Download Quick Access Info Folder for Major Infectious Disease Emergencies

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
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Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK
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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).
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Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK
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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
________________________
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Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK
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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
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Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK
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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).
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1 Edition (1 October 2009)
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Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK
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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.
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Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK
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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.
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Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK
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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
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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.
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INFECTION CONTROL PRACTICES FOR PATIENT MANAGEMENT
X
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Unknown Other
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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
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X#
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3
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*
*
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3
3
Laboratory Specimens
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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
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Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK
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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.
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Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK
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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)
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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
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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)
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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.
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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.
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Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK
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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
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Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK
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Quick access info folder for major infectious disease emergencies and bioterrorism preparedness in HK
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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/
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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.
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