Bioterrorism Readiness Plan

Shands Hospital at the University of Florida

2001

Tokyo Train Station

Aerial view of anthrax production facility

Where and when will bioterrorism hit next?

Biological Weapons?????

Bioterrorism Readiness Planning Subcommittee

Sub committee of Infection Prevention and Control Committee

Chair: Kenneth Rand, MD Multidisciplinary Membership

Multidisciplinary Membership

Infection Control Staff Hospital Epidemiologist Physicians

• Infectious Disease Physicians

• Emergency Medicine Chief and other ER Physicians

• Surgeons

Emergency Department Nurse Manager

Safety Director

Public Relations Respiratory Care Laboratory Facilities Operations Public Health

Administrator & other agencies

Materials Management Administration

Bioterrorism Readiness Plan Purpose

To be a: Reference on bioterrorism A practical and realistic institutional response for

a real or suspected bioterrorism attack Plan that incorporates local and state health

agencies recommendations A branch of existing disaster preparedness and

other emergency plans

Bioterrorism Readiness Plan Components

Infection Control Activities Laboratory Policies Public Inquiry Disease Specific Information Appendix

FBI Field Offices Telephone Directory of State and Territorial

Public Health Directors Relevant Websites

Indications of a Possible Bioterrorism Event

Unusual illness in a population Large number of ill persons with similar disease Large numbers of cases of unexplained diseases or death Higher morbidity or mortality in association with a

common disease or syndrome Single case of unusual agent No illness in persons not exposed to common ventilation

system Threat received indicating exposure

Bioterrorism Readiness PlanBasic Premises

In a case of suspected/real bioterrorism related event or outbreak All personnel are responsible for immediately

reporting suspected event. The Shands Disaster Plan shall be activated in

conjunction with this Bioterrorism Readiness Plan.

Bioterrorism Readiness Plan Authority to rapidly implement prevention and control measures

Administration Director On Call

Infection Prevention and Control Hospital Epidemiologist Chairman Director or designee

Safety and Security Director or designee

Bioterrorism Readiness PlanCommunication Network

IndividualShands

Operator

Infection Control & Safety and Security

Director-On-Call

Public Health

Local and State Authorities

( EMS, Police, Fire Departments)

FBI

CDC

Administration

DEPTS

Public Relations

Maximum Containment Lab

Bioterrorism Readiness Plan Staff Education

Initial special program to introduce plan Video tape and module

Ongoing education incorporated into orientation and annual Infection Control and Safety programs

Bioterrorism Preparedness Drills

Bioterrorism Readiness PlanSection I: General Recommendation for any Suspected Event

Reporting Requirements and Contact Information Internal External

Potential Agents Syndrome Based Epidemiologic Features

Patient, Visitor and Public Information Pharmacy

Bioterrorism Readiness PlanSection I: General Recommendation for any Suspected Event: Infection Control Practices

Isolation Patient Placement Patient Transport Cleaning, Disinfection and Sterilization Discharge Management Post-mortem Care Post Exposure Management

Decontamination of Patients and Environment Prophylaxis and post-exposure management Triage Psychological Aspects of Bioterrorism

Bioterrorism Readiness PlanSection I: General Recommendation for any Suspected Event: Infection Control Practices

Laboratory Support and Confirmation Obtaining diagnostic samples Criteria for processing Transportation of clinical specimens Management and handling of criminal investigation

specimens

Bioterrorism Readiness PlanSection II: Agent Specific Recommendations

Anthrax Botulinum Toxin Plague Smallpox Ricin

Anthrax

Anthrax Transmission:

Inhalation Ingestion Skin contact

Associated with infected animals such as sheep, goats, and cattle (Woolsorter’s disease)

No person to person transmission occurs from patients with respiratory disease caused by anthrax

Direct exposure to cutaneous anthrax lesions may result in secondary cutaneous infections

Anthrax: Mode of Transmission for Bioterrorism

Spore is durable Delivered as an aerosol= inhale spores Ingestion of contaminated food Cutaneous contact with spores or spore-

contaminated material

Anthrax time curve after incident

InhalationAnthrax

Incubation Period Range 1 day to 8 weeks (average 5 days)

Period of Communicability A person infected with the respiratory form of

anthrax can not spread it to others.

AnthraxClinical Features

Pulmonary

• Non-specific flu-like symptoms

• 2-4 days after symptoms

– Abrupt onset of respiratory failureWidened mediastinum on chest x-ray

• High mortality almost 100% if treatment initiated after onset of respiratory symptoms

AnthraxPreventive Measures

Standard Precautions Antibiotic Therapy

Ciprofloxacin Levofloxacin Ofloxacin Doxycycline Amoxicillin for exposed children

Vaccination

Botulism

Botulism

Clostridium botulism Present in soil and marine sediment

Foodborne botulism most common disease Inhalation botulism may also occur

BotulismClinical Features

GI symptoms for food borne disease Responsive patient with absence of feverBlurred visionSymmetric ( on both sides) descending

weakness and paralysisRespiratory failure- inability to breathe

Botulism: Mode of Transmission

Mode of Transmission Ingestion of toxin-contaminated food Aerosolization of toxin

Incubation Period Neurologic symptoms from food borne botulism

begin 12-36 hours after ingestion Neurologic symptoms of inhalation botulism begin

24-72 hours after aerosol exposure

Not transmitted person to person

Botulism: Exposure Management

Preventative Measures Vaccine

Standard Precautions Prophylaxis and Post exposure immunization

Botulinum antitoxin Patients may require mechanical ventilation

Plague

Causative agent:

Yersinia pestis, a gram-negative bacillus usually zoonotic disease of rodents usually transmitted by infected fleas

• Bubonic plague - Lymph system infection

• Septicemia plague - Bloodstream infection

Bioterrorism exposure are expected to be airborne resulting in a pulmonary variant, pneumonic plague - Respiratory Infection

Life cycle of plague

PlagueClinical Features

Pneumonic Plague Fever, cough, chest painHemoptysis (Bloody sputum)

Bubonic Plague - skin and tissue disease form

Plague

Transmission Normally from an infected rodent to man by infected flea Bioterrorism-related = dispersion of an aerosol Person to person transmission of pneumonic plague is possible

via large aerosol droplets Communicability

Via Productive cough Droplet Precautions until 72 hours after initiation of effective

antimicrobial therapy Incubation: 2-8 days due to fleaborne disease or 1-3 days for

pulmonary exposure

PlaguePreventive Measures

Droplet Precautions Private Room or put cases in together in a

room(cohort), doors closed but no special ventilation needed

Maintain isolation for 72 hours after antibiotics are given

Vaccine not practical since requires multiple doses over several weeks and post exposure immunity has no utility

Post exposure Prophylaxis - See your doctor

Last known person with smallpox in the world

Public Health Quarantine Sign

Smallpox

Causative agent:Variola virus Eradicated clinical smallpox from world

Two WHO labs store virus Severe morbidity if released into non-immune

population Single case is considered a public health emergency

Can be aerosolized or contaminated items can be used to deploy this virus as a biological warfare agent

Smallpox in Child

SmallpoxClinical Features

Acute viral illness with severe skin lesions Can have fever and aches for 2-4 days before rash

Rash most prominent on face and extremities Rash scabs in 1-2 weeks

Variola rash occurs all at once in contrast to varicella’s “crops” of lesions

Smallpox

Mode of transmission:

airborne, droplet and contact.

Person to person spread Incubation Period = 7-17 days (ave. = 12 days) Period of Communicability = Variola becomes

infectious at onset of rash and continues to be infectious until their scabs fall off which is approximately 3 weeks

SmallpoxPreventive Measures

STRICT ISOLATION Negative air pressure room, doors must remain

closed, verify ventilation Mask, gown and glove for entry into room Limit transport Handle all surfaces and supplies as

contaminated

SmallpoxPreventive Measures

Smallpox vaccine Vaccinia virus is used for vaccine(not smallpox

virus) Does not confer lifelong immunity Must be given within 7 days post exposure to

be effective

Ricin

Causative agent:

A biological toxin (poison) derived from the castor plant and castor oil.

Exposure routes: inhalation (breathe it in) percutaneous (injection or contact with skin,

eyes, and mucous membranes) ingestion (eat it!)

RicinClinical Features

Weakness, fever, cough and fluid in lungs occur within 18 hours after inhalation(breathe in toxin) exposure

Progresses to severe breathing trouble and then death from hypoxemia within 36-72 hours

Diagnosis: signs and symptoms found in large number of a geographically clustered group and/or lab tests

Ricin

Treatment:

support patient, manage symptoms and keep comfortable

Prophylaxis: None available Prevention

Protective mask to prevent inhalation Standard Precautions

• Weak hypochlorite solution (0.1% sodium hypochlorite) and/or soap and water can decontaminate skin surfaces

Steps in Preparing for a Bioterrorism Event

Know how to locate policy

Review Executive Summary of Plan for inclusion in Disaster Manual

Access Specific Departmental Policies ER Pharmacy

Use Information Sheets for Patients and Public

Learn about bioterrorism by completing module. Get your questions

answered by experts

Coordinate plan with state and local authorities