin,
SEB, ricin,
Smallpox – Bangladesh, 1976
A child stricken by
smallpox is relatively
cured but his health is
still threatened by
malnutrition and
secondary infection.
(Courtesy of the National
Archives, 76-845)
 Biological Event

• Infection borne through air, food and

water
• Incubation period - delay from time of
exposure until clinical symptoms arise
• Extensive exposure may occur before
the primary event is appreciated.
Rare Diseases can be Overseen

Rare color
photo of baby
with smallpox.
National
Archive film
footage from
Vietnam (RG-
428-NPC-
38594)
 Biological Event

 Delivered with conventional explosives

 Emergency care, decontamination is
necessary (outside the hospital)
 Personnel must be trained in patient
decontamination
 Decontamination Area
 Storage for decontamination equipment and
supplies
 Decontamination area - cooled to reduce the heat
load on personnel caused by their protective
equipment
 The decontamination site has 3 zones:
 Hot zone – incoming casualties
 Warm zone – decontamination area
 Cold zone – triage and transport Fill in the Blanks
3 Zones of Decontamination Area
Crowd
control line
wind

Hot line

amp Exclusion (hot) zone

CORRIDOR Decontamination
line
Contamination reduction
(warm) zone

Access Support (cold) zone

control
points
 Decontamination Area

 First responders and medical personnel

SHOULD PROTECT THEMSELVES
 Personal Protective Equipment (PPE)
 Protect eyes, lungs and skin  
       

Fill in the Blanks

 Decontamination Area
Storage for decontamination equipment and
supplies
Decontamination area
 cooled to reduce the heat load on
personnel caused by their protective
equipment
Decontamination Area
 Decontamination Area
Patients
Support zone
No special protective gear

clean stretcher and blankets

Decontamination wash and final rinse/soap and shampoo

zone
wash and rinse

remove victim’s contaminated clothing

HAZMAT teams with proper protective gear

Hot zone gross contaminates removed here

 Decontamination Area

 
 Decontamination Area
 First responders (decontamination)
protect themselves through PPE.
 Personal Protective Equipment (PPE)
respiratory equipment
 Garments and barrier material        
 Decontamination Area

 Maximum protection is achieved through

use of positive pressure respirators and
total body encapsulation.
 Surgical mask and a pair of latex gloves
provide minimum protection
Decontamination Area
 Personal Protective Equipment
Red Cross workers of Boston,
MA, removing bundles of masks
for American soldiers from a
table where other women are
busily engaged in making them.
March 1919.
(Courtesy of the National Archives, 165-WW-
269B-37)
 Medical Response
 Pandemic
 large number of
casualties with similar
symptoms
 dissemination device
 receipt of a warning
 hospital may receive
untreated casualties
directly from the site
Emergency Hospital at Brookline,
MA to care for influenza cases.
October 1918
 Medical Response
First responders and
medical personnel
SHOULD PROTECT
THEMSELVES

September 11
 Medical Response
Why is the level of
Epidemic preparedness
so critical?
 Because the
consequences of not
being prepared are so
catastrophic! Smallpox Vaccine
 Category A

High-priority agents include organisms that

pose a risk to national security because they –
 can be easily disseminated or transmitted
person-to-person;
 cause high mortality, with potential for
major public health impact;
 Category A
continued…
 might cause public panic and social
disruption; and
 require special action for public
health preparedness.
 Category ‘A’ Agents Include:

 Variola major (Smallpox):

 Bacillus anthracis (Anthrax);
 Yersinia pestis (Plague);
 Clostridium botulinium toxin (Botulism);
 Francisella tullarensis (Tularemia);

Fill in the Blanks

 Category ‘A’ Agents Include:

 Filoviruses
- Ebola Hemorrhagic Fever;
- Marburg Hemorrhagic Fever; and
 Arenaviruses
- Lassa (Lassa Fever)
- Junin (Argentine Hemorrhagic Fever) and
related viruses.

Fill in the Blanks

 Category B
Second-highest priority agents:
 moderately easy to disseminate

 cause moderate morbidity and low mortality

 require specific enhancements of CDC’s

diagnostic capacity and enhanced disease
surveillance
 Category B agents include:
 Coxiella burnetti (Q fever)
 Brucella species (Brucellosis)
 Burkholderia mallei (Glanders)
 Alphaviruses
 Venezuelan encephalomyelitis
 Eastern and Western equine
encephalomyelitis
 Category B agents include:
continued…

 Rich toxin from Ricinus communis (castor

beans)
 Epsilon toxin of Clostridium perfringens
 Staphylococcus enterotoxin B
 Category B

A subset of List B agents include pathogens that are

food or waterborne. These pathogens include, but
are not limited to:
 Salmonella species
 Shigella dysenteriae
 Escherichia coli O157:H7
 Vibrio cholerae
 Cryptosporidium parvum
 Category C
Third-highest priority agents include emerging
pathogens that could be engineered for mass
dissemination in the future because of:
 availability
 ease of production and dissemination
 potential for high morbidity and mortality
due to major health impacts
 Category C agents include:
 Nipah virus
 Hantaviruses
 Tickbone hemorrhagic fever viruses
 Tickbone encephalitis viruses
 Yellow fever
 Multi-drug resistant tuberculosis
 Category C

Preparedness for List C agents requires ongoing

research to improve disease detection, diagnosis,
treatment and prevention.

Linking bio-terrorism preparedness efforts with ongoing

disease surveillance and outbreak response activities
as defined in CDC’s emerging infectious disease
strategy is imperative.
 History of the IHR
 Cholera epidemic, Europe 1830 - 1847 intensive
infectious disease diplomacy multilateral
cooperation; First International Sanitary
Conference, Paris 1851
 1948 WHO Constitution
 1951 WHO adopted International Sanitary
Regulations
 International Health Regulations, 1969
 History of the IHR
IHR (1969) to monitor and control six serious
infectious diseases:
Cholera, Plague, Yellow fever,
Smallpox, Relapsing fever and Typhus

IHR (1969) - Cholera, Plague and Yellow fever remain

of concern
WHO must be informed
 History of the IHR

1990's resurgence of epidemics

Cholera - South America
Plague - India
Emergence of infectious agents Ebola
(48th World Health Assembly, 1995 revision of IHR,
May 2001)
WHA 54.14, Global health security: epidemic alert
and response
 History of the IHR

• May 2003 resolution WHA56.28 Revision of IHR

• IGWG sessions in Nov 2004 and Feb/May 2005

• 58th World Health Assembly adopted IHR (2005)

23 May 2005 resolution WHA58.3.a
Declaration of
Policies
International Health Regulations of
2005, Article 5-1 Surveillance

• urges Member States to develop, strengthen and

maintain as soon as possible, but no later than
five years from entry into force of these
regulations, and the capacity to detect, assess,
notify and report events in accordance with these
regulations.
Priority Diseases/Syndromes And Conditions Targeted For Surveillance

Category II (Weekly Notifiable)

Category I (Immediately
Notifiable) 1. Acute Bloody Diarrhea
2. Acute Encephalitis
1. Acute Flaccid Paralysis Syndrome
2. Adverse Event Following 3. Acute Hemorrhagic Fever
Immunization (AEFI) Syndrome
3. Anthrax 4. Acute Viral Hepatitis
4. Human Avian Influenza 5. Bacterial Meningitis
5. Measles 6. Cholera
6. Meningococcal Disease 7. Dengue
7. Neonatal Tetanus 8. Diphtheria
8. Paralytic Shellfish 9. Influenza-like Illness
Poisoning 10. Leptospirosis
9.Rabies 11. Malaria
10.Severe Acute 12. Non-neonatal Tetanus
Respiratory 13.Pertussis
Syndrome (SARS) 14.Typhoid and Paratyphoid
Fever

DOH – CHD, REGIONAL EPIDEMIOLOGY and SURVEILLANCE UNIT (RESU) - Philippines

 Medical Response

First responders must take care that

they don't become victims
themselves.
 Medical Response
A 1995 NBC exercise in New York City determined the
first 100 emergency responders to arrive on scene
'killed'
 not adequately prepared or trained to deal with
this incident
Los Angeles exercise
 doctors admitting that 'victims' have seriously
contaminated hospitals
 Why is the level of epidemic
preparedness so critical?

Because the consequences of not

being prepared are so catastrophic! 
 Summary
 Epidemics pose challenges for medical
personnel.
 Preparedness for an appropriate hospital
response activated is essential, while
ensuring the safety of personnel.
 EMS may not provide the most effective and
immediate medical response.
 Summary
Continue…

 Successful outcome of the medical care requires

adequate preparedness.

 Planning, disciplined and coordinated behavior

by personnel, mobilization ability, availability of
medical resources, and communication are
essential in effective care.
 Review of Objective
Upon completion of this unit you will be able to:
 Identify the fundamentals of a hospital
preparedness and response plan for
epidemics.
 Exercise
 What resources does your hospital have which
can be applied to a CBR incident?

 What training is required for EM personnel in

order to mount a safe and effective hospital
response to a CBR incident?

 With what other agencies should the hospital be

conducting joint CBR exercises?
 Exercise
Continue…

 With whom should the hospital coordinate

regularly on CBR issues?
 Who should be represented on your
hospital’s CBR functional preparedness
committee?