Download Protocol for dealing with suspected anthrax in Ireland

Protocol for dealing with suspected
anthrax in Ireland
Immediate steps to be taken in the event of the discovery of a suspect package

Call Gardai (999 or 112).

Gardai to tightly seal off site and to carry out preliminary investigation

If suspicious, Gardai to contact
-Army
-Fire and Ambulance Services and
-Directors of Public Health

Fire and ambulance services (decontamination units) to carry out
decontamination of exposed individuals on site using mobile units.

Army to carry out decontamination of environment if required. Army will
arrange transport of all clinical and environmental specimens to Public Health
Laboratory in Cherry Orchard Hospital.

Director of Public Health to get a list of exposed individuals, to ensure that the
correct clinical specimens are taken and to ensure that appropriate
chemoprophylaxis is given.
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1. Description of Agent/ Syndrome
a. Aetiology
Anthrax is an acute infectious disease caused by Bacillus anthracis, a spore forming,
gram-positive bacillus. Associated disease occurs most frequently in animals which
acquire spores through ingestion of contaminated soil. Humans can become infected
through skin contact, ingestion, or inhalation of B. anthracis spores from infected
animals or animal products or through bioterrorism. Person-to-person transmission
of inhalational disease does not occur. Direct exposure to vesicle secretions of
cutaneous anthrax lesions may result in secondary cutaneous infection.
b. Clinical features
Human anthrax infection can occur in three forms: pulmonary, cutaneous, or
gastrointestinal, depending on the route of exposure. Of these forms, pulmonary
anthrax is associated with bioterrorism exposure to aerosolised spores. Clinical
features for each form of anthrax include:
Pulmonary
Non-specific prodrome of flu-like symptoms follows inhalation of infectious
spores.
Possible brief interim improvement.
Two to four days after initial symptoms, abrupt onset of respiratory failure and
hemodynamic collapse, possibly accompanied by thoracic edema and a widened
mediastinum on chest radiograph suggestive of mediastinal lymphadenopathy and
hemorrhagic mediastinitis.
Gram-positive bacilli on blood culture, usually after the first two or three days of
illness.
Treatable in early prodromal 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 or bacilli.
Commonly seen 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 diarrhoea, hematemesis.
Gram-positive bacilli on blood culture, usually after the first two or three days of
illness.
Usually fatal after progression to toxemia and sepsis.
c. Modes of transmission
The spore form of B. anthracis is durable. As a bioterrorism agent, it could be
delivered as an aerosol. The modes of transmission for anthrax include:
 Inhalation of spores.
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

Cutaneous contact with spores or spore-contaminated materials.
Ingestion of contaminated food.
d. Incubation period
The incubation period following exposure to B. anthracis ranges from 1 day to 8
weeks (average 5 days), depending on the exposure route and dose:
2-60 days following pulmonary exposure.
1-7 days following cutaneous exposure.
1-7 days following ingestion.
e. Period of communicability
Transmission of anthrax infections from person to person is unlikely. Airborne
transmission does not occur, but direct contact with skin lesions may result in
cutaneous infection.
2. Preventive Measures
Vaccination against anthrax is not recommended for the general public to prevent
disease.
3. Infection control practices for management of patients with
anthrax
Standard precautions are used for the care of patients with anthrax. (Standard
precautions include the routine use of gloves for contact with nonintact skin,
including rashes and skin lesions).
Patient placement
Private room placement for patients with anthrax is not necessary. Airborne
transmission of anthrax does not occur. Skin lesions may be infectious, but this
requires direct skin contact.
Patient transport
Standard precautions should be used for transport and movement of patients with B.
anthracis infections.
Cleaning, disinfection, and sterilisation of equipment and environment
Principles of standard precautions should be generally applied for the management of
patient-care equipment and for environmental control.
Hypochlorite is the disinfectant of first choice with hydrogen peroxide, peracetic
acid or glutaraldehyde as alternatives. Spores require steam sterilisation,
autoclaving or burning to effectively disinfect. Fumigation and chemical
disinfection can be used for valuable equipment.
Post-mortem care
Standard precautions should be used for post-mortem care. (Standard precautions
include wearing appropriate personal protective equipment, including masks and eye
protection, when generation of aerosols or splatter of body fluids is anticipated).Full
post mortems however are not recommended in cases of anthrax.
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4. Post Exposure Management
a. Decontamination of patients (To be carried out by the fire brigade and
ambulance services)
The risk for re-aerosolization of B. anthracis spores appears to be extremely low in
settings where spores were released intentionally. In situations where the threat of
gross exposure to B. anthracis spores exists, cleansing of skin and potentially
contaminated fomites (e.g. clothing or environmental surfaces) may be considered to
reduce the risk for cutaneous and gastrointestinal forms of disease. The plan for
decontaminating patients exposed to anthrax may include the following:
Instructing patients to remove contaminated clothing and possessions and store in labeled, plastic
bags.
Handling clothing minimally to avoid agitation.
Instructing patients to shower thoroughly with soap and water (and providing assistance if necessary).
Instructing attending personnel regarding Standard Precautions and wearing appropriate barriers (e.g.
gloves, gown and surgical masks) when handling contaminated clothing or other contaminated fomites.
Decontaminating environmental surfaces using an approved sporicidal/germicidal agent or 0.5%
hypochlorite solution (one part household bleach added to nine parts water).
The emergency services (fire brigade and ambulance services) will provide mobile
decontamination units. Emergency staff should avoid close contact with exposed
persons until they have been decontaminated.
b. Prophylaxis and post-exposure immunisation
All patients with suspected anthrax exposure should be commenced immediately on
chemoprophylaxis. Prophylaxis should continue until B. anthracis exposure has been
excluded. If exposure is confirmed, prophylaxis should continue for 8 weeks.
During this period, no special precautions are required for exposed persons. However
they should receive an anthrax information sheet and be instructed to seek medical
attention immediately in the event of any suspicious symptoms developing.
Table 1. Recommended post-exposure prophylaxis after exposure to Bacillus anthracis
Antimicrobial agent
Adults
Children
Oral fluoroquinolones
Ciprofloxacin
500mg bd
20-30mg per kg of body mass daily,
divided into two doses – as a guide
10kg: 125mg bd
20kg: 250mg bd
30kg: 375mg bd
40kg: as for adult
If fluoroquinolones
are not available or
are contraindicated
Doxycycline
100mg bd
5mg per kg body mass per day divided
into two doses
Paediatric use of fluoroquinolones and tetracyclines can be associated with adverse effects that must
be weighed against the risk of developing a lethal disease.
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If B.anthracis exposure is confirmed, the organism must be tested for penicillin
susceptibility. If susceptible, exposed children may be treated with oral amoxycillin
40mg per kg of body mass per day divided with doses 8 hourly (not to exceed 500mg,
three times daily).
(c) Treatment
The treatment for anthrax is shown below in Table 2.
Table 2: Recommended treatment for inhalation and ingestion anthrax
Initial Therapy
Optional therapy if strain is
proven susceptible
Duration
Adults
Ciprofloxacin
400mg iv every 12hr
(change to oral 500
mg bd when
appropriate)
Penicillin G.
4 million iU iv every 4hr
(change to oral therapy when
appropriate)
8 weeks
Children*
Ciprofloxacin
20-30mg/kg per day
iv divided into 2 daily
doses, not to exceed
1g per day
Age <12y:
penicillin G 50,000 iu/kg iv every
6hr
Age 12y:
penicillin G 4million iu iv every
4hr
(change to oral therapy when appropriate)
8 weeks
Pregnancy
Same as for non pregnant adult
*Ciprofloxacin is not licensed for use in children or pregnant women.
Change to oral therapy when considered appropriate.
Note that cephalosporins are ineffective for the treatment of anthrax.
Treatment of cutaneous anthrax is with oral Ciprofloxacin 500mg bd for 7 days. This
can be changed to penicillin if the organism is found to be sensitive.
Contacts of cases
There is no need to provide antibiotic prophylaxis or immunisation to contacts of
patients unless there is concern that they were also exposed to the initial release.
(d) Environmental decontamination (To be carried out by the army)
The greatest risk to human health following a release of anthrax spores occurs during
the period in which anthrax spores remain airborne, called primary aerosolisation.
The duration and scale of the infectious risk depends on the duration for which spores
remain airborne and the distance they travel before they fall to the ground. This
depends on meteorological conditions and aerobiological properties of the dispersed
aerosol. The aerosol is likely to be fully dispersed within hours to 1 day at most, well
before the first symptomatic cases would be seen.
An exposed zone will be defined according to the time and place of release in order to
identify all persons exposed to primary aerosolisation. The area surrounding the site
of release will remain designated as an exposed zone until sufficient time has elapsed
and the risk of infection has subsided. Once the spores have settled, although they
remain infectious for long periods, the risk to human health is much lower.
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Decontamination of small areas may be achieved with 0.5% hypochlorite solution
(one part household bleach added to nine parts water).
The room in which the package and other areas of the building deemed to be
contaminated should remain tightly sealed until results from the suspicious substance
are known. If they are positive further advice in decontamination will be provided. If
this advice is not deemed feasible, decontamination of the exposed zone may be
achieved as described above.
Protection of frontline workers
This includes all emergency staff involved in management at the scene of a release, as
well as those involved in treating patients with anthrax.
Protective clothing
The exposed zone presents a high risk of infection, and anyone entering it should
wear full protective equipment including high-efficacy air filter masks conferring full
biological protection. Healthcare workers will not normally be asked to enter this
zone. It is possible, however, that they may be called to treat casualties, for example if
an explosive device has accompanied the release of biological agent. In this case the
appropriate protective clothing should be worn.
Exposed persons will normally be moved from the exposed zone, through
decontamination, and into a holding area for medical assessment and administration
of prophylactic treatment. Those involved in decontamination, and others who have
who have any contact with contaminated clothing and fomites should observe
standard l Precautions - gloves, masks, gowns, eye protection and hand washing.
Emergency staff who attend exposed persons after decontamination has been
completed do not need to take any special precautions.
For healthcare workers involved in the management of hospitalised patients with all
forms of anthrax, standard precautions provide sufficient protection, and mortuary
staff should use similar barrier protection. More sophisticated countermeasures for
airborne protection such as high-efficacy air filter masks airborne protection are not
required.
Antibiotic prophylaxis and immunisation
Healthcare workers entering the exposed zone should be offered antibiotic
prophylaxis as in Table 1. Prophylactic treatment may also be considered for frontline
workers involved in other activities including:

 Handling exposed persons.
 Management of patients or disposal of bodies infected with anthrax.
Decisions about who should receive prophylaxis should be taken on an individual
basis according to duration and degree of potential exposure, and taking into account
the availability and side effects of prophylactic treatments.
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5. Laboratory Support and Confirmation
B anthracis is a hazard group 3 pathogen. All laboratory procedures should be
performed in a Containment Level 3 laboratory using a Class 1 microbiology safety
cabinet by experienced medical laboratory scientists. Diagnosis of anthrax is
confirmed by aerobic culture performed in a CL-3 laboratory. Use of standard
precautions (gloves, masks, gowns, eye protection and hand washing) in the
laboratory reduces the risk of cutaneous anthrax to zero.
Samples to be taken from humans

negative).
 Nasal swabs (laboratory diagnosis is easier if these are sent dry since this
prevents growth of other organisms and facilitates detection of anthrax
spores).
 Swabs from cutaneous lesions.
ALL HUMAN SAMPLES SHOULD BE SENT TO THE PUBLIC HEALTH
LAB IN CHERRY ORCHARD HOSPITAL.
Samples to be taken from the environment
Samples should be taken from any material (soil, dust, clothing, swabbing etc) present
in the environmental area thought to have been exposed to the release of anthrax
spores, or soiled by exudates from humans.
ALL ENVIRONMENTAL SAMPLES SHOULD BE SENT TO THE PUBLIC
HEALTH LAB IN CHERRY ORCHARD HOSPITAL WHO WILL SEND
THEM ON TO THE UK.
Post mortem specimens
Samples may be taken from dead humans to assist diagnosis, including:
 Blood (approx 10ml) from a vein

 Swabs of haemorrhagic exudate from orifices.
 Swabs or sample of other body fluids if appropriate.
However full post-mortems are discouraged if anthrax is suspected because of the risk
of releasing anthrax spores present in body fluids, drips etc.
Procedure
 Phone laboratory to inform them that samples are on their way
(01)6206175 office hours/ (01)6264702 out of hours
 To accompany sample
-Put code on sample (BAB/number of sample)
-Brief details of incident
-Name of doctor in charge
-Contact telephone number of doctor in charge
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Appendix 1: Adapted from CDC Health Advisory document
HOW TO HANDLE ANTHRAX AND OTHER BIOLOGICAL AGENT THREATS
Many facilities in the USA have received anthrax threat letters. Most were empty envelopes;
some have contained powdery substances. The purpose of these guidelines is to recommend
procedures for handling such incidents.
DO NOT PANIC
1.
Anthrax organisms can cause infection in the skin, gastrointestinal system, or the
lungs. To do, so the organism must be rubbed into abraded skin, swallowed, or
inhaled as a fine, aerosolized mist. Disease can be prevented after exposure to the
anthrax spores by early treatment with the appropriate antibiotics. Anthrax is not
spread from one person to another person.
2.
For anthrax to be effective as a covert agent, it must be aerosolized into very small
particles. This is difficult to do, and requires a great deal of technical skill and
special equipment. If these small particles are inhaled, life-threatening lung infection
can occur, but prompt recognition and treatment are effective.
SUSPICIOUS UNOPENED LETTER OR PACKAGE MARKED WITH
THREATENING MESSAGE SUCH AS “ANTHRAX”:
1. Do not shake or empty the contents of any suspicious envelope or package.
2. PLACE the envelope or package in a plastic bag or some other type of container to
prevent leakage of contents.
3. If you do not have any container, then COVER the envelope or package with
anything (e.g., clothing, paper, trash can, etc.) and do not remove this cover.
4. Then LEAVE the room and CLOSE the door, or section off the area to prevent others
from entering (i.e., keep others away).
5. WASH your hands with soap and water to prevent spreading any powder to your
face.
6. What to do next…


If you are at HOME, then report the incident to the Gardai.
If you are at WORK, then report the incident to the Gardai, and notify your
building security official or an available supervisor.
7. LIST all people who were in the room or area when this suspicious letter or package
was recognized. Give this list to both the local public health authorities and the gardai
for follow-up investigations and advice.
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ENVELOPE WITH POWDER AND POWDER SPILLS OUT ONTO SURFACE:
1. DO NOT try to CLEAN UP the powder. COVER the spilled contents immediately
with anything (e.g., clothing, paper, trash can, etc.) and do not remove this cover!
2. Then LEAVE the room and CLOSE the door, or section off the area to prevent others
from entering (i.e., keep others away).
3. WASH your hands with soap and water to prevent spreading any powder to your
face.
4. What to do next…


If you are at HOME, then report the incident to the Gardai.
If you are at WORK, then report the incident to the Gardai, and notify your
building security official or an available supervisor.
5. REMOVE heavily contaminated clothing as soon as possible and place in a plastic
bag, or some other container that can be sealed. This clothing bag should be given to
the emergency responders for proper handling.
6. SHOWER with soap and water as soon as possible. Do Not Use Bleach Or Other
Disinfectant On Your Skin.
7. If possible, list all people who were in the room or area, especially those who had
actual contact with the powder. Give this list to both the local public health
authorities so that proper instructions can be given for medical follow-up, and to the
Gardai for further investigation.
QUESTION OF ROOM CONTAMINATION BY AEROSOLIZATION:
For example: small device triggered, warning that air handling system is contaminated,
or warning that a biological agent released in a public space.
1. Turn off local fans or ventilation units in the area.
2. LEAVE area immediately.
3. CLOSE the door, or section off the area to prevent others from entering (i.e., keep
others away).
4. What to do next…
-
If you are at HOME, then dial “999” to report the incident to Gardai.
If you are at WORK, then dial “999” to report the incident to Gardai and notify
your building security official or an available supervisor.
5. SHUT down air handling system in the building, if possible.
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6. If possible, list all people who were in the room or area. Give this list to both the local
public health authorities so that proper instructions can be given for medical followup, and to law enforcement officials for further investigation.
HOW TO IDENTIFY SUSPICIOUS PACKAGES AND LETTERS
Some characteristics of suspicious packages and letters include the following…















Excessive postage
Handwritten or poorly typed addresses
Incorrect titles
Title, but no name
Misspellings of common words
Oily stains, discolorations or odour
No return address
Excessive weight
Lopsided or uneven envelope
Protruding wires or aluminum foil
Excessive security material such as masking tape, string, etc.
Visual distractions
Ticking sound
Marked with restrictive endorsements, such as “Personal” or “Confidential”
Shows a city or state in the postmark that does not match the return address
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Appendix 2: Summary of steps to be taken if a case of anthrax is suspected by a
medical practitioner in a health care institution
1. Notify case or suspected case to Director of Public Health
2. Patient to be commenced on oral ciprofloxacin as per protocol.
3. Clinical samples to be taken including blood cultures and nasal swab.
4. Standard precautions to be used include the routine use of gloves for contact
with non-intact skin, including rashes and skin lesions.
5. Private room placement for patients with anthrax is not necessary.
6. Standard precautions should be used for transport and movement of patients
with suspected anthrax infection and for the management of patient-care
equipment and for environmental control.
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Appendix 3: Action to be taken by physician who suspects case of anthrax
(NCHD to discuss case
with consultant)
? Bioterrorism
Notify Director of Public
Health and Infection
Control Team
Preliminary investigation
(epidemiological/
microbiological)
Not Bioterrorism
Bioterrorism probable or definite
Director of Public Health to notify
 Local emergency response
coordinator
 Gardai
 National emergency planning unit
 Department of Health and Children
 National Disease Surveillance Centre
 National Disease Surveillance Centre
Activate Bioterrorism Advisory
Group in Department of Health
and Children
AND
Activate National Major
Emergency Response Team
(inter-agency/ interdepartmental)
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Appendix 4: Summary of steps to be taken if a case of anthrax is notified to a
Director of Public Health

Establish local group with public health, environmental health and
microbiological representation to oversee epidemiological investigation.
Commence epidemiological investigation. (Health Board CEOs to make
arrangements for appropriate 24 hour cover).

Director of Public Health to contact Department of Health and Children and
National Disease Surveillance Centre immediately bioterrorist attack is
suspected.

Notify Directors of Public Health in other health board areas.

Allocate extra public health staff to affected area.

Provide information to A&E departments, laboratories, GPs and other
clinicians.

Liaise with communication director. Provide regular information to public via
media, telephone helplines, website etc.


Bioterrorism plan should be integrated with local emergency planning
In the event that the suspect package contains anthrax, an information leaflet
should be circulated to all exposed persons with advice on actions to be taken
in the event of developing suspicious symptoms.
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Contacts
Dr Brian O’Herlihy
Director of Public Health
Eastern Regional Health Authority
Steevens Hospital
Dublin 8
Dr Orlaith O’Reilly
Director of Public Health
South Eastern Health Board
Head Office
Lacken
Dublin Road
Kilkenny
Dr Declan McKeown
Director of Public Health
Western Health Board
Merlin Park
Galway
Dr Rosaleen Corcoran
Director of Public Health
North Eastern Health Board
Kells
Co. Meath
Dr Pat Doorley
Director of Public Health
Midland Health Board
Arden Road
Tullamore
Co. Offaly
Dr Sean Denyer
Director of Public Health
North Western Health Board
Manorhamilton
Co. Leitrim
Dr Kevin Kelleher
Director of Public Health
Mid Western Health Board
31-33 Catherine Street
Limerick
Dr Elizabeth Keane
Director of Public Health
Southern Health Board
Sarsfield House
Sarsfield Road
Wilton
Cork
Tel: 01-635 2170
Fax: 01-671 0606
Email [email protected]
Tel: 056 51702
Fax: 056 70842
[email protected]
Tel: 091 751131
Fax: 091 758 283
[email protected]
Tel: 046 49145
Fax:046 72325
[email protected]
Tel: 0506 21868
Fax: 0506 51760
[email protected]
Tel: 072 55123
Fax: 072 55627
[email protected]
Tel: 061 316655
Fax: 061 316870
[email protected]
Tel: 021 346060
Fax: 021 346063
[email protected]
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Dr. Darina O’Flanagan
Director
National Disease Surveillance Centre
Sir Patrick Dun’s Hospital
Lower Grand Canal St
Dublin 2
Dr John Devlin
Tel: 01-6617346
Fax: 01-6617347
[email protected]
Tel: 01-6354249
Deputy Chief Medical Officer
Deot of Health and Children
Dublin 2
Professor William Hall
Director
Virus Reference Laboratory
Belfield
Dublin 4
Cherry Orchard Hospital
David Sexton
Defence forces
Fire and ambulance services
Tel: 01-7061354
Fax: 01-2697611
[email protected]
Tel: 01-6206175 (office hours)
01-6264702 (out of hours)
Tel – 01-8042624
Pager 2003110
Tel – 999 or 112
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