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HSE420Module4Chapter6Slides.pptxBiosecurity & Bioterrorism: Containing and Preventing Biological Threats
Chapter 6
Recognize, Avoid, Isolate, Notify (RAIN)
Learning Objectives
List and discuss the components of RAIN.
Discuss how individuals or responders might recognize biothreat agents or the diseases they cause.
Describe methodologies used to detect biological agents in the field.
Discuss the limitations of field tools for biothreat pathogen detection.
Discuss methods and strategies to avoid biological contamination.
Discuss methods and strategies to isolate biological agents or contagious persons or animals from others.
Discuss notification procedures and considerations once biological agents have been disseminated or enter a population of people or animals.
Key Terminology
Accuracy
First responders
First receivers
Gold standard
RAIN
Sensitivity
Specificity
Introduction
Nunn-Lugar-Domenici (NLD) Defense against Weapons of Mass Destruction Act of 1996 (Public Law 104-201) mandated training for “first to respond”
First Responders
First Receivers for EMTs, Paramedics and Emergency Department personnel
Domestic Preparedness Programs – post 9/11 and Amerithrax made these more prominent
Community Response Organizations
Response to CBRNE hazards bounded by 29 CFR – 1910.120
First responder awareness level
First responder operations level
Hazardous materials technicians
Hazardous materials specialists
On scene incident commander
RAIN
Recognize
Avoid
Isolate
Notify
Devised by preparedness trainers in the development training guidelines and curriculum for the original (1997) Domestic Preparedness program’s Awareness level training (Socher and Leap, 2005)
Recognize
Recognize the hazard or threat
What do I see, hear, or smell that indicates a biological threat is present?
The goal is to get first responders and first receivers to rapidly interpret and mentally process a suspicious event for what it is.
Image courtesy of Department of Defense
Indications of a Possible Biowarfare Attack
The discovery of a disease due to a pathogen that does not occur naturally in a given geographic area
Multiple disease entities in the same patients, indicating that mixed agents have been used in the attack
Large numbers of both military and civilian casualties when such populations inhabit the same area
Data from a biosensor suggesting a massive point-source outbreak
Sentinel dead animals of multiple species
Indications (continued)
Large outbreak of disease due to an apparent inhalation route of infection
High percentage morbidity and mortality relative to the at risk population
Illness limited to fairly localized or circumscribed geographical areas
Low attack rates in personnel who work in areas with filtered air supplies or closed ventilation systems
Absence of a competent natural vector in the area of outbreak (for a biological agent that is vector-borne in nature)
Critical Thinking
Biothreat agents have delayed effects. Responders are not likely the first to note that an event has taken place. Rather, the medical community would probably be the first to see the trends in case reporting. There has been one major act of bioterrorism in the post-9/11 era - Amerithrax. How was the Amerithrax incident revealed to us?
Agent Detection Technologies
Means to detect and identify biological incidents is much smaller than current capabilities for chemical and radiological detection
Samples are collected on-site observing rules of evidence and maintaining chain of custody.
Samples are then taken to a highly-sophisticated laboratory where they are analyzed with various techniques that includes bioassay, immunoassay, nucleic-acid assay, and the culture of living organisms
On-site detection of biological agents is currently not practical for most responders
Sampling
Don’t take bad samples to good tests!
Environmental vs. clinical samples – dramatically different matrices
There is no single method for sampling biological agents
Sampling method often depends on the matrix being sampled and the test(s) that the sample will be subjected to
Contact the lab where the sample is going to for definitive testing
Use the lab’s protocol
Image courtesy of Department of Defense
Critical Thinking
What confounding factors might affect the taking of an environmental sample?
What is meant by the statement: Never take bad samples to a good test.
Test Accuracy
In comparison to a “Gold Standard”
Sensitivity
Specificity
Positive Predictive Value (PPV)
Negative Predictive Value (NPV)
True Positive / False Positive
True Negative / False Negative
Limit of Detection
Common Field Testing Methods
Handheld Assays (HHA)
Wicking Assays
The U.S. Department of Health and Human Services recommends against use by first responders of hand-held assays to evaluate and respond to an incident involving unknown powders suspected to be anthrax or other biological agents. HHS Statement Issued July 2002
This statement has not been retracted
Critical Thinking
There is a plethora of biothreat agent rapid detection tools for first responders. However, definitive identification of a biothreat agent must be performed by an authorized laboratory (i.e., CDC Laboratory Response Network). What factors should response organization consider before they utilize these rapid tools for screening samples in the field?
Avoid
Avoid the hazard/contamination/injury
What do I stay away from?
What actions must responders and receivers take to avoid liquids, powders, clouds, or vapors that are potentially harmful to them?
Time, distance, and shielding (TDS) = avoiding exposure time to the threat, putting distance between people and the threat, and shielding with protective equipment or barriers.
TDS is often applied for radiological hazards, but it has merit also with biological materials, assuming one is aware of the release site.
Image courtesy of Department of Defense
Isolate
Isolate the hazard area
Whom do I protect?
What actions will be necessary for responders and receivers to isolate or reduce exposure to contamination or threat; attempt to remove other people who may be in the contaminated area, and to keep people from going into the contaminated area?
Critical Thinking
What should a responder, or any individual, do when recognizing that something is suspicious or hazardous?
Notify
Notify the appropriate support
Whom do I call?
What actions will be needed to notify the proper authorities and agencies, giving them as much information as possible about the event?
State Bioterrorism Coordinator
Local law enforcement
FBI WMD Coordinator
Critical Thinking
Consider the use of isolation and protection zones outlined in the Emergency Response Guidebook (ERG; U.S. Department of Transportation, 2012) in relation to a biological agent release. Are the distances specified in the guidebook practical for use by an incident commander? What environmental conditions could affect those distances?
Chapter Summary
First responders and first receivers need to be trained and properly equipped to perform their duties in a hazardous environment
RAIN is a valuable concept
Key is Recognition - All other actions related to life and safety depend on this
No field test for biothreat organisms has been approved for responder use by the Department of Health and Human Services
Don’t bring bad samples to a good test!
Know how to avoid the hazard, isolate it to protect others and notify proper authorities
Discussion Questions
In what way(s) are we likely to recognize the next big act of bioterrorism?
Responders are called to a “white powder” incident at a high-rise office building. What reliable tools do they have to determine if the suspicious substance contains a biothreat agent?
How important is it to take a “good sample”?
What guidance is out there for biological sampling for responders to follow? Conduct an Internet search to determine if there is one method for sampling powders from nonporous surfaces.
Discuss some of the signs and clues that responders might encounter at the site of a suspected WMD event involving biological agents.
What field tools do responders have to detect biological agents? How practical and accurate are they? Has DHS approved them for use in the field?
What are the implications of a false negative field test result?
