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Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
EM.02.01.01.2.b
Effective
Department Generating Policy
Safety
Affected Departments
All
Prepared By
Richard L. Parker
EC
4/2008
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Dept/Title
Plant Operations
Dept / Committee Approval
(If Applicable)
Date/Title
February 1, 2009
Administrative Approval
(If Applicable)
Date/Title
22
POLICY:
Northwest Medical Center (NMC) maintains a plan for Chemical/Biological/Nuclear Terrorism or
Weapons of Mass Destruction readiness.
PURPOSE:
To have a plan in place to respond to chemical/biological/nuclear (weapons of mass destruction) events.
SCOPE:
All NMC Facilities
DEFINITIONS:
 Weapons of Mass Destruction - includes nuclear, explosive, biological and chemical incidents
where there is potential mass destruction, death and injury. May also be referred to as NBC
incidents.
 NBC – Incident involving Nuclear, Biological, or Chemical substance or contamination.
 Nuclear Incident – This type of incident ranges from detonation of nuclear devices to
contamination of food or other products with radioactive materials.
 Biological or Bioterrorism – A threat or incident using living organisms such as bacteria or
viruses or their toxins.
 Chemical Incident – A threat from any chemical compound that can harm others.
GUIDELINES:
Authorization:
A. The Administrator or Administrative Supervisor, or designee is authorized to initiate Emergency
Preparedness Procedures in the event of a NBC incident. NMC uses the Hospital Incident
Command System (HICS) for Emergency Preparedness.
B. Infection Control Physician/Infection Control Coordinator or designee is authorized to rapidly
implement prevention and control measures in response to a suspected biological incident.
C. Should a weapons of mass destruction event be suspected, a network of communication is
activated to involve administration, infection control personnel, local and state health
departments, the Federal Bureau of Investigation (FBI) field office, and CDC.
Steps for Responding to Any Suspected NBC Event
NBC events can be obvious (overt) events in which an explosion or other obvious event occurs
and exposes people to biological, chemical or radiation agents. Also, these events can be un-
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
EM.02.01.01.2.b
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noticed (covert) where people are exposed to undetected biological, chemical or radioactive
contamination that causes illness and death hours or days after the exposure. Healthcare facilities
may be the initial site of recognition and response to covert events. If a covert event is suspected,
local emergency response systems are activated. Notification includes: infection control
personnel, administration, the local and state health departments, FBI field office, local police,
CDC, and medical emergency services.
Terrorism acts may involve chemical, nuclear or biological contamination. General
decontamination procedures are used for all three types of contamination. A Geiger counter
should be utilized to assess nuclear (radioactive) contamination. Reference is made to the Policy
“Radioactive Contaminated Patients”. Chemical and nuclear contamination is more likely to be
from overt incidents and we are more likely to know or suspect what the contaminate is before we
receive patients. Chemical agents are referenced in the Policy “Rapid Response to Biological or
Chemical Terrorist Event” Table.
Emergency Contact: Call 911
In the event that multiple persons show up in the Emergency Department with suspected chemical
or biological contamination:
1) Quarantine
2) Initiate “Rapid Response to Biological or Chemical Terrorist Event” Policy available in
the Emergency Response Manual
3) Northwest Medical Center uses the Acronym DISARM to describe the response to
terrorist events.
D
Detection/Identification
I
Isolate
S
Standard Precautions Plus
A
Alert authorities
R
(Rx) Treat the victims/Decontamination
M
Manage exposed personnel
4) If this is a situation requiring decontamination, activate the HICS system
5) The Operator should page “Code Triage-external” or “Code Orange” depending on
the situation to activate the hospital decontamination team. Reference the Emergency
Decontamination Policy available in the Emergency Response Manual
6) Call 911 directly for connection with the outside Hazardous Materials Team.
7) Initiate decontamination procedures as needed. Admit only decontaminated persons into
the ED (patient treatment area).
8) Isolate any areas that were possibly contaminated by potentially contaminated patients
with yellow and black stripped tape. Patients are removed and restricted from the area.
Security Personnel secure the area.
Internal Contacts:
1) Infection Control (520) 469-8275 (Beeper 712-3021)
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
EM.02.01.01.2.b
Effective
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EC
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2) Emergency Management Coordinator (520) 469-8007 (Digital Pager 712-5369)
3) Safety Officer (520) 469-8192
4) Public Relations (520) 469-8738 or Media Line Pager (520) 566-2351
External Contacts:
1) Local Health Department (520) 740-8315 (After Hours: (520) 743-7987)
2) These contacts will be contacted by the local health department personnel:
a)
State Health Department (602) 364-3676
b)
Bioterrorism Emergency Number, CDC Emergency Response Office (770) 4887100
c)
CDC Hospital Infections Program (404) 639-6413
Detection of Outbreaks Caused by Agents of Bioterrorism
The key to rapid intervention and prevention is to maintain a high level of vigilance. The early clinical
symptoms of infection for most bioterrorism agents may be similar to common diseases seen by health
care professionals every day. The principles of epidemiology should be used to distinguish cases of a
disease currently circulating in the community from those representing an unusual event. The most
common features of an outbreak caused by a bioterrorist agent include:
 A rapid increase (hours, days, or weeks) in the number of previously healthy persons with similar
symptoms seeking medical treatment;
 A cluster of previously healthy persons with similar symptoms who live, work, or recreate in a
common geographical area;
 An unusual clinical presentation;
 An increase in reports of dead animals;
 Lower rates of illness in those persons who are protected (e.g., confined to home; no exposure to
large crowds);
 An increased number of patients who expire within 72 hours after admission to the hospital;
 Any person without a history of recent (within the past 2-4 weeks) travel to a foreign country who
presents with symptoms of high fever, rigors, delirium, rash (not characteristic of measles or
chickenpox), extreme myalgias, prostration, shock, diffuse hemorrhagic lesions or petechiae;
and/or extreme dehydration due to vomiting or diarrhea with or without blood loss.
Required Reporting
A. Communicable Disease Reporting. See “Communicable Disease Reporting” Policy.
1) Immediate reporting of all bioterrorist threat diseases is critical for limiting the impact of a
bioterrorist.
2) The regulations require health care providers to immediately report by telephone all
suspected and confirmed cases of anthrax, botulism, brucellosis, plague (animal and human),
smallpox, tularemia, varicella (deaths only), viral hemorrhagic fevers and outbreaks of any
disease.
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
EM.02.01.01.2.b
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3) In addition, unusual diseases defined as rare diseases or a newly apparent or emerging disease
or syndrome of uncertain etiology that a health care provider has reason to believe could
possibly be caused by a transmissible infectious agent or by a microbial toxin are also
immediately reportable.
4) The laboratories are required report results indicative of a specified bioterrorist agent to the
local health department.
INFECTION CONTROL PRACTICES FOR PATIENT MANAGEMENT
Isolation precautions
1) Agents of bioterrorism are generally not transmitted from person to person; re-aerosolization of
these agents is unlikely. Contagious bioterrorism agents include smallpox, plague and viral
hemorrhagic fevers. If these items are suspected, they must be looked up individually for
Infection Control Measures. Most other agents are managed using routine Infection Control
measures.
2) Manage patients including symptomatic patients with suspected or confirmed bioterrorism-related
illnesses utilizing Standard Precautions.
3) Standard Precautions are designed to reduce transmission from both recognized and unrecognized
sources of infection, and are recommended for all patients receiving care, regardless of their
diagnosis or presumed infection status. Standard Precautions prevent direct contact with all body
fluids (including blood), secretions, excretions, non-intact skin (including rashes), and mucous
membranes.
4) For contagious diseases or syndromes such as smallpox, pneumonic plague and hemorraghic
fever viruses, additional precautions are needed to reduce the likelihood for transmission. See
“Rapid Response to Biological or Chemical Terrorist Event” Table for reference of specific
agents. Isolation Precautions for specific diseases is also available in the “Disease Precautions”
Policy. A NMC Bioterrorism Guideline with specific disease precautions is available through the
Infection Control Department or the Emergency Department.
Patient Placement
1) In small-scale events, routine facility patient placement and infection control practices should be
followed.
2) However, when the number of patients presenting to a healthcare facility is too large to allow
routine triage and isolation strategies (if required), it is necessary to apply alternatives. These
include cohorting patients who present with similar syndromes, i.e., grouping affected patients
into a designated section of a clinic or emergency department, or a designated unit of a facility, or
even setting up a response center at a separate building. The triage or cohort site is controlled
entry to minimize the possibility for transmission to other patients at the facility and to staff
members not directly involved in managing the outbreak. At the same time, reasonable access to
vital diagnostic services, e.g., radiography departments are maintained.
Patient Transport
1) Most infections associated with bioterrorism agents cannot be transmitted from patient-to-patient.
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
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2) In general, the transport and move patients with bioterrorism-related infections as you would
move patients with any epidemiologically important infection (e.g., pulmonary tuberculosis,
chickenpox, measles). Transport should be limited to movement that is essential to provide
patient care, thus reducing the opportunities for transmission of microorganisms within the
facility.
Cleaning, Disinfection, and Sterilization of Equipment and Environment
1) Principles of Standard Precautions are applied for the management of patient-care equipment and
environmental control.
2) Follow routine procedures for patient care, cleaning, and disinfection of environmental surfaces,
beds, bed rails, bedside equipment, and other frequently touched surfaces and equipment.
3) Facility-approved germicidal cleaning agents are available in patient care areas to use for
cleaning spills of contaminated material and disinfecting non-critical equipment.
4) Used patient-care equipment soiled or potentially contaminated with blood, body fluids,
secretions, or excretions is handled in a manner that prevents exposures to skin and mucous
membranes, avoids contamination of clothing, and minimizes the likelihood of transfer of
microbes to other patients and environments.
5) Reusable equipment is not used for the care of another patient until it has been appropriately
cleaned and reprocessed, and single-use patient items are discarded.
6) Sterilization is required for all instruments or equipment that enter normally sterile tissues or
through which blood flows.
7) Rooms and bedside equipment of patients with bioterrorism-related infections are cleaned using
the same procedures that are used for all patients as a component of Standard Precautions, unless
the infecting microorganism and the amount of environmental contamination indicates special
cleaning.
8) In addition to adequate cleaning, thorough disinfection of bedside equipment and environmental
surfaces may be indicated for certain organisms that can survive in the inanimate environment for
extended periods of time.
9) Patient linen is handled in accordance with Standard Precautions. Although linen may be
contaminated, the risk of disease transmission is negligible if it is handled, transported, and
laundered in a manner that avoids transfer of microorganisms to other patients, personnel and
environments. The possible exception is smallpox. Infection Control would establish laundry and
waste handling guidelines in the event of a smallpox case.
10) Contaminated waste is sorted and discarded in accordance with NMC policy.
11) Policies for the prevention of occupational injury and exposure to bloodborne pathogens in
accordance with Standard Precautions are in place.
Discharge Management
1) In all probability, patients in the hospital at the time that a bioterrorist event is evolving will have
to be evaluated for discharge. If patients require continued acute care, hospitals may make
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
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arrangements to transfer patients to other hospitals, or if stable, to home or long-term care
facilities.
2) Patients with bioterrorist-related infections should not be discharged until they are deemed noninfectious (plague, smallpox, and viral hemorrhagic fever). Home care instructions are available
in the NMC Bioterrorism planning guide available through Infection Control. These were
developed primarily to care for patients who cannot be admitted to the hospital because maximum
bed capacity and staffing levels has been reached or exceeded.
Post-Mortem Care
1) Deceased persons from a biological or chemical terrorist event are doubled body bagged and the
outer bag sealed with duct tape.
2) Deceased persons should not be released to funeral homes until the Pima County Health
department authorizes the disposition.
Post Exposure Management
1) Prophylaxis and post-exposure immunization recommendations for prophylaxis are subject to
change.
2) Up-to-date recommendations should be obtained in consultation with local and state health
departments and CDC.
3) In general, maintenance of accurate occupational health records facilitates identification,
contact, assessment, and delivery of post-exposure care to potentially exposed healthcare
workers.
4) Agent specific prophylaxis recommendations are available in the “Rapid Response to
Biological and Chemical Terrorism Events” agent specific table.
Managing the Psychological Aspects of Bioterrorism
A. Following a bioterrorism event, anxiety and alarm can be expected from infected patients, their
families, healthcare workers, and the worried well. Psychological responses may include anger,
fear, panic, unrealistic concerns about infection, fear of contagion, paranoia, and social isolation.
B. Communicate clear, concise information about the infection, how it is transmitted, what treatment
and preventive options are currently available, when prophylactic antibiotics, antitoxin serum or
vaccines will be available, and how prophylaxis or vaccination will be distributed;
C. Provide counseling to the worried well and victims’ family members;
D. Provide educational materials in the form of frequently asked questions (FAQ);
E. Provide home care instructions;
F. Provide information on isolation;
G. Information released to the public should be coordinated with local and state health officials.
Laboratory Support
A. With the possible exception of Yersinia pestis (plague) and some food or water-borne disease
agents, most hospital clinical laboratories are not equipped to confirm the identity bioterrorist
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
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C.
D.
E.
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pathogens. However, they can make presumptive identification of early cases, rule out the
presence of many agents, and refer specimens to higher-level laboratories for more definitive
identification.
Laboratory personnel consult with local law enforcement and the FBI to determine what
information should be included in chain-of-custody documents.
Laboratories collecting blood specimens for serology testing should retain an aliquot for a short
time to accommodate lost specimens. The retained blood specimens should be kept in a secure
locked cabinet.
Laboratory personnel should take maximum precautions when handling clinical specimens.
1) Laboratory personnel should wear appropriate personal protective equipment.
2) Specimens should be opened, plated, or aliquotted in a biosafety hood.
3) Use Standard Precautions when collecting clinical specimens. (exception: see
recommendations for isolation for smallpox and viral hemorrhagic fevers)
4) Use biological safety cabinets to prevent the release of aerosols. Masks, gowns, gloves and
eye protectors are used in addition to biological safety hoods when handing all suspected
bioterrorism agents.
Packaging Specimens:
1) Place biohazard label on each specimen container (culture or blood specimen)
2) Wrap specimen container with absorbent material and place in a leak proof container with a
tight cover.
3) Place a biohazard label on primary container
4) Place wrapped specimen container in the primary container
5) Place primary container into a second leak proof container and seal tightly
6) Place biohazard label on second container
7) Place dry ice or ice pack (not ice) in the second container if require. If the specimen is a
paper or powder form, ice should be omitted.
8) Place the second container into a third container.
9) The third container should meet the state and federal regulations for shipping of hazardous
materials and be properly labeled
Transporting Specimens:
1) Transportation of clinical specimens to the local health or state health department should be
coordinated with the local FBI or law enforcement agency.
Evidence Collection
A. In a bioterrorist event, the primary goal is to protect and preserve the life and safety of the public.
By the time the first patients seek treatment and a bioterrorist event is suspected, there may be no
evidence to collect.
B. In collaboration with local law enforcement and regional FBI representatives, Northwest Medical
Center has established lines of authority about who will be responsible for evidence collection.
See policy for further information.
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
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Program Readiness
A. Preparing and maintaining a program for response to biological/chemical/nuclear terrorist events
is incorporated into the Emergency Preparedness function of the Environment of Care.
B. Decontamination drills are practiced on a regular basis.
C. Emergency Preparedness procedures are reviewed at orientation, with the annual safety education
and through drills. Additional education is offered through the Medical Metropolitan Response
System (MMRS).
D. A Decon Team is maintained.
E. Numerous resources are available through the MMRS system and the local and state public health
departments.
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
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Date/Title
22
Characteristics of Biological/Chemical Agents
ATTACHMENT B
Biological/Bacterial Agents:
Agent
Anthrax:
Inhalation
Anthrax: Cutaneous
Incubation / Route
Symptoms
1 – 6 days (up to 60 days)
Prodromal stage of
fever, malaise, fatigue,
cough, and mild chest
discomfort lasting 2-3
days with brief interim
improvement. Followed
by severe respiratory
distress with dyspnea,
diaphoresis, stridor, and
cyanosis: shock and
death. Widened
mediastinum may be
seen on CXR and
hemorrhagic meningitis
occurs in 50% of cases.
Treatable with
antibiotics in prodromal
stage.
Itching of exposed skin
2 – 6 days following
Decontamination
Required
Only for actual
contamination with
spores or powder
suspicious of containing
anthrax spores
Only for actual
Precautions
Standard Precautions
The toxin from the
bacteria causes illness
within the body. Spore
producing bacteria are
not produced in active
disease so spores are
not directly excreted
from infected
individuals. No special
precautions are needed
for intubation,
ventilation or other
medical procedures.
Standard Precautions
Disinfection
Procedure
Remove and bag clothing,
wash with soap and water.
Use 10% Hypochlorite
bleach to disinfect
surfaces, equipment,
clothing and other objects
Contagious / Risk
Not contagious from
person to person
High mortality (>90%)
when not treated in
prodromal stage.
No prophylaxis
recommended for
contact with an infected
patient.
Prophylaxis
recommended for
exposure to spores.
Remove and bag clothing,
Not contagious from
Agent
Anthrax: Gastrointestinal
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
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Incubation / Route
Symptoms
exposure of broken skin to
spores
occurs first followed by
a skin lesion that
becomes papular, then
vesicular, and in 2-6
days develops into a
depressed black eschar
that may be surrounded
by moderate to severe
edema, sometimes
secondary vesicles.
Generally not painful.
May resemble brown
recluse spider bite.
Food poisoning illness
with abdominal distress,
nausea, vomiting and
fever, vomiting blood
and bloody diarrhea.
Signs of sepsis may be
present. There may be
involvement of the
pharynx characterized
by lesions at the base
of the tongue, sore
throat, dysphagia, fever
and regional lymphadenopathy
1-7 days Usually follows
the consumption of raw or
contaminated meat or
ingestion of spores.
Infective dose is unclear.
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Decontamination
Required
contamination with
spores or powder
suspicious of containing
anthrax spores
Only for actual
contamination with
spores or powder
suspicious of containing
anthrax spores
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Precautions
Contain and control
drainage from lesion.
Actual drainage is
potentially infectious but
is controlled with
Standard Precautions.
Dispose of moist
dressings in Infectious
Waste container.
Standard Precautions
The toxin from the
bacteria causes illness
within the body. Spore
producing bacteria are
not produced in active
disease so spores are
not directly excreted
from infected
individuals. No special
precautions are needed
for intubation,
ventilation or other
medical procedures.
Disinfection
Procedure
wash with soap and water.
Use 10% Hypochlorite
bleach to disinfect
surfaces, equipment,
clothing and other objects
Contagious / Risk
person to person
Mortality rate 5-20%
when untreated.
No prophylaxis
recommended for
contact with an infected
patient.
Remove and bag clothing,
wash with soap and water.
Prophylaxis
recommended for
exposure to spores.
Not contagious from
person to person
Use 10% Hypochlorite
bleach to disinfect
surfaces, equipment,
clothing and other objects
Mortality is thought to
be high. This is the
rarest form and little
information is available.
No prophylaxis
recommended for
contact with an infected
patient.
Prophylaxis
recommended for
Agent
Botulism
Brucellosis
Cholera
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Bioterrorism Readiness
Manual Location
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Incubation / Route
Symptoms
Oral and Inhalation
Symptoms begin 12-36
hours after ingestion and
24 – 72 hours after
aerosol exposure.
Incubation can range from
6 hours to 10 days.
Aerosolized botulism toxin
is slightly less toxic than
ingested toxin.
Responsive patient with
lack of fever, Multiple
cranial nerve palsies
such as drooping
eyelids, weakened jaw
clench, difficulty
swallowing or speaking.
Bulbar palsies are
prominent with blurred
vision, diplopia, ptosis
and photophobia.
Symmetric descending
weakness in a proximal
to distal pattern.
Respiratory dysfunction
from respiratory muscle
paralysis.
Systemic infection
characterized by
undulant fever pattern.
Non-specific febrile
illness with chills,
sweats, headache,
fatigue, myalgias,
arthalgias and anorexia.
Only for actual
suspected
contamination with
botulism toxin
containing aerosols.
None required for
ingestion of toxin
contaminated food or
water.
Sudden onset of
Not required
Inhalation of contaminated
aerosols, ingestion of
contaminated milk or
meat, contamination of
abraded skin or
conjunctival surfaces.
Incubation period can
range from 5-60 days with
an average of 1-2 months.
Ingestion of contaminated
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Precautions
Standard Precautions
Not contagious from
person to person
Disinfection
Procedure
For aerosol exposure,
wash with soap and water.
Routine environmental
disinfection.
Contagious / Risk
exposure to spores.
Untreated mortality rate
60% with less than 5%
mortality rate if patient
receives appropriate
treatment. Long term
mechanical ventilation
may be required for
several weeks to
months.
No prophylaxis
recommended for
patient exposure.
No. Only in a rare case
where aerosol
contamination is known
to have occurred.
Standard Precautions
“C”
Contact
For aerosol exposure,
wash with soap and water.
Routine environmental
disinfection.
Routine disinfection
Low mortality rate of
less than 5% in
untreated cases. Not
contagious from person
to person.
No prophylaxis
recommended for
patient exposure.
Untreated mortality rate
Agent
Glanders
(Burkholderia mallei)
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Bioterrorism Readiness
Manual Location
Policy/Procedure #
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Incubation / Route
Symptoms
food or water. Incubation
period ranges from 4
hours to 5 days with an
average of 2-3 days.
vomiting, abdominal
distension, headache
pain with little or no
fever. Perfuse watery
“rice water” diarrhea.
Fluid loss can result in
dehydration,
hypovolemia and shock.
Inhalation of droplets or
infectious airborne
particles.
Incubation 10-14 days.
May cause localized,
septic, pulmonary or
cutaneous infection.
Highly communicable
disease of horses,
mules and donkeys.
Generally, human
infection is rare. Has
been used for
intentional livestock
infection in the past.
Septic form: Fever,
rigors, sweats,
myalgias, pleuritic chest
pain, photophobia,
lacrimation, diarrhea,
cervical adenopathy,
splenomegally, mild
leukocytosis.
Pumonary: miliary
nodules
bronchopneumonia or
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Decontamination
Required
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Precautions
precautions
Only in cases where
direct aerosol
contamination is known
to have occurred.
12
Standard Precautions
for patient care.
Person to person
transmission thought to
be unlikely.
Disinfection
Procedure
procedures for
environment and patient
care equipment.
For direct aerosol
exposure wash with 10%
bleach and soap and
water.
Use 10% bleach for
routine disinfection of
environment and patient
care equipment.
Contagious / Risk
of 50-80% mainly due
to fluid loss. Treatment
is mainly supportive.
Mortality rate drops to
3-30% with treatment.
Post exposure
prophylaxis may be
indicated for household
or close contacts.
Almost always fatal
with out ABX treatment.
Mortality is still high
with ABX treatment.
Occurrence in the
absence of animal
exposure is
presumptive for a
bioterrorism attack.
Prophylactic antibiotics
may be useful for direct
patient exposures.
Agent
Hemorrhagic Fevers:
Marburg, Ebola
Plague (Yersinia
pestis)
3 types: Pneumonic,
Gastrointestinal and
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Bioterrorism Readiness
Manual Location
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Incubation / Route
Direct Contact with
infected blood, secretions,
organs or semen.
Incubation Marburg 3-9
days, Ebola 2-21 days.
Inhalation, fleabite, direct
contact with infected blood
and tissues. Average
onset 1-7 days,
Symptoms
necrotizing nodular
lesions. Oral/nasal or
conjunctival mucosa:
blood streaked
discharge, turbinate
nodules, ulcerations,
papular or pustular rash
(may resemble
smallpox)
Severe acute viral
illness with sudden
onset of fever, malaise
and headache followed
by pharangitis,
vomiting, diarrhea, and
maculopapular rash,
prominent on the trunk.
Bleeding manifestations
such as petechiae,
ecchymoses and
hemorrhages.
Lymphopenia, thrombocytopenia and elevated
AST/ALT
Onset of pneumonic
plague is acute and
fulminant with high
fever, cough, chest
EC
1/2008
Page
Decontamination
Required
Decontamination not
generally necessary
Dept/Title
of
22
Plant Operations
Precautions
Strict Contact
Precautions to avoid
contact with any body
substance
“D” Category; Airborne
Precautions have been
recommended but
classic airborne strains
have not been identified
in humans.
NO shared equipment
by patients.
Most likely method of
dispersion is by aerosol
resulting in possible
pneumonic plague.
13
Droplet “B” type
precautions.
TB grade mask
Disinfection
Procedure
Contagious / Risk
10% bleach and routine
hospital grade
disinfectants. Strict barrier
precautions for cleaning
up body substance. Items
heavily contaminated with
blood and body substance
should be disposed of into
Infectious Waste
Container. Strict
Precautions for handling
dead bodies.
Mortality rates vary per
specific virus. Marburg
25%
Ebola 50 – 90%
For aerosol exposure,
wash with soap and water.
Routine environmental
disinfection. Strict
Mortality rates for
untreated pneumonic
plague is 90-100%.
Untreated bubonic
No prophylaxis
available.
Agent
Bubonic
Q Fever
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
EM.02.01.01.2.b
Effective
Department Generating Policy
Safety
Affected Departments
All
Prepared By
Richard L. Parker
Incubation / Route
pneumonic plague 2-4
days
Inhalation, consumption of
contaminated food and
water is also possible.
Incubation ranges from
10-40 days.
Symptoms
pain, malaise,
hemoptysis or
mucopurulent or watery
sputum. CXR shows
broncho-pneumonia
and disease rapidly
progresses to dyspnea,
stridor, cyanosis. GI
symptoms include
nausea, vomiting,
diarrhea and abdominal
pain. Bubonic plague
usually develops from a
fleabite in which the
affected lymph nodes
swell, are inflamed and
may suppurate. If
untreated, may
progress to septicemia.
Acute febrile illness with
chills, fever, severe
sweats, retrobulbar
headache, fatigue,
weakness and
myalgias. Pneumonia
occurs in 50% of cases.
Self limiting illness
lasting 2 days to 2
EC
1/2008
Page
Decontamination
Required
Only required for actual
contamination with
aerosol.
Dept/Title
14
of
22
Plant Operations
Precautions
essential.
Disinfection
Procedure
Precautions necessary for
handling dead bodies.
Contagious / Risk
plague is 50-60%.
Mortality drops to 5%
with timely appropriate
antibiotic treatment.
Prophylaxis
recommended for face
to face contact with
infected patient.
Most likely to be
dispersed through
aerosol or food/water
contamination.
Only required for actual
contamination with
aerosol.
Standard Precautions.
Not transmissible from
person to person.
The organism has unusual
stability and is highly
resistant to many
disinfectants.
For direct aerosol
contamination: Remove
and bag clothing, wash
with soap and water.
Use 10% Hypochlorite
While highly
incapacitating, mortality
rates for Q-fever are
very low
< 1-3%.
No prophylaxis
recommended for
patient exposure.
Agent
Ricin:
A potent protein
toxin derived from
the castor bean plant
Salmonellosis
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
EM.02.01.01.2.b
Effective
Department Generating Policy
Safety
Affected Departments
All
Prepared By
Richard L. Parker
Incubation / Route
Inhalation or Ingestion
Incubation ranges from
18-24 hours
Ingestion of contaminated
food or water.
Symptoms
weeks. Complications
of Hepatitis,
endocarditis, aseptic
meningitis, encephalitis
and oseomyelitis may
occur.
When inhaled,
weakness, fever,
cough, and hypothermia
occur initially. Within
18-24 hours,
hypotension,
cardiovascular collapse,
pulmonary edema
occur. Death from
respiratory distress
usually occurs within 72
hours. Ingestion results
in rapid onset of
nausea, vomiting,
abdominal cramps,
severe diarrhea and
vascular collapse.
Activated charcoal may
be helpful with ingestion
cases.
Nausea, vomiting,
abdominal cramps,
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1/2008
Page
Decontamination
Required
Most likely to be
dispersed through
aerosol or food/water
contamination.
Dept/Title
of
22
Plant Operations
Precautions
Standard Precautions
Ricin is not volatile and
secondary aerosols are
not a danger.
Only required for actual
contamination with
aerosol.
None required.
15
Disinfection
Procedure
bleach to disinfect
surfaces, equipment,
clothing and other objects.
For direct aerosol
contamination: Remove
and bag clothing, wash
with soap and water.
Use 10% Hypochlorite
bleach to disinfect
surfaces, equipment,
clothing and other objects.
Contact “C”
Precautions for patient
Routine disinfection
procedures for
Contagious / Risk
Once initial
contamination is
controlled there is not
risk of secondary
exposure.
Mortality rate is high.
Treatment is supportive
and there is no known
prophylaxis.
Mortality rate is low to
moderate being <1%
Agent
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
EM.02.01.01.2.b
Effective
Department Generating Policy
Safety
Affected Departments
All
Prepared By
Richard L. Parker
Incubation / Route
Incubation ranges from 6
to 72 hours with an
average of 12 to 36 hours.
Smallpox
Airborne and droplet
exposure to infected
patient. Direct contact
with drainage form
lesions.
Incubation 7-17 days,
commonly 10-12 days to
onset of illness and 2-4
days more to onset of
rash.
Symptoms
diarrhea which is
sometimes bloody.
Weakness, chills, fever
may also be present.
Typhoid syndrome
additionally may include
abdominal distention,
septicemia, enlarged
spleen and occasional
meningeal signs.
Nonspecific prodrome
of fever and myalgias
for 2-4 days before
onset of rash. Smallpox
rash is vesicular /
pustular being more
prominent on the face
and extremities and
lesions develop at the
same time. Lesions are
usually present on the
oral mucosa and may
appear on the palms of
hands and soles of feet.
Chicken pox rash is
most prominent on the
trunk and develops in
successive groups
EC
1/2008
Page
Decontamination
Required
Infection most likely to
be through ingestion.
Dept/Title
16
of
22
Plant Operations
Precautions
with active diarrhea or
those who are
incontinent of stool.
General environmental
decontamination is
generally not required
as the emphasis is on
controlling exposure to
infected patients.
Airborne “A”
Precautions and strict
Contact “C”
precautions.
Patient may be
quarantined for 17
days.
patients from public
-Remove suspicious
areas
-Place patient in a
negative air pressure
room or use HEPA air
Disinfection
Procedure
environment and patient
care equipment.
Contagious / Risk
for most serotypes.
No prophylaxis
recommended for
patient exposure.
Disinfect patient room and
any reusable equipment
with 10% bleach . Red
Bag all disposable items
that have had patient
contact and dispose of as
infectious waste. Laundry
should be collected
separately, labeled and
autoclaved before
laundering or disposed of
as infectious waste.
A single case of
suspected Smallpox is
a Public Health
Emergency and
requires immediate
reporting to the Health
Department.
Overall mortality rate is
30%. There are other
less common but more
severe strains of
smallpox such as the
hemorrhagic type that
causes toxemia and
have mortality rates of
90-100%.
The main methods of
control are
Agent
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
EM.02.01.01.2.b
Effective
Department Generating Policy
Safety
Affected Departments
All
Prepared By
Richard L. Parker
Incubation / Route
Symptoms
EC
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Page
Decontamination
Required
Dept/Title
17
of
22
Plant Operations
Precautions
Disinfection
Procedure
filtration unit
Staph
Enterotoxin B
Inhalation or ingestion of
contaminated food or
water
Incubation 4 to 6 hours
Sudden onset with
fever, chills, headache,
myalgia,and
nonproductive cough.
Some may develop
respiratory distress and
retrosternal pain. If
Only required for actual
contamination with
aerosol.
-All staff use a TB grade
mask to enter the room
-All staff use full
barriers: gowns, shoe
covers, gloves, masks
and eye protection to
enter the room
-Try to assign staff who
have received smallpox
vaccine (in the past) to
the patient. Such
persons are not
considered “Immune”
but they may have
lower risk for disease
morbidity / mortality.
-Limit # of personnel
caring for pt.
Standard Precautions
No Prophylaxis needed.
Contagious / Risk
Quarantine and
vaccination.
Vaccination given
within 3-4 days of
exposure may prevent
disease development.
Persons who were
previously vaccinated
may develop immunity
at a faster rate than
unvaccinated persons.
Possible treatment or
prophylaxis with antiviral drugs.
For direct aerosol
exposure wash with soap
and water.
Routine disinfection of
hospital environment and
equipment.
Not transmissible from
person to person.
Mortality rate less than
1%. Some inhalation
cases may require
respiratory support.
Agent
T-2 Mycotoxins
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
EM.02.01.01.2.b
Effective
Department Generating Policy
Safety
Affected Departments
All
Prepared By
Richard L. Parker
Incubation / Route
Can be inhaled, ingested
or absorbed through the
skin. Is a yellow or
greenish oily liquid.
Incubation minutes to
hours
Tularemia
Inoculation of the skin or
mucous membranes with
blood or tissue from
infected animals or bites
from infected insects are
most common. Inhalation
of contaminated dust or
ingestion of contaminated
food or water is less
common.
Incubation ranges from 114 days with an average
of 3-5 days.
Symptoms
ingested, nausea,
vomiting and diarrhea.
Skin pain, pruritis,
redness, vesicles,
necrosis; nose and
throat pain, nasal
discharge, itching and
sneezing, cough,
dyspnea, wheezing,
chest pain, and
hemoptysis; ataxia,
shock and death.
Typhoidal, GI,
pneumonia, bacteremia,
and ocuglandular forms
of disease can occur.
Pneumonia manifests
with fever, headache,
substernal discomfort,
and non-productive
cough. CXR may show
pneumonia or
mediastinal Lymphadenopathy. The GI
form presents with
abdominal pain,
EC
1/2008
Page
Decontamination
Required
Yes, for direct contact
with toxin.
Most likely to be
dispersed through
aerosol or food/water
contamination.
Only required for actual
contamination with
aerosol.
Dept/Title
18
of
22
Plant Operations
Precautions
“C” Contact Precautions
until disinfection
complete.
Disinfection
Procedure
Remove clothing and
wash with soap and water.
Rinse eyes with copious
amounts of saline if eye
No prophylaxis
contamination is possible.
available.
Contamination must be
thoroughly removed from
the environment since the
toxin can be absorbed
through the skin. Routine
disinfection protocol may
be used.
Standard Precautions.
For aerosol exposure,
wash with soap and
Not readily transmissible
water. Routine
from person to person
environmental
through droplets.
disinfection. Strict
contact precautions for
Contact “C” precautions
handling dead bodies.
should be used if draining
lesions are present.
Culturing of the organism
is potentially dangerous.
Notify Lab personnel if
Tularemia is suspected.
Contagious / Risk
Rated as having
moderate lethality. Can
be absorbed through
the skin and from direct
person to person
contact until toxin is
removed.
No prophylaxis
available.
Mortality rate without
treatment is 33%.
Appropriate and timely
treatment decreases
mortality to 2%.
Prophylactic antibiotic
treatment is
recommended for
persons exposed to
patients, aerosols or
laboratory cultures.
Agent
Viral encephalitis
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
EM.02.01.01.2.b
Effective
Department Generating Policy
Safety
Affected Departments
All
Prepared By
Richard L. Parker
Incubation / Route
Generally spread through
infected vectors such as
mosquitoes. May be
aerosolized.
Incubation is 1-6 days.
Symptoms
nausea, vomiting.
Sudden onset with
malaise, spiking fever,
rigors, severe
headache, photophobia,
and myalgias. Nausea,
vomiting, cough, sore
throat, and diarrhea
may follow.
EC
1/2008
Page
Decontamination
Required
Only required for actual
contamination with
aerosol.
Dept/Title
19
of
22
Plant Operations
Precautions
Soap and water for
possible aerosol
contamination.
Disinfection
Procedure
Standard Precautions.
Routine Procedures for
disinfection of
environment and
equipment.
Contagious / Risk
Generally has low
mortality rates. Rates
vary according to
specific virus.
No prophylaxis.
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
EM.02.01.01.2.b
Effective
Department Generating Policy
Safety
Affected Departments
All
Prepared By
Richard L. Parker
EC
1/2008
Page
Dept/Title
20
of
22
Plant Operations
Chemical Agents:
Agent
Nerve Agents:
Tabun (GA)
Sarin (GB)
Soman (GD)
VX
Vesicants (Blister
Agents):
Nitrogen Mustard
Lewisite
Phosgene Oxime
(CX)
Incubation / Route
Symptoms
Inhalation and skin contact
Onset seconds to 18
hours
Generally, rapid onset.
Colorless odorless, low
volatility, oily liquid.
Miosis, difficulty
breathing, headache,
muscular twitching,
salivation, lacrimation,
urination, defecation, GI
distress, emesis
(SLUDGE), seizures,
coma, death
Vapor effects peak in 5
minutes.
Tearing or burning
eyes, runny nose,
sneezing, cough,
redness on skin,
followed by blisters.
Symptoms are delayed
but tissue damage
occurs within minutes of
contamination.
-Mustard: Blisters or
irritation to skin, eyes,
lungs
Inhalation and skin
contact.
Onset 2 to 24 hours.
-Mustard: Possible garlic
odor, medium volatility,
oily liquid. Delayed onset
4-6 hours.
Decontamination
Required
Yes
Precautions
Standard Precautions for
patient care after
disinfection.
Full Barriers for initial
patient disinfection.
Yes
Must be completed in
30 min to decrease
systemic effects
Standard Precautions
for patient care after
disinfection.
Full Barriers for initial
patient disinfection
Disinfection
Procedure
Contagious / Risk
Remove clothing and
wash with soap and
water then 1:10 Sodium
hypoclorite (bleach) and
water rinse
Avoid skin contact with
contaminated patients.
Remove clothing and wash
thoroughly with soap and
water or with a 10% bleach
solution.
Antidote: Atropine,
2-PAM or diazepam
Avoid skin contact with
contaminated patients.
No antidote, patient
management is
supportive symptom
management.
Cyanide Inhalation and/or skin contact. Immediate onset, rapid progression of symptoms. Smells of bitter almonds. High dose needed to cause effects. Cherry red skin, headache,
dizziness, vomiting to hypernea, seizures and death within 6-10 minutes of exposure. Use Standard Precautions for patient care after disinfection. Contain any body fluids
expelled. Off-gassing is a concern. Full Barriers for initial patient decontamination. Remove clothing and decontaminate with 10% bleach and water solution and soap and water.
Avoid skin contact with contaminated patients. Antidotes: Amyl nitrite perles (place in bag ventilator), sodium nitrite and sodium thiosulfate.
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
EM.02.01.01.2.b
Effective
Department Generating Policy
Safety
Affected Departments
All
Prepared By
Richard L. Parker
Incubation / Route
Symptoms
Pulmonary (Choking
Agents):
Phosphene (CG)
Chlorine
Inhalation
Onset 20 minutes to 24
hours
-Phosphene: Fresh cut
grass odor, heavy gas.
Immediate irritation in high
concentration and delayed
reaction (several hours in
low concentrations)
Incapacitating (Riot
Control Agents):
Mace (CN)
Tear Gas (CS)
Adamsite (DM)
Inhalation, Skin absorption
and ingestion
Immediate onset within
seconds
Eye and airway
irritation, dyspnea,
chest tightness,
bronchospasm, delayed
non-cardiogenic
pulmonary edema.
- Phosgene: coughing,
choking, followed by
chest tightness,
nausea, tearing,
vomiting, headaches.
Death due to fluid
accumulation in the
lungs
Burning pain on
mucous membranes,
skin, and eyes, tearing,
burning in nostrils,
elevated blood
pressure, irregular
respiration, can be fatal
in confined spaces,
Agent
Oleoresin capsicum
(pepper spray)
EC
1/2008
Page
Decontamination
Required
Yes
Dept/Title
21
of
22
Plant Operations
Precautions
Standard Precautions
for patient care after
disinfection
Disinfection
Procedure
Remove clothing and wash
with soap and water.
Irrigate Eyes.
Yes, for heavy
contamination before
entry to healthcare
facility or confined
space.
Standard Precautions
Rinse eyes and skin with
copious amounts of water.
Do not use bleach
(hypochlorite) which will
worsen skin symptoms.
References: 1) Tucson Fire Department Chemical Reference Tables.
2) Bioterrorism Agent Profiles for Healthcare Workers, Arizona Department of Health Services and Samaritan Regional Poison Center, August 2001
3) Control of Communicable Disease Manual, 1995.
Compiled by Melva Morrow M.T., CIC October 2001
Contagious / Risk
No antidote, patient
management is
supportive symptom
management
Symptoms will usually
resolve in 15-20
minutes after removal
to fresh air.
Policy/Procedure Title
Bioterrorism Readiness
Manual Location
Policy/Procedure #
EM.02.01.01.2.b
Effective
Department Generating Policy
Safety
Affected Departments
All
Prepared By
Richard L. Parker
EC
1/2008
Page
Dept/Title
22
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Plant Operations
REFERENCES:
"California Hospital Bioterrorism Response Planning Guides" California Department of Health Services 2002 & Policy 6321 Attachments and
Tables
Reviews/Revisions:
Date:
By:
1st
1/2009
R. Parker
2nd
_____________
_____________
3rd
_____________
_____________
4th
_____________
_____________
5th
_____________
_____________