Bioterrorism Response Plan

Bioterrorism Response Plan

Plan Prepared By:

APIC Bioterrorism Task Force

Judith F. English, Mae Y. Cundiff, John D. Malone & Jeanne A Pfeiffer

CDC Hospital Infections Program Bioterrorism Working Group

Michael Bell, Lynn Steele, & J. Michael Miller

The APIC/ CDC template was revised and adapted for Spartanburg Regional Healthcare

Adoption date: October 2001

Revision Date / Review Date
February 2003 / March 2005, May 2006, Sept 2007
December 2004 / September 2009

Table of Contents

Overview of Infection Control Activities / 3-8
Laboratory Issues / 8
Disease Specific Information / 12-17
Anthrax / 12-13
Plague / 14
Smallpox / 15
Botulism / 17

Internal Contacts

SRMCNursing Administration / Office 864-560-6380 After hours, page - 1153
SHRC Nursing Administration / 864- 253-1150
EC Group Emergency page / 864-620-5388
SRMCSecurity / 864-560-6333
SHRC Security / 864-809-1905
SRMCSafetyDirector / 864-253-2663
SHRC Support Services Coordinator / 864-809-1836
SRMC Infection Prevention / Page through hospital operator
864-560-6000
SHRC Infection Prevention / 864-560-3232
Epidemiologist / Page Infectious Disease Physician on call through Hospital Operator – 864-560-6000
Administration/ Public Affairs SRMC/ SHRC / Page through hospital operator – 864-560-6000
Administrator on Call / 864-253-7858

External Contact

Local Health Department
After hours page / 864-596-3337
864-620-2587
State Health Department / 803-898-3432
FBI Field Office / 864-948-1497
Bioterrorism Emergency Number / 770-488-7100
CDCHospital Infections Program / 404-639-3311

Contact Information

At SRHS we realize that healthcare facilities may be the initial site of recognition and response to bioterrorism events. If a bioterrorism event is suspected, the Bioterrorism Call Tree will be activated at the point of suspicion. The Biologic group page includes those areas that are REDand italicized.

Bioterrorism Event Call Tree

Section I: General Categorical Recommendations for Any Suspected Bioterrorism Event

Potential Agents:

Four diseases with recognized bioterrorism potential (anthrax, botulism, plague, and smallpox) and the agents responsible for them are described in Section II of this document. There are other agents with the potential to be used in bioterrorism events such as tularemia, brucellosis, Q fever, viral hemorrhagic fevers, and viral encephalitis. Information on these agents may be obtained from the Infection Control Department.

Detection of Outbreaks Caused by Agents of Bioterrorism:

Bioterrorism may occur as covert events, in which persons are unknowingly exposed and an outbreak is suspected only upon recognition of unusual disease clusters or symptoms. Bioterrorism may also occur as announced events, in which persons are warned that an exposure has occurred. The possibility of such events should be confirmed or ruled out with assistance from the FBI and state health officials.

Covert Events- Syndrome based criteria:

Because of the rapid progression to illness and potential for dissemination of some of these agents, it may be impractical to await diagnostic laboratory confirmation. Instead, it will be necessary to initiate a response based on the recognition of high-risk syndromes. Each of the agent specific plans in Section II includes a syndrome description that should alert healthcare workers to the possibility of a bioterrorism-related outbreak. Healthcare providers should be alert to the following illnesses or clinical presentations that might signal an unusual disease outbreak.

▪Widened mediastinum

▪Hemorrhagic gastroenteritis

▪Localized lesions potentially with black eschar

▪Gram negative pneumonia with hemoptysis

▪Vesicular pustular rash starting on face and hands with lesions at the same stage of development.

▪Unusual presentation of neurological illnesses

Epidemiologic principles must be used to assess whether a patient’s presentation is typical of an endemic disease or is an unusual event that should raise concern. Features that should alert healthcare providers to the possibility of a bioterrorism event related outbreak include:

▪A rapidly increasing disease incidence (within hours or days) in a normally healthy population.

▪An unusual increase in the number of people seeking care, especially with fever, respiratory, gastrointestinal complaints, encephalitis, meningitis, neuromuscular illness or bleeding disorders.

▪An endemic disease rapidly emerging at an uncharacteristic time or in an unusual pattern.

▪Lower attack rate among people who had been indoors, especially in areas with filtered air or closed ventilation systems, compared with people who had been outdoors.

▪Clusters of patients arriving from a single locale

▪Large numbers of rapidly fatal cases

If a patient care area identifies one of the associated syndromes or one of the epidemiologic features, Infection Control must be notified. Infection Control in consult with the Infectious Disease Physician will decide whether or not to activate the Biologic Group page. Refer to page 3.

Concurrent Surveillance:

Physicians in the system have been alerted to the syndromes caused by potential bioterrorism agents, and Infection Control monitors daily admissions for trends.

Announced Events:

Most announced events have been determined to be hoaxes, nevertheless SRHS has a response plan to minimize exposure to staff, patients, and visitors until a risk assessment can be completed. Attachment A provides an algorithm for action steps to be taken wherever the patient may present. The key management principles are to contain the exposure, determine if a true exposure occurred, differentiate between biologic and chemical agent, and mobilize appropriate resources.

InfectionPrevention Practices for Patient Management

The management of patients following suspected or confirmed bioterrorism events must be well organized and rehearsed. Strong leadership and effective communication are paramount.

Isolation Precautions

All patients in healthcare facilities, including symptomatic patients with suspected or confirmed bioterrorism-related illnesses, should be managed utilizing standard precautions. For certain disease or syndromes (smallpox and pneumonic plague), additional precautions are necessary to reduce the likelihood of transmission. See Section II for specific disease requirements.

Patient Placement

When the number of patients presenting to the facility is too large to allow routine triage and isolation strategies (if required), it will be necessary to apply practical alternatives. There may be a need to cohort patients who present with similar syndromes or present as a result of a suspected bioterrorism attack. This involves grouping affected patients into a designated section of the EmergencyCenter, or setting up a response center at a separate site. During a large-scale event such cohorting will allow more control over the situation. The designated site in a bioterrorism event in which administration deems an alternative site necessary will be the Therapy Area off of the main lobby.This area will be utilized for triage and short-term processing of patients. If a large-scale event occurs the command center may activate the External Disaster plan.

In the event of a large-scale smallpox outbreak, the External Disaster Plan will be activated. The following plans will be utilized based on the number of patients involved.

Plan A: The negative pressure rooms at SRMC will be utilized initially.

Plan B: If SRMC’S capacity to isolate cases in negative pressure rooms is exceeded, Infectious Disease, Infection Control, and SRHS Administration will designate SpartanburgHospital for Restorative Care (SHRC) for Smallpox patients. This involves KEY parts of the Disaster plan:

All possible discharges will be facilitated
Elective procedures will be halted
Patients that could not be discharged from SHRC would be transferred to available beds at SRMC.

Plan C: If the number of cases exceeds the capability of SHRC and other facilities for airborne isolation patients are not available, some patients may be discharged for home care.

Discharge Management

Ideally, patients with bioterrorism-related infections will not be discharged from the facility until they are deemed non-infectious. However, home-care instructions will be provided in the event that large numbers of persons exposed may preclude admission of all infected patients.

Post-mortem Care

Pathology departments and clinical laboratories should be informed of a potentially infectious outbreak prior to submitting any specimens for examination or disposal. All autopsies should be performed carefully using all personal protective equipment and standards of practice in accordance with Standard Precautions.

Key components of the External Disaster plan that would be utilized:

Element of Disaster Plan / Department Responsible
Establishing network of communication lines of authority required to coordinate on-site care / Administration
Cancellation of non-emergency procedures and services / Administration
Identifying sources able to supply available vaccine, immune globulin, antibiotics, and botulinum anti-toxin (with assistance from local and state health departments) / Pharmacy/Local and State Health Departments
Discharge planning of patient / Health Management
Distribution of discharge instructions for patients determined to be non-contagious or in need of additional follow-up / Health Management/ Infection Control/ Local and State Health Department
Determining availability and sources for additional medical equipment and supplies that may be needed for urgent large-scale events (Vents) / Materials/ Respiratory Therapy
Planning for re-allocation of scarce equipment in the event of a large-scale event (e.g., duration of ventilator support of terminally ill individuals) / Medical Ethics Committee
Dealing with a sudden increase of cadaver / Pathology/Safety
Managing the psychological needs of patients, visitors and employees / Needs development in the External Disaster plan. Should involve Human Resources, Chaplains office, and Mental Health professionals.
Media Relations / Administration/ Public Relations/Infection Control/ Infectious Disease

Post-Exposure Management

1. Decontamination of Patients and Environment

The need for decontamination depends on the suspected exposure and in most cases will not be necessary. The goal of decontamination after a potential exposure to a bioterrorism agent is to reduce the extent of external contamination of the patient and contain the contamination to prevent further spread. Decontamination should only be considered in instances of visible contamination. In the event that persons arrive at the facility obviously contaminated with an unknown agent, their clothes should be removed and contained in a sealable plastic bag with identifying information. These items may need to be turned over to local authorities for testing. All personnel assisting in these activities will wear gloves, gown and an N95 respirator. Care should be used in dealing with contaminated articles to limit the amount of re-aerosolization of the agent. Once the individual’s clothes have been removed they should be instructed to shower with soap and water. If the agent is unknown and potentially a chemical agent the procedure for chemical decontamination in the Disaster plan should be followed. Potentially harmful practices, such as bathing patients with bleach solutions, are unnecessary and should be avoided. Decontamination requirements for specific potential agents of bioterrorism are listed in Section II.

2. Prophylaxis and post-exposure immunization

Recommendations for prophylaxis are subject to change. Current recommendations for post-exposure prophylaxis and immunizations are provided in Section II for relevant potential bioterrorism agents. However, up-to-date recommendations should be obtained in consultation with local and state health departments and CDC. All employees that are exposed to an infectious agent will complete a SREO (supervisory report of employee occurrence). If multiple personnel in the same department are involved, one form can be completed and forwarded to EOHS (Employee Occupational Health Services). EOHS will follow employees post exposure.

3. Psychological aspects of bioterrorism

Following a bioterrorism-related event, fear and panic can be expected form both patients and healthcare providers. Psychological responses following a bioterrorism event may include horror, anger, and panic, unrealistic concerns about infection, paranoia, social isolation, or demoralization. Infection Control will provide information on involved agents. Refer to the External Disaster Plan for details.

Needs development

Laboratory Support and Confirmation

SRHS will work with local, state and federal public health services to tailor diagnostic strategies to specific events. Currently the Bioterrorism Emergency Number at CDC is at the Emergency Response Office, NCEH, 770-488-7100.

1. Obtaining diagnostic samples

See specific recommendations for diagnostic sampling for each agent. Sampling should be performed in accordance with Standard Precautions. In all cases of suspected bioterrorism, collect an acute phase serum sample to be analyzed, aliquotted, and saved for comparison to a later convalescent serum sample.

2. Transport requirements

Specimen packaging and transport must be coordinated with local and state health departments, and the FBI. A chain of custody document should accompany the specimen from the moment of collection. For specific instructions, contact the Bioterrorism Emergency Number at the CDC Emergency Response Office, 770-488-7100.

Patient, Visitor and Public Information

Clear, consistent, understandable information should be provided to patients, visitors, and the public. During bioterrorism-related outbreaks, visitors may be limited. Education and appropriate personal protective equipment if necessary will be issued to immediate family members of hospitalized patients. Infection Control and Infectious Disease Physicians will work with Administration and Public Relations to keep the media informed.

Reference List

Anonymous. Bioterrorism alleging use of anthrax and interim guidelines for management -- United States, 1998. MMWR Morb Mortal Wkly Rep 1999;48:69-74.
Noah DL, Sovel AL, Ostroff SM, Kildew JA. Biological warfare training: infectious disease outbreak differentiation criteria. Mil Med 1998;163:198-201.
DOD DFFUaE. NBC Domestic preparedness response workbook.1998.
Simon JD. Biological terrorism. JAMA 1997;278:428-30.
California Department of Health Services. CaliforniaHospital Bioterrorism Response Planning Guide. 2001.
Centers for Disease Control and Prevention, the Hospital Infection Control Practices Advisory Committee (HICPAC). Recommendations for isolation precautions in hospitals. Am J Infect Control 1996;24:24-52.
American public health association. Control of communicable diseases in man. WashingtonDC:American public health association; 1995.
Tucker JB. National health and medical services response to incidents of chemical and biological terrorism. JAMA 1997;278:362-8.
Holloway HC, Norwood AE, Fullerton CS, Engel CC Jr, Ursano RJ. The threat of biological weapons. Prophylaxis and mitigation of psychological and social consequences. JAMA 1997;278:425-7.
Pile JC, Malone JD, Eitzen EM, Friedlander AM. Anthrax as a potential biological warfare agent. Arch Intern Med 1998;158:429-34.
Franz D, Jahrling PB, Friedlander AM, McClain DJ, Hoover DL, Bryne WR, et al. Clinical recognition and management of patients exposed to biological warfare agents. JAMA 1997;278:399-411.
U.S.Army medical research institute of infectious diseases. Medical management of biological casualties. Fort Detrick:USAMRIID; 1998.
Anonymous. Drugs and vaccines against biological weapons. Med Lett Drugs Ther 1999;41:15-6.
Shapiro RL, Hatheway C, Becher J, Swerdlow DL. Botulism surveillance and emergency response. JAMA 1997;278:433-5.
Shapiro RL, Hatheway C, Swerdlow DL. Botulism in the United States: A clinical and epidemiological review. Arch Intern Med 1998;129:221-8.
Federal Register. Respiratory protective devices; final rules and notice. 1995.

Resources for Additional Information

Websites Relevant to Bioterrorism Readiness

Other sources of information:

USAMRIID 301/619-2833

BIOPORT (producers of anthrax vaccine) 517/327-1500

US PUBLIC HEALTH SERVICE 1-800-872-6367

DOMESTIC PREPAREDNESS INFORMATION LINE 1-800-368-6498

NATIONAL RESPONSE CENTER1-800-424-8802

CAUSATIVE AGENT / INCUBATION PERIOD / SYMPTOMS / INFECTION CONTROL MANAGEMENT / POST EXPOSURE MANAGEMENT
Bacillus anthracis / 1 day to 8 weeks / Pulmonary

Non-specific flu-like symptoms initially.

Possible brief interim improvement

2-4 days after initial symptoms, abrupt onset of respiratory failure and hemodynamic collapse, possible thoracic edema and a widened mediastinum on chest x-ray.

Gram-positive bacilli on blood culture, usually after 2-3 days.
Treatable in early stage. Mortality remains extremely high despite antibiotic treatment if it is initiated after onset of respiratory symptoms.

Cutaneous

Local skin involvement after direct contact with spores

Commonly on the head, forearms or hands.
Localized itching followed by a papular lesion that turns vesicular, and within 2-6 days develops into a depressed black eschar.

Usually non-fatal if treated with antibiotics.
Gastro-intestinal

Abdominal pain, nausea, vomiting, and fever following ingestion of contaminated food, usually meat.
Bloody diarrhea, hematemesis

Gram-positive bacilli on blood culture, usually after 2-3 days of illness.

Usually fatal after progression to toxemia & sepsis. / Mode of Transmission:
The spore form of B. anthracis is durable. The modes of transmission for anthrax include:

Inhalation of spores.
Cutaneous contact with spores or.
Ingestion of contaminated food.

Isolation Management: Standard Precautions
Immunization Recommendations: Routinely administered to military personnel. Routine vaccination of civilians not recommended. / Decontamination of patient / environment:
The risk for re-aerosolization of B. anthracis spores appears to be low. In situations involving the threat of gross exposure to B. anthracis spores, cleansing of skin and potentially contaminated items will reduce the risk for cutaneous and gastrointestinal forms of disease.
Post exposure prophylaxis:
No post exposure prophylaxis is recommended for healthcare workers exposed to infected individual patients. Only exposed to the agent. Seek Infectious Disease Consult.

Anthrax – Home Care Instructions

In the event of an intentional release of the germ that causes anthrax, many people may require hospitalization within a few days. Hospitals may become overcrowded and it may become necessary for many sick people to be cared for in their home by relatives or friends. The following information may be helpful in providing care to sick persons at home.

Wash your hands with soap and water before you eat or drink, after using the bathroom and after contact with the sick person.
Wear gloves (vinyl or latex) when you have contact with the sick person’s blood and other body fluids (urine, feces, vomit, wound drainage, mucous or saliva). Wash your hands after removing the gloves. If gloves are not available, wash your hands with soap and water after contact with the sick person’s blood and other body fluids.
Wash the sick person’s hands after using the bathroom, before eating or drinking and after contact with pets.
If an antibiotic is recommended, give it exactly as prescribed by the doctor or nurse. If an allergic reaction develops, seek medical advice immediately.
Take the person’s temperature at least twice a day. If the temperature goes above 100° F, give Tylenol® (if not allergic) or other medicine such as Motrin® or Advil®. Follow the instructions on the package insert. If the temperature is not controlled by the medicine, call your health care provider (doctor or nurse) or take the person to the nearest designated emergency center or hospital.
If the person is having trouble breathing, go immediately to the nearest designated emergency center or hospital.
Give the person plenty of fluids such as water or juice. Allow the person to eat solid food as tolerated.
Change the sick person’s clothes and bed linens frequently especially if soiled with blood or other body fluids.
Wash soiled clothes and bed linens in warm water using any commercial laundry product.
Disinfect the bathroom and kitchen with a disinfectant such as Lysol® every day or when surfaces become soiled with blood or other body fluids.
As a caregiver, you must take care of yourself. Get plenty of rest, drink fluids frequently, and eat a healthy diet. Even if you are not taking an antibiotic, take your temperature in the morning and afternoon for 3 weeks. If you develop a fever above 100° F or if you have shortness or breath, seek medical attention immediately.