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Handbook of Bioterrorism

and Disaster Medicine

Robert E. Antosia John D. Cahill Harvard Medical School Department of Emergency Medicine and and Division of Infectious Diseases Department of Emergency Medicine St. Luke’s/Roosevelt Hospital Center Beth Israel Deaconess Medical Center New York, NY 10019 Boston, MA 02215 USA USA

Cover illustration: Cover design “Tribute in Light” courtesy of Charles Nesbit and Richard Nash Gould. A project of John Bennett, Gustavo Bonevardi, Richard Nash Gould, Julian Laverdiere, Paul Marantz, Paul Myoda, The Municipal Art Society, Creative Time.

Library of Congress Control Number: 2006922412

ISBN-10: 0-387-24369-0 e-ISBN-10: 0-387-32804- ISBN-13: 978-0387-24369-6 e-ISBN-13: 978-0387-32804-

Printed on acid-free paper.

© 2006 Springer Science +Business Media, LLC All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights.

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CONTRIBUTORS

Amesh Adalja, M.D ., Department of Emergency Medicine, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA

Mara Aloi, M.D ., Department of Emergency Medicine, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA

Phillip Anderson, M.D ., Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA

Robert Antosia, M.D., M.P.H ., Harvard Medical School, and Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA

Robert Buckner II, M.D ., Department of Emergency Medicine, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA

Frederick Burkle, M.D., M.P.H ., The Center for International Emergency, Disaster and Refugee Studies, The John Hopkins University Medical Institutions, Baltimore, Maryland, USA

Michelle Burns, M.D ., Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA

John D. Cahill, M.D ., Department of Emergency Medicine and Division of Infectious Diseases, St. Luke’s/Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, New York, New York, USA

Christopher Cammarata, M.D ., Department of Emergency Medicine, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA

Anna Chen, M.D ., Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA

Scott Cohen, M.D ., Global Pediatric Alliance, Oakland, California, USA

Manuel Colon, M.D ., Department of Emergency Medicine, St. Luke’s/Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, New York, New York, USA

Marina Del Rios, M.D ., Department of Emergency Medicine, St. Luke’s/Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, New York, New York, USA

Michael Levine, M.D ., Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA

Lawrence Lo, M.D ., Department of Emergency Medicine, St. Luke’s/Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, New York, New York, USA

Rishi Malholtra, M.D ., Department of Medicine, St. Luke’s/Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, New York, New York, USA

Shannon Manzi, Pharm.D ., Children’s Hospital Boston, Boston, Massachusetts, USA

Peter S. Martin, M.D ., Department of Emergency Medicine, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA

George F. McKinley, M.D ., Division of Infectious Diseases, St. Luke’s/Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, New York, New York, USA

Roland Merchant, M.D ., Department of Emergency Medicine, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA

Maria Mileno, M.D ., Division of Infectious Diseases, The Miriam Hospital, Brown University, Providence, Rhode Island, USA

Matt Miles, M.D ., Department of Emergency Medicine, Albany Medical Center, Albany, New York, USA

Mischa Mirin, M.D ., Department of Emergency Medicine, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA

Joshua Nagler, M.D ., Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA

Lise Nigrovic, M.D ., Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA

Neha Parikh, M.D ., Department of Emergency Medicine, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA

William Porcaro, M.D ., Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA

Charles Pozner, M.D ., Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA

David J. Prezant, M.D ., Pulmonary Division, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA

Arathi Rao, M.D ., Division of Infectious Diseases, The Miriam Hospital, Brown University, Providence, Rhode Island, USA

George J. Raukar, M.D ., Department of Orthopedics, West Virginia University, Morgantown, West Virginia, USA

David Riley, M.D ., Department of Emergency Medicine, St. Luke’s/Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, New York, New York, USA

HANDBOOK OF BIOTERRORISM AND DISASTER MEDICINE XVII

Kaushal Shah, M.D ., Department of Emergency Medicine, St. Luke’s/Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, New York, New York, USA

Michael Shannon, M.D ., Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA

Sam Shen, M.D., M.B.A ., Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA

Sophie Skarbek-Borowska, Verso Publishing, London, UK

George W. Skarbek-Borowski, M.D ., Department of Emergency Medicine, Memorial Hospital, Brown University, Pawtucket, Rhode Island, USA

Dorsett D. Smith, M.D ., Division of Pulmonary Disease and Critical Care, Department of Medicine, University of Washington, Seattle, Washington, USA

Ramona Sunderwirth, M.D ., Department of Emergency Medicine, St. Luke’s/Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, New York, New York, USA

Stephen Traub, M.D ., Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA

Deborah Weiner, M.D., Ph.D ., Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA

Dan Wiener, M.D ., Department of Emergency Medicine, St. Luke’s/Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, New York, New York, USA

Tommy Wong, M.D ., Department of Emergency Medicine, St. Luke’s/Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, New York, New York, USA

Tracy H. Zivin-Tutela, M.D ., Division of Infectious Diseases, St. Luke’s/Roosevelt Hospital Center, Columbia College of Physicians and Surgeons, New York, New York, USA

XVIII CONTRIBUTORS

I am indebted to Andrea Macaluso from Springer for her patience and faith in this book. A special thanks to Aaron Johnson for helping to get this project off the ground, to Tim Oliver for his expertise in copyediting and typesetting, and to Mara Aloi MD for all her efforts and help. Thank you to all the contributing authors, for this book would not have been possible without them. Finally, thanks to my wife Rachel for her endless support and help with this proj- ect. — John D. Cahill

Numerous people have helped and supported me in my endeavors. Most espe- cially, I thank my mother and father for showing me the right path and for their end- less love and support. I would also like to acknowledge Dr. Bert Woolard for introducing me the special- ty of Emergency Medicine; Drs. Dave Wagner, Jim Roberts, Bob McNamara, and Thomas Alessi for showing me what an emergency physician is and for being such great role models; Dr. Jennifer Leaning for both helping me and inspiring me to under- stand the need to enhance disaster medical care throughout the world—and the pas- sion for making a difference; and Dr. Troy Brennan for his mentoring and unwavering support. Finally, I wish to thank my wife Janelle; she gives me the love and strength to fol- low on the path. — Robert E. Antosia

ACKNOWLEDGMENTS

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The Handbook of Bioterrorism and Disaster Medicine was created because we felt there was no effective handbook that covered the breadth and scope of this field. Our book incorporates concise chapters, on topics and diseases with abundant web-based references, and careful organization. We hope that all healthcare providers interested or involved with the care of victims of bioterrorism or disaster — including prehospi- tal care providers, medical students, nurses, physicians, and those involved with pub- lic health or humanitarian aide — find it indispensable. We wish to thank the numerous authors who contributed to this handbook. Throughout the book, consistency of style and depth provide the reader with easy and reliable access to the vast amount of information needed to understand, prepare for, and deal with a bioterrorist attack or disaster. The chapters in this book have been based on scientific studies and data when available. However, more research is need- ed to more fully understand these complex events. These events often occur with little or no warning, and they typically dispropor- tionately harm the very young, the very old, and the impoverished.

PREFACE

IV. M EDICAL MANAGEMENT OF DISASTER-RELATED INJURIES AND DISEASE

• 1. Defining a Disaster
• 2. Early Warning Systems
• 3. Epidemiology of Disasters
• 4. Triage
• 5. Disaster Logistics
• 6. Public Health Preparedness
• 7. Intergovernmental and Governmental Organizations
• 8. Nongovernmental Organizations
• 9. Complex Humanitarian Emergencies
• 10. Earthquakes II. NATURAL DISASTERS
• 11. Volcanoes
• 12. Floods
• 13. Tsunamis
• 14. Hurricanes and Typhoons
• 15. Tornadoes
• 16. Drought
• 17. Firestorms and Wildfires
• 18. Heat Wave/Hyperthermia
• 19. Winter Storm Disasters and Hypothermia
• 20. The Epidemiology of War and Conflict III. BIOEVENTS AND MANMADE DISASTERS
• 21. Weapons of Mass Destruction
• 22. Anthrax
• 23. Smallpox
• 24. Plague
• 25. Tularemia
• 26. Viral Hemorrhagic Fevers
• 27. Botulism
• 28. Q Fever
• 29. Brucellosis
• 30. Alphaviruses
• 31. Ricin
• 32. Epsilon Toxin
• 33. Staphylococcus Enterotoxin B
• 34. Food- and Water-borne Agents
• 35. Melioidosis
• 36. Nerve Agents
• 37. Vesicants
• 38. Pulmonary Agents
• 39. Cyanides
• 40. Nuclear Detonation/Ionizing Radiation Exposure
• 41. Hazardous Material Disasters
• 42. Maritime Disasters
• 43. Aviation Disasters
• 44. The ABCs and Resuscitation Algorithms for IVA. B ASIC EMERGENCY MEDICINE
• 45. Shock: Diagnosis and Management Cardiopulmonary Arrest
• 46. Intravenous Fluid Requirements and Blood Products
• 47. Decontamination
• 48. Acute Inhalation Injury
• 49. Electrical Injuries
• 50. Toxicology
• 51. Measles IVB. INFECTIOUS DISEASES OF DISASTER
• 52. Approach to Diarrhea and Dysentery
• 53. Malaria
• 54. Meningitis and Encephalitis
• 55. Tuberculosis
• 56. Human Immunodeficiency Virus, Type 1, and AIDS
• 57. Sexually Transmitted Diseases
• 58. Schistosomiasis
• 59. Tetanus
• 60. Bite Wounds and Rabies
• 61. Tick-Borne Diseases
• 62. Leptospirosis
• 63. Wound Care Management IVC. BASIC TRAUMA MANAGEMENT
• 64. Abdominal Trauma
• 65. Thoracic Trauma
• 66. Neurotrauma
• 67. Blast Injuries
• 68. Crush Injuries
• 69. Missile Injuries
• 70. Burn Management
• 71. Pediatric Problems in Developing Countries V. PEDIATRIC CONSIDERATIONS AND DISASTERS
• 72. Nutritional Assessment in Malnutrition
• 73. Treatment of Malnutrition in Children
• 74. Evaluation and Management of Pediatric
• 75. Pediatric-Specific Disaster-Related Considerations Disaster Victims
• 76. Pediatric Specialty Team Response to Disaster
• 77. Water, Sanitation, and Hygiene VI. MEDICAL AND HUMANITARIAN DISASTERS
• 78. Shelter
• 79. Refugees and Internally Displaced Populations
• 80. Child Soldiers
• 81. Reproductive Health
• 82. Emergency Preparedness VII. EDUCATION, HEALTH ISSUES, AND RESOURCES
• 83. Syndromic Surveillance
• 84. JCAHO Emergency Management Standards
• 85. Health and the Humanitarian/Disaster Worker
• 86. Immunization Schedules and Recommendations
• 87. Healthcare Worker Exposures to Blood and Body Fluids
• 88. Post-Traumatic Stress Disorder
• 89. International Law: A Primer for
• 90. A Guide to the Worldwide Web Healthcare Professionals
• INDEX

Robert E. Antosia, MD , MPH *

Disasters are highly complex events resulting in immediate medical problems, as well as longer-term public health consequences. They are generally considered "low probability–high impact" events. As such they are not defined by a specific number of casualties but rather by the event itself and the venue in which it occurs. The definition of disaster is variable and usually reflects the nature and focus of the organization or individuals defining it. The World Health Organization (WHO) defines a disaster as a sudden ecological phenomenon of sufficient magnitude to require external assistance. This broad definition may exclude some events that result in mass casualties. A more focused definition generally accepted by the specialty of emergency medicine is: when the number of patients presenting within a given time period are such that the emergency department cannot provide care for them without assistance. This definition excludes events that result in mass death but place little or no stress on the medical system. At the community level, disasters can be defined operationally as any emergency that seriously affects people's lives and property and exceeds the capacity of the community to respond effectively to that emergency. Disasters affect a community in numerous ways. Roads, telephone lines, and other transportation and communication lines are often destroyed; public utilities and energy supplies are often disrupted. Many victims are often rendered homeless. The community's industrial or economic base may be damaged or destroyed. Casualties may require urgent or emergent medical care. Damage to water and sanitation sys- tems, food sources and utilities may create public health threats. All disasters are unique because each affected region of the world has different social, economic, and baseline health conditions. However, some similarities exist and each disaster follows a general pattern in its development. This pattern is often repeat- ed and is illustrated in Figure 1. While the divisions are artificial as one phase merges with another, this simplified disaster cycle model is useful to help understand and plan for these complex events. Initially, a quiescent level or interdisaster period is seen during which the combi- nation of events that will lead to a disaster are occurring but not readily apparent. A

DEFINING A

DISASTER

*Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston

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prodrome or warning phase develops next and lasts a variable length of time. The warning period represents a time during which a particular event (e.g. a hurricane, volcanic eruption, military conflict) is likely to occur. However, some disasters occur with little or no warning. The impact phase coincides with the occurrence of the event and may be short or protracted depending upon the particular event. The rescue phase (also known as the emergency, relief, or isolation phase) represents a time when immediate assistance can save lives. During this time, first responders' actions, basic and advanced life support, as well as search and rescue, are critical but often over- whelmed or incapacitated. The recovery or reconstruction phase constitutes all of the actions and elements needed to return the population back to a functional society. It involves the coordinated efforts of emergency medical services, public health agen- cies, government and social services as well as other agencies and can last months or years.

REFERENCES

Hogan DE, Burstein JL. 2002. Disaster medicine. Philadelphia: Lippincott, Williams, and Wilkins. Noji EK. 1997. The public health consequences of disasters. New York: Oxford University Press. Waeckerle JF. 1991, Disaster Planning and Response. N Engl J Med 324 :815–821.

4 1 H ANTOSIA: DEFINING A DISASTER

Figure 1. General phases of the disaster life cycle. Reprinted with permission from Hogan and Burstein (2002).

Unfortunately, most terrorist attacks occur with little or no warning. In response to the terrorist attacks in the US on September 11, 2001, the United States created the Department of Homeland Security. This entity has nine components: border and transportation security, emergency preparedness and response, information analysis and infrastructure protection, science and technology, management, coast guard, secret service, citizenship and immigration services, and the inspector general. The department overlooking emergency preparedness and response established a five- tiered, color-coded security advisory system based on the perceived threat level of a terrorist attack. The highest risk level is termed "severe" and is coded red; a "high" level of risk is coded orange; an "elevated" or significant risk is coded yellow; a "guarded" or general level of risk is coded blue; and a "low" risk of terrorist attacks is coded green. This serves to notify the media, general public, police and military offi- cers, and public health agencies in an attempt to improve awareness and readiness should an attack occur. European governments and most other countries have avoided the drastic orga- nizational changes for disaster planning and management that have recently occurred in the US. In many countries, the preparation and response to bioterrorism and other public health problems are led by applied epidemiology and training programs (AETPs), which are part of, or closely affiliated with, the host country's ministry of health. AETPs cover approximately 45 countries, and most are strengthened by sup- port from various partners, including representatives from the Centers for Disease Control (CDC) and the World Health Organization (WHO). Improved global surveillance efforts should be instituted with as close to real-time data gathering as possible. All facets of surveillance should be used and should include emergency department visits, laboratory data, pharmacy use, school absen- teeism, and any other data that may correlate with an outbreak of infectious disease. Robust surveillance systems are essential in detecting any emerging or reemerging diseases that may represent a possible BT attack. Quick recognition of any change in disease patterns will facilitate determination of the source and help limit further expo- sure. With applied epidemiology and training programs, close attention to disease patterns, and a basic knowledge and understanding of the threat of BT, actions can be taken to decrease the impact of disease and disasters, regardless of their etiology.

RESOURCES

http://www.hewsweb.org/home_page/default.asp http://www.reliefweb.int/resources/ewarn.html

REFERENCES

Department of Homeland Security. 2004. www.dhs.gov/dhspublic Perry RW, Lindell MK. 2003. Preparedness for emergency response: guidelines for the emer- gency planning process. Disasters 27 (4):336– Sandhu HS, Thomas C, Nsubuga P, et al. 2003. A global network for early warning and response to infectious diseases and bioterrorism: applied epidemiology and training programs. Am J Pub Health 93 :10. Zygmunt-Lubkowski JB. 2005. Managing tsunami risk. Lancet 365 :271–273.

6 2 H ANTOSIA: EARLY WARNING SYSTEMS

Robert E. Antosia, MD , MPH *

Epidemiology is based on two fundamental assumptions; first, that human dis- ease does not occur at random, and second, that human disease has causal and pre- ventable factors that can be identified through systematic investigation. It is the study of the distribution, determinants, and frequency of disease in human populations. Epidemiology is also concerned with the broader causes of disease. Note that the term "disease" refers to a broad array of health-related states and events, including diseases, injuries, disabilities, and death. Disasters are predictable—not in time or place, but in their inevitability. A major disaster occurs almost daily, and a natural disaster that requires international assis- tance for affected populations occurs weekly. The rate of occurrence of such events may be increasing; this is possibly due to regular variation in natural cycles such as solar flares, earthquakes, and volcanic activity. Also, global warming is projected to increase storm activity in some areas and to cause drought in others. Although the likelihood of natural disasters is relatively high, the chance of a bioterrorist (BT) attack or other manmade disaster is both unknown and unpre- dictable. In contrast to nuclear and chemical weapons, for which both short- and long- term consequences can be rather well established, the consequences of the use of bio- logical weapons are hardly foreseeable. The spread of BT agents, unlike other wea- pons, can go undetected, and when noticed they may have already infected a major portion of the population. Despite advances in preparedness, nations remain vulnerable. This is especially true of civilian populations, who often do no have readily available protective equip- ment or vaccines. Unlike natural disasters, the unfortunate fact remains that humans are often the most sensitive, or the only, detector of a biological attack. Without prior knowledge of an attack, an increased number of patients presenting with signs and symptoms caused by the disseminated disease agent is most likely the first indicator that a BT attack has occurred. A comprehensive epidemiologic investigation of a disease outbreak, whether nat- ural or manmade, will assist medical personnel in identifying the pathogen as well as

EPIDEMIOLOGY

OF DISASTERS

*Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston

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