BENCANA BIOLOGI

(Biological Disaster)
Ns. Jon Hafan S, M.Kep., Sp.Kep.MB
 DEFINISI
 Biological
disaster merupakan masuknya
organisme berbahaya yang terdampak
pada sekumpulan orang (masyarakat)
yang rentan sehingga dapat terjadi
penyebaran infeksi dengan cepat di
lingkungan, wilayah maupun dari negara
satu ke negara yang lain (Nasional
Disaster Management Authority, 2008).
 Source of FDM course

Smallpox

Variola virus
 SEJARAH Smallpox
 Smallpox ditemukan pertama
kali padaabad ke 3 Sebelum
masehi pada kerajaan mesir
yaitu raja Pharaoh Ramses V
 Terakhir kasus ditemukan pada
tahun 1977 di Somalia
 Rata-rata kasus kematian yang
tinggi sekitar (30%) case fatality
rate
 Penyebab 500 juta orang
meninggal pada abad 20
 Proses vaksinasi rutin sudah
berlangsung pada tahun 1972 di
US
 Sebagai senjata biologis pada
perang dunia ke 2 dan teroris
 What is Smallpox?
 Smallpox adalah salah
satu penyakit yang
sangat menular, yang
ditularkan dari satu orang
ke orang lain dan dapat
mengakibatkan kematian.
 Penyebab penyakit ini
adalah virus variola
 3 dari 10 pasien yang
menderita penyakit ini
meninggal.
(Centers for Disease Control and
Prevention/CDC, 2016)
 Smallpox
 Smallpox disebabkan oleh variola virus yang
merupakan genus orthopoxvirus.
 Masa Inkubaksi: 7 sampai 19 hari (rata-rata12 hari)

 Muncul bercak erythematous nonspesifik pada hari

ke 2 dan 3, yang berkembang menjadi kegagalan
multisistem sampai kematian.

 Macular lesions become papular, then pustular,

in crops, appear at same time, in same stage,
more in face and limbs than trunk (contrast to
Varicella)
Contoh lesi pada kulit
How does Smallpox Spread?
BERDASARKAN CDC, (2016) PROSES
PENYEBARAN SMALLPOX:
 AWALNYA, pasien yang menderita smallpox
akan merasakan sakit pada daerah mulut dan
tenggorokan (early rash stage)
 Pada tahap itu, virus dapat menyebar ketika
klien batuk atau bersin dan virus dapat
menempel ke orang lain melalui cara ini
(droplets).
 Virus juga dapat menyebar melalui objek atau
barang yang terkontaminasi dengan cairan yang
bersentuhan langsung dengan pasien seperti:
selimut atau baju.
 Jarang sekali, smallpox menyebar melalui udara
misalkan pada ruangan yang tertutup/ gedung
(airborne route).
 Smallpox can be spread by humans only.
Scientists have no evidence that smallpox
can be spread by insects or animals.
 Smallpox
Day 1
Two to 4 days after
exposure, after the patient
first becomes ill with fever

Only a few raised papules

appear.

It may not be known that

the patient was exposed 2
weeks before, and
smallpox may not be
immediately diagnosed.
 Smallpox
Day 2
On the second day of
rash, more papules
appear.

They differ somewhat in

size, but they all have a
very similar appearance.
 Smallpox
Day 3
The rash is now raised
above the skin surface.

Fluid is accumulating in
the papules forming
vesicles.
 Smallpox
Day 4
The vesicles are more
distinct.

Although they contain

fluid, they feel very firm
to the touch.

They do not collapse

when broken because
the fluid is contained in
many small
compartments.
 Smallpox
Day 5
The pocks are now
called pustules as the
fluid in the vesicles has
become cloudy and
looks like pus.

The patient feels much

more ill, as the fever
rises.
 Smallpox
Day 7
The pocks, although
varying somewhat in size,
all resemble each other in
appearance.

The rash is now so

characteristic that there
should be no mistake in
diagnosis.
 Smallpox
Days 8 and 9

The pustules increase

somewhat in size.

They are firm to the touch

and deeply embedded in
the skin.
 Smallpox
Days 10 to 14
The pustules eventually
dry up and dark scabs
form.

The scabs contain live

smallpox virus. Until all
scabs fall off, the patient
may infect others
World Health Organization.
Smallpox
Review
 Smallpox
Day 20

The scabs have come off.

Light-colored or depigmented
areas are observed.

Over a period of many weeks

the skin gradually returns to its
normal appearance. However,
scars which last for life may
remain on the face.
 Symptoms

 Fever (38°C-40°C)  Occasional vomiting

 Malaise  Rashes

 Head and body aches  Pustules

 Smallpox
Confirming Diagnosis
 Confirmation of smallpox outbreak via
laboratory findings is crucial.

 Prior to collecting specimens, laboratory

workers should have been previously
vaccinated or vaccinated the day of collection.
Standard precautions (gloves/mask) must be
observed.
 Smallpox

 Category A agent:
 High mortality

 Disseminates, transmits easily

 High likelihood of causing widespread panic

 Smallpox
 Prevention: vaccination with Vaccinia
 Unclear how long protection persists
 May also immunize postexposure to Variola

 Isolation
 Measure temp. If 38 degrees C or higher, smallpox infection is
possible.
 Patients are contagious at onset of rash and until scabs separate
(approx. 3 weeks).
 Isolation at home if stable with airborne and contact precautions
 Isolation in hospital with negative pressure rooms and airborne,
contact, and standard precautions
 Smallpox
Postexposure Therapy
 There is no known effective treatment for
smallpox.
 Postexposure vaccination with Vaccinia within 4
days is moderately effective.
 Vaccinia immune globulin (VIG) within 3 days of
exposure for chemoprophylaxis
 Cidofovir has activity against other pox viruses
and in vitro activity against variola virus.
 Currently available supportive care (intensive
care) may reduce mortality.
 Smallpox
Decontamination — Prevention
 It is believed that Variola virus (smallpox) may
behave similarly to Vaccinia virus, and may persist
for as long as 24 hours (or longer under optimal
conditions) if released as an aerosol.

 Decontamination only necessary for overt exposure

with grossly contaminated (e.g., powder) patient

 By the time patients had become ill from a covert

aerosol release of smallpox virus, there would be no
viable smallpox virus in the environment.
 Smallpox
Decontamination — Prevention
 Smallpox infection among personnel who handled
laundry from infected patients is well documented. It
is believed that virus in such material remains viable
for extended periods.

 Special measures need to be taken to ensure that all

bedding and clothing of smallpox patients is
autoclaved or laundered in hot water to which bleach
has been added.
 Smallpox
Decontamination — Prevention

 Disinfectants that are used for standard hospital

infection control, such as hypochlorite and
quaternary ammonia, are effective for cleaning
surfaces possibly contaminated with virus.
 Viral Agents

Viral Hemorrhagic Fevers

 Viral Hemorrhagic Fevers
 Caused by multiple viruses from several different
families
 Greatest threat as bioweapons:
 Lassa fever virus

 Ebola virus

 Marburg virus

 Congo-Crimean hemorrhagic fever virus

 4 South American hemorrhagic fever viruses

 Viral Hemorrhagic Fevers
Agent Transmissible Treatment
 Filoviruses Yes None
 Ebola
 Marburg

 Arenaviruses Yes Ribavirin

 South American
 Hemorrhagic Fevers
 Lassa Fever

 Bunyavirus No Ribavirin
 Rift Valley Fever

 Flaviviruses No None
 Yellow Fever and others
 Viral Hemorrhagic Fevers

 Incubation period: 5 to 10 days

 Abrupt/mendadak onset of fever, myalgia,

headache, followed by nausea and vomiting,
abdominal pain, diarrhea, chest pain, cough,
chest pain, pharyngitis

 Initial conjuctival inspection, hypotension,

flushing, followed by maculopapular rash,
progressing to bleeding (petechiae,
ecchymoses, frank hemorrhage, with neurologic
and pulmonary involvement)
 Viral Hemorrhagic Fevers
Assessment & Management
 Diagnosis: Thrombocytopenia, leukopenia,
proteinuria, hematuria, culture and isolation of virus,
serology, IgM, 4-fold rise in titers
 Care largely supportive
 Treatment of shock and blood product replacement
 Ribavirin effective for some agents
 Prevention of secondary cases of great concern
 Private room

 Contact and airborne precautions

 Viral Hemorrhagic Fevers
Prevention of Secondary Cases

 Strict contact and airborne precautions.

 Face shield, eye protection, surgical mask, and
droplet precautions
 Excreta and contaminated materials should be
autoclaved or treated with hypochlorite or phenolic
disinfectants.
 Victims’ corpses should be cremated or effectively
sealed in leak-proof material and buried promptly.
 Case 1
64-year-old Asian woman
 Day 1: T= 104˚F, diaphoresis, headache,
nausea, myalgias
 Day 2: Vomiting and diarrhea
 Day 3: Admitted for dehydration,
gastroenteritis-elevated
transaminases, PT, PTT
 Days 4-6: Edema, third-spacing of fluids
 Day 7: Rash and conjunctival hemorrhage
develop, diarrhea becomes
bloody
Borio, JAMA, 2002.
Illustrated Health encyclopedia Adam Images
and Content under license from adam.com, Inc
 DENGUE HEMORRHAGIC FEVER IN
INDONESIA
 DHF has ben infecting since 1968.

 The diseases transmitted through Aedes Aegepty & Aedes

albopictus frequently frightens people due to its rapid spread and
harmful power to cause fatal dead.

 DHF morbidity in 2007 raised its peak on January-february, declined

on march, lowest level on September-October.

 Incidence rate, the highest (2007) was in DKI Jakarta, Bali and East
Kalimantan. Case fatality rate, the highest in Papua, North Maluku
and Bengkulu
ENCHEPALITIS
 Alphaviruses: Western, Eastern,
and Venezuelan Encephalitis

 Incubation period: 1 to 6 days

 Sudden onset of fever, with rigors, severe

headache and myalgias in legs and
lumbosacral areas, nausea and vomiting,
diarrhea, confusion and obtundation,
dysphagia, seizures, paresis, ataxia, cranial
nerve palsies
 Alphaviruses: Western, Eastern,
and Venezuelan Encephalitis

 Normally transmitted by mosquitoes

 Highly infectious by aeorsolization and
inhalation, so are therefore suitable agents for
biowarfare
 Occurrence outside known endemic areas
highly suspicious of intentional release
 Multiple subtypes within each category
 Alphaviruses
Assessment and Management
 Striking leukopenia with
lymphopenia, CSF opening
pressure is increased, and cell
counts in hundreds to 1,000
WBC/mm2 (monocytes)
 Virus can be isolated or
detected by PCR from blood,
CSF, or throat washes in
febrile prodromal period; rarely
in encephalitic phase
 Antibody detectable in
second week by ELISA
 Diagnosis by serology
with 4-fold rise in titers
 Airborne precautions for
inhalation, biowarfare,
exposure, as well as
standard precautions
 No specific therapy;
supportive
 Vaccine available:
Venezuelan equine
encephalitis
ISOLATION, EARLY TREATMENT
 Standard Precautions Only
No Isolation Required
 Botulinum toxin
 Anthrax
 Tularemia (laboratory hazard)
 Q Fever: Coxiella burnettii
 Alphaviruses
 Western, Eastern, and Venezuelan

Encephalitis
 Ricin
 Staphylococcal enterotoxin B
 Isolation Requirements

Agent Type of Isolation

Plague Droplet
Smallpox Airborne,Contact
VHFs Airborne, Contact
T-2 Mycotoxins Contact
 Agents Requiring Early
Specific Treatment
Agent Treatment
Anthrax Doxycycline
Ciprofloxacin
Clindamycin

Plague Streptomycin
Gentamicin

Tularemia Streptomycin or
Gentamicin

Botulinum toxin Trivalent antitoxin

 Agents Requiring Early
Specific Treatment
Agent Treatment

Smallpox Cidofovir

VH Fevers IV Ribavirin
 Prophylaxis for Those Exposed
to Infected Patients
Agent Prophylaxis

Plague Doxycycline or ciprofloxacin

If fever, IV streptomycin or
gentamicin

Smallpox Vaccine

VH Fevers Surveillance, monitor temp.

If fever, IV ribavirin
 Education
 Knowing how to protect oneself reduces fear and
panic.

 A properly trained staff member is more likely to

feel safe and to come to work.

 All hospital staff must be educated:

 Physicians, nurses, therapists, laboratory staff,

laundry handlers, housekeepers, mortuary staff,

pathology staff, others.
 Development of Protocols
 Building Engineering:
 Can extra negative pressure rooms or wards be

created if need be?

 Capacity to support mechanical ventilation (wall

oxygen, electrical outlets)

 Clinical Laboratory:
 Where and how will routine labs and blood cultures be

processed?

 Infection Control:
 Isolation procedures

 Postexposure prophylaxis
 Strategic National Stockpile
 Phase 1: “12-hour Push Pack”
 Arrives in 12 hours

 Medical material for response to a broad range of

threats: antibiotics, antitoxins, vaccines, and isolation

supplies
 Distribution by local officials may take several days.

 Phase 2:
 Agent-specific materials and treatments

 Ventilators

 Hospitals must stockpile several days of materials

and medicine.
Disaster Management of Biological Attacks

 Comparison to other disasters

 Case scenarios
 Advance planning critical:
 Education and protocols

 Supplies

 Isolation and containment

 Treatment

 Prophylaxis
 Summary
 Prepare now
 Educate
 Isolation - most conservative approach
 CDC Emergency Response Hotline:
770-488-7100
 Get the most up-to-date information
 All treatment and prophylaxis regimens are

subject to change.
 REFERENCE
https://www.cdc.gov.html
Nasional Disaster Management Authority,
2008. National Disaster Management
Guidelines; Management Of Biological
Disasters. Government Of India.
THANKS