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Quick Access Info Folder for Major Infectious Disease Emergencies & Bioterrorism Preparedness in Hong Kong Prepared by 1. Hospital Authority Infectious Disease Control Training Centre 2. Infection Control Branch, Centre for Health Protection 3. Hospital Authority Infectious Disease Centre at Princess Margaret Hospital First Edition 1st October 2009 1 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 LEFT COLUMN This Quick Access Info Folder for Major Infectious Disease Emergencies and Bioterrorism Preparedness is prepared by the Hospital Authority Infectious Disease Control Training Centre (HA IDCTC), Infection Control Branch of Centre Health Protection (ICB, CHP) and Hospital Authority Infectious Disease Centre at Princess Margaret Hospital (HA IDC at PMH) for HA public hospitals in Hong Kong Special Administrative Region as an instant reference point to identify, notify, transfer cases and implement infection control measures in major infectious disease (e.g. Avian Influenza and Severe Acute Respiratory Syndrome) and bioterrorism (e.g. Anthrax and Smallpox). These materials will be updated with current knowledge in infectious diseases and infection control. Users may download the relevant information sheet from HA intranet to keep the materials up-to-date. In Nov 2008, a commissioned training in Major Infectious Disease Emergency and Bioterrorism Preparedness Conference was held in Princess Margaret Hospital, Hong Kong to enhance frontline health workers and other relevant parties in preparedness. This guideline has taken reference to the recommendations and expertise input in drafting the contents. We welcome your feedback on the contents and presentation of this guide references. You can contact us on [email protected]. Acknowledgement We would like to thank the Johns Hopkins Hospital for its permission to take reference and adopt the materials from its Bioterrorism Quick Reference Guide in preparing this quick access folder. We would also like to thank the expert comments from the Centre for Health Protection (Emergency Response and Information Branch, Public Health Laboratory Service Branch, Surveillance & Epidemiology Branch) and Hospital Authority (Central Committee on Infectious Diseases & Emergency Response, Chief Infection Control Officer Office, Coordinating Committee on Accident & Emergency Medicine). 2 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 RIGHT COLUMN How to report a suspected bioterrorism attack in accident and emergency department? STEP ONE: Notify HA Head Office Duty Officer (HODO), the Centre for Health Protection (CHP) of Department of Health (DH), and Police if biological agent attack is suspected. Use the attached form “Notification of Suspected Cases of Biological Agent Attacks” and call HODO & CHP/ Medical Control Officer immediately before fax or email. HODO 24 hr pager: 7116 3328 A/C 999 CHP Central Notification Office Office hours: Tel: 2477 2772 (Mon: 9am – 1pm / 2pm – 6pm; Tue – Fri: 9am – 1pm / 2pm – 5:45pm; except Public Holiday) Outside office hours to CHP Medical Control Officer: Pager 7116 3300 A/C 9179 Police: 999 STEP TWO: Report in NDORS (Notifiable Diseases and Outbreak Reporting System) STEP THREE: Enter information in Accident & Emergency Information System (AEIS) Disaster Helpdesk Module Other Emergency contact numbers: Local Infection Control Team Contact Person________________________ Telephone________________________ Fax________________________ Email________________________ Local Security Office Contact Person________________________ Telephone________________________ Local Laboratory Contact Person________________________ Telephone________________________ Fax________________________ Local Administrator/HCE Contact Person________________________ Telephone________________________ Fax________________________ Email________________________ Local Operator ________________________ 3 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 Quick Access Info Folder for Major Infectious Disease Emergencies & Bioterrorism Preparedness in Hong Kong CONTENTS: INTRODUCTION PREPARATION FOR BIOTERRORISM CLINICAL RECOGNITION AND MANAGEMENT OF SUSPECTED BIOTERRORISM 5 6 7 STANDARD & TRANSMISSION BASED PRECAUTIONS FOR BIOAGENT AND EMERGING PATHOGENS 8 KEY ELEMENTS OF HEALTHCARE FACILITY INFECTION CONTROL FOR AVIAN INFLUENZA 9 INFECTION CONTROL PRACTICES FOR PATIENT MANAGEMENT 10 DISEASE IDENTIFICATION AND RESPONSE BIOTERRORISM EMERGENCIES 11 Anthrax Botulism 12 13 Plague 14 Smallpox 15 Viral Haemorraghic Fever 16 MANAGEMENT OF PATIENT SUSPECTED TO BE CONTAMINATED WITH BIOLOGICAL AGENTS AT ACCIDENT AND EMERGENCY DEPARTMENTS NOTIFICATION FORM OF SUSPECTED CASES OF BIOLOGICAL ATTACKS 17 18 MAJOR INFECTIOUS DISEASE EMERGENCIES 19 FLOW CHART OF A&E and GOPD TRIAGE ASSESSMENT FOR FEBRILE PATIENTS WITH NO SPECIFIC FOCUS IDENTIFIED OTHER THAN RESPIRATORY SYMPTOMS 20 4 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 209 INTRODUCTION This “Quick Access Info Folder for Major Infectious Disease emergencies & Bioterrorism Preparedness for Hong Kong” is designed to guide you to recognition or suspicion of a threat of bioterrorism or an occurrence of infectious diseases caused by emerging pathogens (e.g. SARS, pandemic flu). Bioterrorism is defined as the intentional or threatened use of viruses, bacteria, fungi and toxins from living organisms to produce death or disease in humans, animals, or plants. This quick access info folder will provide a brief summary of clinically relevant information dealing with the recognition, reporting, treatment and implications of infection control or public health of several of the potential biological agents that could be utilized, as well as with some of the possible emerging infectious disease agents that could be encountered. You can obtain a copy of “Quick Access Info Folder for Major Infectious Disease Emergencies & Bioterrorism Preparedness for Hong Kong” by email to [email protected] (Infectious Disease Control Training Centre Hospital Authority). st st 1 Edition (1 October 2009) 5 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 PREPARATION FOR BIOTERRORISM Based on Hospital Authority Contingency Plan for Biological Agent Attack 2008 from Hospital Authority N.B. For the sake of occupational health and case management, the potential possibility of terrorist attack with toxic/ hazardous chemicals should be excluded. . Clinical areas, especially Accident and Emergency Department and Intensive Care Unit Should alert to cases compatible with diseases associated with these biological agents and the necessary precautions. Early suspicion based on signs and symptoms, and looking for any unusual and sudden increase of cases compatible with the use of biological agents, especially those with a history of travel and possible exposure in other parts of the world. Should review cases of sudden death in otherwise healthy subjects to see if any possibility exists for exposure to these biological agents. familiarize with the reporting and notification mechanism on effective notification of such suspected cases, especially for those that are not notifiable diseases. should notify hospital laboratory/ Public Health Laboratory Centre (PHLC) of suspected cases prior to sending any patient specimens for testing as there may be potential danger to laboratory workers. in transporting specimens, staff should follow the ”Guideline on Transport of Clinical Specimens and Infectious Substances“ (Revised in July 2006). familiarize with the arrangement with the PHLC of the Centre for Health Protection in submitting patient specimens and suspicious isolates promptly for confirmation. 2. Microbiology Laboratory though specimen would be sent by the police to Public Health Laboratory Service Branch (PHLSB) of CHP in the first instance if police consider the object suspicious, microbiology laboratory should also make available, as far as possible, tests for the detection of biological agents and standardize testing protocols. should enhance training on techniques required in the detection and identification of these biological agents. familiarize with the arrangement with the PHLC in submitting patient specimens and suspicious isolates promptly for confirmation. 3. Hospital Infection Control Team (ICT) should be aware of proper isolation and environmental decontamination procedures in handling patients with suspected exposure or infection due to these biological agents. should arrange educational seminars to update staff in the necessary precautions in infections due to these biological agents. 4. Pharmacy should make available the necessary drug items, including antibiotics, antitoxins and vaccine, in case their uses are indicated. 1. 6 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 CLINICAL RECOGNITION AND MANAGEMENT OF SUSPECTED BIOTERRORISM Based on Bioterrorism quick reference guide from Johns Hopkins Hospital, USA Healthcare provider should be alert to illness patterns and diagnostic clues that might signal an unusual infectious disease outbreak due to the intentional release of a biological agent and should notify these concerns immediately to the Hospital Authority Head Office Duty Officer, the Centre for Health Protection of Department of Health and police when biological agent attack is suspected. Unlike a chemical or nuclear release, the covert of a biological agent will not have an immediate impact because of the delay between exposure and illness onset. Consequently, the first indication of a biological attack may only be identified when ill patients present with symptoms to health care providers for clinical care. Look for the following clinical and epidemiological clues that may suggest a possible bioterrorist event: 1. 2. 3. 4. 5. 6. Any unusual increase or clustering of patients presenting with clinical symptoms that suggest an infectious disease outbreak (e.g., greater than two patients presenting with an unexplained febrile illness associated with sepsis, pneumonia, adult respiratory distress, mediastinitis, rash or a botulism-like syndrome with flaccid muscle paralysis, especially if occurring in otherwise health individuals). Any case of a suspected or confirmed communicable disease due to a Category A bioterrorism agent as defined in Centre for Disease Control and Prevention (CDC), USA (e.g., anthrax, plague, tularemia, smallpox, viral hemorrhagic fever or botulism). Any unusual age distributions for common diseases (e.g. severe chickenpox-like illness among adult patients). Any unusual temporal and/or geographical clustering of illness (e.g., persons who attended the same public event or gathering). Any sudden increase in the following non-specific syndromes, especially if illness is occurring in previously healthy individuals and if there is an obvious common site of exposure: Bleeding disorders Encephalitis or meningitis Fever with rash Gastrointestinal illness Neuromuscular illness (e.g., botulism) Respiratory illness with fever Simultaneous disease outbreaks in human and animal populations. 7 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 STANDARD & TRANSMISSION BASED PRECAUTIONS FOR BIOAGENT AND EMERGING PATHOGEN STANDARD PRECAUTIONS Standard Precautions are employed in the care of ALL patients under ALL circumstances: Practice hand hygiene after each patient contact and after removing gloves Wear gloves when touching blood, body fluids secretions, excretions and contaminated items Wear a mask and eye protection, or a face shield, during procedures likely to generate splashes or sprays of blood, body fluids, secretions or excretions 4. Use proper personal protective equipment to handle contaminated patient care equipment and contaminated linens 5. Exercise care when handling sharps and disposed of in proper sharps containers 6. Practice respiratory hygiene and cough etiquette in managing patients 1. 2. 3. TRANSMISSION BASED PRECAUTIONS Depending on the infections concerned, transmission based precautions may be needed in addition to Standard Precautions. 1. Airborne Precautions 1. 2. 3. Place patient in a single room with negative pressure Wear proper respiratory protection when entering the room, e.g., N95 respirator Limit movement and transport of the patient. Place a surgical mask on the patient if he/she needs to be moved Agents requiring Airborne Precautions: Smallpox Viral haemorrhagic fever 2. Droplet Precautions 1. 2. 3. Place patient in a single room (preferred) or cohort with patients infected with the same organism Wear a surgical mask for contact within one metre of the patient Limit movement and transport of the patient. Place a surgical mask on the patient if he/she needs to be moved Agents requiring Droplet Precautions: Pneumonic plague SARS (airborne precautions for aerosol generating procedures) 3. Contact Precautions 1. 2. 3. Place patient in a single room (preferred) or cohort with patients with the same organism Wear gown and gloves for direct patient contact Limit movement and transport of the patient Agents requiring Contact Precautions: Smallpox Viral hemorrhagic fever 8 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 KEY ELEMENTS OF HEALTHCARE FACILITY INFECTION CONTROL FOR AVIAN INFLUENZA (AI): Adapted from WHO aide-memoire: healthcare facility infection control for avian influenza (AI) 1. Early recognition and reporting of AI cases: Apply FTOCC principles in all patients. 2. Health-care facility engineering controls: Place AI patients in single rooms (negative pressure if available). If single rooms are not available, cohort patients in wards keeping at least 1 metre between beds. 3. Isolation precautions for suspected and confirmed AI cases: Standard, Contact and Droplet Precautions for all persons entering the isolation room. Airborne precautions for aerosol generating procedures. 4. Specimen collection/transport/handling within health-care facilities: Use Standard, Contact and Droplet Precautions for specimen collection. Use Standard Precautions for specimen transport to the laboratory. Health-care facility laboratories should follow good biosafety practices. 5. Patient transport within health-care facilities: Limit patient transfer for essential activities only. AI patient should wear surgical mask. Health-care workers doing transport should wear gowns and gloves. 6. Patient care equipment: Dedicate to AI patient. If not possible, clean and disinfect before reuse in another patient. 7. Dishes/eating utensils: Wash with routine procedures, water and detergent. Use non-sterile rubber gloves 8. Linen and laundry: Wash with routine procedures, water and detergent; avoid shaking linen/laundry during handling. Use non-sterile rubber gloves. 9. Waste disposal: Treat waste which may be contaminated with AI virus as clinical waste. 10. Environmental cleaning and disinfection: Clean soiled and/or frequently touched surfaces regularly. 11. Additional measures to reduce nosocomial AI transmission: Limit numbers of health-care workers/family members/visitors exposed to the AI patient. Family members/visitors should be limited to those essential for patient support and should use the same infection control precautions as health-care workers. 12. Duration of AI infection control precautions: 7 days after resolution of fever for adults >12 years; 21 days after symptom onset for children <12 years. 13. Occupational health recommendations: Monitor health of health-care workers exposed to AI patients. Antiviral prophylaxis should follow prevailing policy. Promote the use of seasonal influenza vaccine. 14. Health-care facility administrative controls: Health-care worker AI education, training, and risk communication. 9 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 INFECTION CONTROL PRACTICES FOR PATIENT MANAGEMENT X X X X X X X Unknown Other X X Botulism X X BIOLOGICAL TOXINS X X X SARS ### X X X Avian Influenza ### X Viral Hemorrhagic Fever X Small Pox Pneumonic Plague X VIRUSES Bubonic Plague ## Isolation Precautions Standard Precautions Contact Precautions Airborne Precautions Droplet Precautions Patient Placement No restrictions Cohort ‘like’ patients when single room unavailable Single Room Negative Pressure Required Patient Transport No restrictions Limit movement to essential medical purposes only Place mask on patient to minimize dispersal of droplets Cleaning, Disinfection of Equipment Routine terminal cleaning of room with approved disinfectant upon discharge and as needed Disinfect surfaces with bleach/water 1:10 solution Dedicated equipment is disinfected prior to leaving room Special linen management Special considerations for medical waste Discharge Management Not discharged from hospital until determined no longer infectious Category for handling and disposal of dead bodies Anthrax BACTERIAL AGENTS Based on Bioterrorism quick reference guide from Johns Hopkins Hospital, USA X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X# X X X X X X X X X X X X X X X X X X X X X X X X X X 3 3 3 2 2 * * X X X X X X X 3 3 Laboratory Specimens X X Notify lab prior to collecting or sending specimen #For cutaneous and GI anthrax ## Add Droplet Precautions if progresses to pneumonic plague ### Airborne precautions for aerosol generating procedures * As advised by the physician i/c, infection control officer or microbiologist X 10 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 DISEASE IDENTIFICATION AND RESPONSE Based on Bioterrorism quick reference guide from Johns Hopkins Hospital, USA and HA guidelines Disease Signs & Symptoms Incubation Time (Range) Person-to-Person Transmission Transmission based Precaution Diagnosis Anthrax A. Inhalational B. Cutaneous C. Gastrointestinal Avian Influenza Botulism Pneumonic Plague SARS Smallpox Flu like symptoms and chest pain; possible 2-4 day improvement then respiratory failure and shock. Meningitis may develop Pruritic papule , then to vesicular lesions in 1-2 days, developing into painless ulcer, then eschar surrounded by edema in a few days 2 - 60 days None 1 - 7 days Direct contact with skin lesions may result in cutaneous infection Abdominal pain, nausea and vomiting, severe diarrhea, GI bleeding and fever. Typical influenza symptoms (fever, cough, sore throat, myalgia). Conjunctivitis, pneumonia and ARDS. Occasional diarrhoea. Afebrile, diplopia, dysphagia, dysarthria, dry mouth, ptosis, symmetric descending weakness, flaccid paralysis and generally normal mental status 1 - 7 days None Probably 2 - 3 days (2 - 8 days) Possibly. Presently spreads by fecal (avian) – oral (human) route Inhalation: 12 - 72 hours None High fever, cough, haemoptysis, chest pain, nausea, vomiting and headache. Advanced disease: purpuric skin lesions, copious watery or purulent sputum production; respiratory failure in 1-6 days. At onset – fever, chills, myalgia and malaise. Respiratory symptoms develop after 3 to 7 days with dry cough, dyspnoea; may develop into pneumonia, ARDS. Diarrhoea in 10%-20% of patients. Prodromal period: malaise, fever, rigors, vomiting, headache, and backache, After 2-4 days, skin lesions appear and progress uniformly from macules to papules to vesicles and pustules, mostly on face, neck, palms, soles and subsequently progress to trunk Chest X-ray evidence of widening mediastinum; obtain sputum and blood cultures. Contact Precautions Peripheral blood smear may demonstrate gram-positive bacilli on unspun smear with sepsis. Culture blood, stool and gastric aspirate. Droplet & contact Precautions (airborne precautions for aerosol generating procedures) Standard Precautions NP aspirate, tracheal aspirate for rapid antigens, PCR tests, viral culture. Gram, Wayson or Wright stain of lymph node aspirates, sputum, or cerebrospinal fluid with gram-negative bacilli with bipolar (safety pin) staining. Acute and convalescent serum specimens. NP aspirate for PCR tests. Foodborne: 12 - 72 hours (2 hours - 8 days) 1 - 3 days Yes, respiratory droplet. Droplet precautions until 48 hours of effective antibiotic therapy 2 - 10 days Yes, respiratory droplet, direct and indirect (fomite), contact. Droplet and contact precautions (airborne precautions for aerosol generating procedures). 12 - 14 days (7 - 17 days) Yes, airborne by droplet nuclei or direct contact with skin lesions or secretions Airborne & contact precautions until all scabs separate and fall off (3 to 4 weeks). Obtain serum, stool, gastric aspirate and suspect food prior to administering antitoxin. Differential diagnosis includes polio, Guillain Barre, myasthenia, tick paralysis, CVA and meningococcal meningitis. Swab culture of vesicular fluid or scab. All lesions similar in appearance and develop synchronously as opposed to chickenpox. Electron microscopy can differentiate variola virus from varicella. 11 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 BIOTERRORISM EMERGENCIES Anthrax Agent Bacillus anthracis, a Gram positive spore-forming, non-motile and non-haemolytic bacillus. Route of transmission 1. Cutaneous contact with spores or spore-contaminated materials 2. Inhalation of aerosolised spores 3. Ingestion of contaminated food Incubation period 1. Cutaneous & intestinal: 1-7 days 2. Inhalational: 2-60 days (usual 9-10 days) Clinical Manifestations 1. 2. 3. Cutaneous Begins as a pruritic papule but within 1-2 days develops into a vesicle and then a painless ulcer, turns to a characteristic black necrotic eschar in a few days. Regional lymph nodes and systemic symptoms may also be present; Mortality - 1-20% Inhalational Begins with non-specific prodrome of flu-like symptoms, fever, dyspnoea, cough, vomiting, weakness, abdominal pain, and chest pain. After 2-4 days, sudden onset of respiratory failure and CXR shows a widened mediastinum; Mortality - 75-97% Intestinal Two forms Oropharyngeal - sore throat, dysphagia, fever, cervical LN, Abdominal - Nausea, vomiting, anorexia, fever, severe abdominal pain, haematemesis, and bloody diarrhea; Mortality - 25-60% Laboratory Diagnosis 1. Specimens for Gram staining and/or culture which are useful for the diagnosis of the 3 forms of Anthrax infection are as follows: Cutaneous - Blood culture, vesicle aspirate, eschar swab Inhalational - Blood culture, CSF, sputum Intestinal - Blood culture, stool & gastric aspirate Infection control measures 1. Standard Precautions are adequate for all three forms of anthrax. 2. Direct person-to-person spread of inhalational anthrax does not occur. Decontamination 1.Remove clothing, and followed by a thorough head-to-toe shower with soap and water 2. Contaminated clothing should be stored in BIOHAZARD-labeled, plastic bags 3. Decontaminate environmental surfaces with 1 in 10 dilution of a “standard” 5.25% hypochlorite solution. Post Exposure Antibiotic Prophylaxis 1. 2. Antibiotic prophylaxis should only be initiated after exposure to Bacillus anthracis that is confirmed by the PHLC or after a thorough epidemiological assessment. The prophylaxis should continue for 8 weeks. All patients When Ciprofloxacin & Doxycycline are contraindicated Adults Ciprofloxacin 500mg po BID Doxycycline 100 mg po BID Oral amoxycillin 500 mg tds OR Children Ciprofloxacin 20-30 mg/kg/day in two divided doses (not to exceed 1g/day) OR Doxycycline: ≤ 8 yrs: 2.2mg/kg po BID > 8yrs and ≤ 45 kg: 2.2mg/kg po BID > 8 yrs and > 45 kg: use adult dose Oral amoxycillin 40 mg/kg/day in 3 divided doses (not to exceed 500mg tds) 12 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 BIOTERRORISM EMERGENCIES Botulism Based on Hospital Authority Fact Sheet on Botulism 2004 from Hospital Authority Agent 1. Clostridium botulinum, a spore- forming anaerobic Gram-positive rod produces Botulinum toxin (BT) 2. Botulinum toxin blocks acetylcholine containing vesicles from fusing with the terminal membranes of motor neuron, leading to flaccid muscle paralysis. Routes of Transmission 1. 2. 3. 4. Wound - C. botulinum & contagious Intestinal - ingesting C. botulinum & contagious Ingestion of toxin - foodborne & NOT contagious Inhalation of toxin - aerosol & NOT contagious Incubation 1. 2. Foodborne: 2 hours to 8 days ( typical 12-72 hours) Inhalational: 12-72 hours Clinical Features 1. 2. 3. 4. 5. Acute, afebrile, symmetric, descending flaccid paralysis that begins in bulbar musculature. Common S/S: diplopia, dysphagia,, dysarthria, dry mouth, ptosis, arm & leg weakness, constipation, and facial palsy. Both onset & severity depends on the amount of Botulinum toxin absorbed into blood stream. Recovery might take weeks or months Mortality : 6% in USA Laboratory Diagnosis 1. 2. Serum, stool, gastric aspirate, vomitus, food remains for toxins assay and have to be kept in refrigerator. Culture of fecal and gastric specimens for C. botulinum Treatment 1. 2. 3. Supportive care Antitoxin (trivalent: type A, B & E) should be given as soon as possible by slow IV infusion. Side effects: anaphylaxis (2%). Antibiotics have no effect on botulinum toxin. Aminoglycoside & clindamycin are contraindicated due to their exacerbation of neuromuscular blockade. Prophylaxis Foodborne: exposed persons should be closely monitored and antitoxins given once s/s develop. Infection Control Measure Standard Precautions are adequate 13 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 BIOTERRORISM EMERGENCIES Plague Agent Yersinia pestis, a Gram-negative bacillus. Routes of Transmission 1. 2. 3. 4. Flea-bite: bitten by infected flea from an infected rodent Direct handling of infected animal tissue Person-to-person spread by infectious droplets from patients suffering from pneumonic plague Aerosol spread Incubation Flea-bite: 2-8 days; Airborne: 1-3 days Clinical Forms and Features 1. 2. 3. Bubonic plague: Sudden onset of fever, acutely swollen tender lymph nodes, up to 10 cm in size Mortality: 14% Septicaemic plague: DIC, necrosis of small vessels and purpuric skin lesions, gangrene of acral regions leading to “Black Death” Pneumonic plague: fever, cough, chest pain, dyspnoea, cyanosis, haemoptysis, CXR evidence of bronchopneumonia Mortality: 33%, higher when treatment is delayed for 24 hrs after onset Laboratory Diagnosis Lymph node aspirate, taken with care to avoid generating aerosol Respiratory samples for staining and culture Blood culture Treatment of choice for Pneumonic Plague Antibiotic listed number 1 is preferred Therapy should continue for 10 days Gentamicin should be adjusted according to renal function Chloramphenicol could be used for cases with meningitis I. Adult 1. 2. 3. Gentamicin 5 mg/kg IM or IV once daily Doxycycline 100 mg IV q12h or 200 mg IV once daily [iv doxycycline is not available in HA formulary] Ciprofloxacin 400 mg IV twice daily II. Children 1. 2. 3. Gentamicin 2.5 mg/kg IM or IV three times daily Doxycycline 2.2 mg/kg IV q12h (if <45 kg, otherwise give adult dose) Ciprofloxacin 15 mg/kg IV q12h Infection Control Aspects Pneumonic plague is transmitted from person-to-person via respiratory droplets. Droplet precautions in addition to Standard Precautions should be followed. Management of Contacts Close contacts (contact at less than 2 meters) with patients suffering from pneumonic plague should receive antibiotic prophylaxis for 7 days (see regime below) and look out for fever and cough. Also put on surgical mask for up to 48 hours after antibiotic prophylaxis. Antibiotic Prophylaxis 1. 2. Doxycycline 100 mg oral twice daily ( child < 45 kg 2.2 mg/kg oral twice daily) or Ciprofloxacin 500 mg oral twice daily (child 20 mg/kg oral bd) 14 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 BIOTERRORISM EMERGENCIES Smallpox Agent: Variola (Smallpox) virus Routes of Transmission 1. 2. Airborne by droplet nuclei expelled from oropharynx of infected patients Direct contact: Virus survives for extended period in laundry from infected patients Incubation 7-17 days (usually 12-14 days) Clinical Forms and Features Onset with high fever, malaise, headache and backache. A maculopapular rash, 2-3 days later, on mouth, pharynx, face and forearm (centrifugal in distribution) with involvement of palms and soles. Lesions evolve at the same rate (i.e. NO CROPPING) over 1 to 2 days into vesicles, and later become deeply embedded pustules. th th Crusts form on 8 to 9 day. Pitted scarring upon recovery. Mortality: 3% in vaccinated and 30% or higher in unvaccinated. Laboratory Diagnosis 1. 2. 3. Specimens should be collected preferably by vaccinated staff with appropriate PPEs. Collect vesicle fluid with a tuberculin syringe and/or swab from fresh vesicles. Collect scabs if lesions are healing. Virus can be detected by Electron Microscopy or PCR. Treatment 1. 2. No specific anti-viral treatment. Treatment of secondary bacterial infection if present. Infection Control Measures 1. 2. 3. 4. 5. 6. Airborne isolation is required immediately once smallpox is suspected. Patients should be isolated until all scabs separate. Standard Precautions, Contact and Airborne Precautions should be observed for all patient care. All laundry and waste should be handled preferably by vaccinated staff. Laundry and linens should be autoclaved or washed in hot water containing hypochlorite bleach. Dispose of all non-sharps waste in red bags. Clean surface with sodium hypochlorite when possibly contaminated. Transport of patient: The patient should be covered in a linen sheet and put on a surgical mask when being transported. A designated route cleared of other people and a nonpublic elevator should be used. Patients die of smallpox should be cremated. Management of Contacts 1. 2. Definition of close contacts: household or face-to-face contact with the patient after the onset of fever. All close contacts, HCWs, laundry, and mortuary staff in hospital caring for patients with smallpox should receive vaccine as soon as possible and preferably within 4 days of exposure and monitor for fever and rash for 17 days. 15 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 BIOTERRORISM EMERGENCIES Viral Haemorraghic Fever Agent: Caused by a number of viruses. Four viruses are of concern: Ebola, Marburg, Lassa and Crimean-Congo haemorrhagic fevers because of known secondary person-to-person infection. Routes of Transmission 1. 2. 3. Direct contact with infected blood, secretions, organs or semen. Risk is highest during the late stages of disease when the patient is vomiting, having diarrhoea, or bleeding. Airborne transmission is a rare possibility if the patient has advanced disease (e.g. extensive pulmonary involvement). Incubation From 9 to 21 days (Marburg: 9 days; Crimean Congo: 13 days; 21 days; Lassa and Ebola: 21 days). Clinical Forms and Features Sudden onset of fever, headache and malaise, followed by vomiting, diarrhoea, pharyngitis and maculopapular rash. The associated bleeding tendency is often accompanied by renal failure, hepatic damage, neurological involvement and shock with multi-organ dysfunction. Laboratory Diagnosis 1. 2. 3. Isolation of viral hemorrhagic fever virus from a clinical specimen Detection of specific virus by nucleic acid testing (e.g. PCR), antigen detection assay, or electronic microscopy from a clinical specimen Ig G seroconversion or a fourfold or greater rise in titre to specific virus Clinical suspicion 1. 2. 3. History of travel to an endemic/epidemic area within the incubation period of illness onset Contact with a confirmed case Exposure to viral hemorrhagic fever infected blood or tissues Treatment No specific anti-viral treatment. Infection Control Measures 1. 2. 3. 4. 5. Standard Precautions, Contact and Airborne Precautions should be observed for all patient care. Patients should be isolated, preferably at negative pressure room All laundry and waste should be packed, sealed and labeled according to Clinical Waste Management Plan (HAHO Operation Circular No. 14/2008) Contact tracing and medical Surveillance of all close contact for 21 days from the last date of exposure should be followed. Transportation of patient should be kept to the minimum and only for essential purposes. Strict isolation precaution must be followed in such circumstances. 16 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 Management of patient suspected to be contaminated with biological agents at Accident and Emergency Departments Based on Hospital Authority Contingency Plan for Biological Agent Attack (Revised 28 Aug 08) by Hospital Authority Central Committee on Infectious Diseases & Emergency Responses Notification Step 1: Notify HA Head Office Duty Officer (HODO), the Centre for Health Protection (CHP) of Department of Health (DH), and Police if biological agent attack is suspected Use the attached form “Notification of Suspected Cases of Biological Agent Attacks” and CALL HODO & CHP (CENO) / MCO immediately before fax or email. HODO 24 hr pager: 7116 3328 A/C 999 CHP Central Notification Office (CENO) Office hours* : Tel: 2477 2772 *(Monday: 9am–1pm/2pm–6pm; Tue – Fri: 9am –1pm/ 2pm – 5:45pm; except public holiday) Outside office hours : Pager 7116 3300 A/C 9179 call CHP Medical Control Officer (MCO) Step 2: Report in NDORS (Notifiable Diseases and Outbreak Reporting System) Step 3: Enter information in Accident & Emergency Information System (AEIS) Disaster Helpdesk Module. Decontamination Patients turn up at accident and emergency departments without going through clearance at the incident site are managed as follows: Clinically non-suspicious – no further action For clinically suspicious cases: 1. Arrange appropriate PPE for staff protection; 2. Arrange decontamination of victims with appropriate level of PPE if required 3. Inform Fire Service Department if mass decontamination is required 4. Notify HODO and CENO CHP and Police 5. Enter information in AEIS Disaster Helpdesk Module 6. For objects brought into AED by the victim: Properties of patients should be collected by Police or hospital security staff with proper labeling. Pack clothes and other items in a pink plastic bag making reference to the bio-hazard arrangement and with patient label. Seek Police advice on arrangement of patients’ belongings. Inform hospital Infection Control Team 17 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 18 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 MAJOR INFECTIOUS DISEASE EMERGENCIES Severe acute respiratory syndrome (SARS) and avian influenza of pandemic potential are two major threats to Hong Kong. Hospital Authority, Centre for Health Protection and the Government of HKSAR have dedicated information portal to update the knowledge on these major infectious diseases on a regular basis. One important dimension to prevent the spread of these dreadful infections is early diagnosis. The TOCC principle (Travel, Occupation, Contact, Clustering) should always be borne in mind in assessing patients. Information regarding the countries/ areas with documented H5N1 infections in human and birds is available from the CHP website: http://www.info.gov.hk/info/flu/eng/global.htm Other useful resources: Avian and pandemic flu Contingency plan: http://www3.ha.org.hk/idctc/news_events/Contigency_plan_AI_master_folder_30_AMR_05_pla ninIII_versionweb_v3.pdf Infection control: http://www3.ha.org.hk/idctc/document/HA%20IC%20Plan%20(AI)%20-%20Chi%20%20080815.pd f SARS Contingency Plan: http://www.ha.org.hk/haho/ho/adm/131657e.pdf Infection control: http://www.ha.org.hk/haho/ho/adm/131656e.pdf Clinical Management Guideline on Management Approach of Influenza-like Illness (ILI) & Community-acquired Pneumonia (CAP) Suspected of Avian Influenza: http://www3.ha.org.hk/idctc/document/Guideline%20on%20Management%20Approach%20of% 20ILI%20%20%20CAP%20Suspected%20of%20AI%20_Eng-11Dec08_.pdf Local organizations 1. Security Bureau of the Hong Kong Special Administrative Region Government http://www.sb.gov.hk/ 2. The Centre for Health Protection (CHP) of the Department of Health http://www.chp.gov.hk/ 3. Hospital Authority Infectious Disease Control Training Centre internet site at http://www3.ha.org.hk/idctc/default.asp Oversea organizations 1. 2. 3. World Health Organization http://www.who.int/en/ Centres for Disease Control and Prevention, USA http://www.cdc.gov/ China CDC http://www.chinacdc.net.cn/ 19 Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK st st 1 edition 1 October 2009 A&E and GOPC triage assessment for febrile patients with no specific focus identified other than respiratory symptoms (revised on 8 Jun 2008) Fever T # Recent travel outside HK Yes T2 - Travel to an area where H5N1 infections in animals or human have T1- Travel to areas other than T2 been suspected or confirmed in the recent 6 months*(Refer to epidemiology table) or travel to an area currently known to have SARS cases No Yes Assess for contact history as listed below (C3 and C4) No Consider other travel related conditions e.g. malaria, dengue, typhoid fever No O Yes Manage accordingly Occupational Exposure Any one of the following: O1 - Working in laboratory with SARS/Avian Influenza (AI) virus specimens; O2 - Contact with risky animals e.g. civet cats; O3 - Contact with wild bird, poultry or other animals in areas/cities known to have AI** Yes No C For patients diagnosed to be Community Acquired Pneumonia (with CXR evidence) Contact history Any one of the following (C1-6) C1) Unprotected close contact with suspected SARS patients in the past 10 days; C2) Hospitalized in or visited a facility with known SARS patients in the past 10 days; -------------------------------------------------------------------------------------------------------C3) Unprotected contact with human case of AI (H5N1) in the past 1 week C4) Unprotected contact with live or dead wild bird/poultry/ consume raw or undercooked poultry in areas known to have animal AI or in areas with report of indigenous human H5N1 case C5) Unprotected contact with environment contaminated by wild bird/poultry excreta in areas known to have animal AI or in areas with report of indigenous human H5N1 case C6) Unprotected close contact with a confirmed H5N1 infected animal other than poultry or wild birds (Refer to epidemiology table) Yes No C ≧2 cases) Clustering ( Yes CG1 - Cluster or persons with fever and pneumonia symptoms of recent onset; or CG2 Known cluster with high attack rate (during time with outbreak) No Consider whether isolation is needed based on clinical syndrome Isolate and notify # Fever in the past 48 hours; with NO other obvious cause of fever other than respiratory symptoms *An area shall be considered as infected with Avian Influenza (H5N1) until at least 6 months have elapsed after the confirmation of the last case and the completion of a stamping-out policy and disinfection procedures. **“In contact with” means "handling" the dead poultries, "working", "slaughtering", or "transporting" poultries in the affected areas. Consider as high risk if patient satisfies the conditions shown in the flowchart Allocate the patient to designated screening area of the Accident & Emergency Department or General Outpatient Clinic according to individual hospital and clinic setting. Ensure speedy consultation and management. 20