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
 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?
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 21 st century.
2. Global Emerging Crisis in Infectious Diseases. Challenges for the 21 st 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

Severe Gastroenteritis

Fatal pneumonia in healthy patient

Widened mediastinum with fever

Rash with synchronous vesicular/pustular lesions

Acute neurologic illness with fever

Advancing cranial nerve palsy with weakness

James W. Buehler et. Al. Syndromic Surveillance and Bioterrorism-related epidemics. Emerging Infectious Diseases, October 2003
 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.

Mascap Inc, Ohio, 2000.
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

2. Global Emerging Crisis in Infectious Diseases. Challenges for the 21 st 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.
 Outbreak Containment in the
Emergency Department
 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.
 Outbreak Containment in the
Emergency Department

 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.
 Outbreak Containment in the
Emergency Department
 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.
 Hospital Response Plans

 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.
 Hospital Response Plans

 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 21 st 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:  Uninfected

 Detection patients
 Isolation  Monitoring
 Containment  protection
Conversion of patient rooms
into isolation rooms
“hotwards”
Designated ambulance service
Back up teams/functional units

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:
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

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

 Diagnosis
 Immunofluorescence or ELISA

 PCR

 Therapy
 Supportive

 No vaccine yet available

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: Current 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

David R. Franz and Russ Zajtchuk. Bioterrorism: Understanding the threat,

1.
Preparation and medical response. Disease-A-Month 48(8), August 2002.
2. Rega. Bioterrorism: A statistical manual to identify and treat diseases of bioterrorism. Mascap
Inc, Ohio, 2000.
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.
13. Global Emerging Crisis in Infectious Diseases. Challenges for the 21 st 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