Disease Control Bulletin: October 2001


disease control bulletin

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.

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).

Respiratory distress

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

Hemorrhagic meningitis

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.

Biological Incidents

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:

Whatever the inciting event, our actions will reflect well-established epidemiologic methods of responding to an emergency event and include:

Radiological Incidents

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:

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.

Chemical Incidents

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:

During a chemical terrorism event the Vermont Department of Health will:

Laboratory Response

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:

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:

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:


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:

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)

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:

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

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


Ann R. Fingar, MD, MPH
State Epidemiologist