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Russell County Hospital 1610 Dowell Road Russell Springs, KY 42642 270-866-4141 DEPARTMENT: Laboratory POLICY/PROCEDURE TITLE Microbiology Bioterrorism Plan POLICY/PROCEDURE NUMBER: 400-PE-MIC-160 Issued: 7/21/04 Revised: 5/6/06 Supercedes: Prepared by: R. Johnson Approved: Reviewed: Medical Director Approved: Reviewed: Laboratory Director I. CLASSIFICATION OF LABORATORIES. Concerns regarding the use of biological agents, such as bacteria, viruses or toxins, has led to the need for increased awareness and education of the laboratory personnel to recognize some of these agents when performing their daily functions in the clinical laboratory. Clinical labs may be the first to see an organism in a covert attack (an unannounced act of terrorism resulting in persons presenting non-specific signs and symptoms). Often these bioterrorism agents will resemble usual flora and environmental contaminants and may be a gram negative bacilli or a coccobacilli that will not be identified by automation. As such, laboratory personnel who work in the microbiology department should become familiar with the culture appearance and biochemical reactions associated with these organisms. They must consistently use good safety and infection control practices and must be able to communicate their findings to the appropriate authorities. As part of the national program to combat the bioterrorism threat, laboratories have been classified as to their role. Our laboratory is a Level A, biosafety level 2 and our role is early detection of organisms and to rule out or refer organisms to a Level B (State Laboratory in Frankfort) or higher laboratory. II. CLASSIFICATION OF BIOTERRORISM ORGANISMS. A. B. Definition of terms: 1. Biowarfare - The intentional use of biological agents to influence the outcome of a military conflict. 2. Biocrime - The intentional use of biological agents to cause harm to an individual or a small discrete targeted population. 3. Bioterrorism - The intentional or threatened (biothreat) use of biological agents to cause harm to a target population and create panic and social disorder. Bioterrorism Agent Classification. The following organisms have been identified as possible bioterrorism agents. Category Characteristics Organisms A (high priority) Easily disseminated or transmitted High morbidity and mortality Panic and social disruption Requires special action for public health preparedness High morbidity and high mortality Variola major virus (smallpox) Bacillus anthracis (anthrax) Yersinia pestis (plague) Clostridium botulinum (botulism) Francisella tularensis (tularemia) Filovirses (Ebola, Marburg VHF) Arenaviruses (Lassa, Junin VHF) B Moderately easy to disseminate Moderate morbidity and mortality Requires enhancement of CDC and public health diagnostic capacity and disease surveillance C Emerging pathogens Ease of production High morbidity and mortality Coxiella burnetti (Q fever) Brucella species (brucellosis) Burkholderia mallei (glanders) Alphaviruses (VEE, EEE, WEE) Ricin toxin (from plants) Epsilon toxin (C. perfringens) Staphylococcal enterotoxin B Salmonella species Shigella species E.coli 0157:h7 Vibrio cholerae Cryptosporidium Nipah virus Hantavirus Tick-borne HF’s Tick-borne encephalitidees Yellow fever virus MDRTB VISA (Vancomycin Intermediate Staph aureus) VRSA (Vancomycin Resistant Staph aureus) Page 1 of 3 Russell County Hospital Policy/procedure name: Microbiology Bioterrorism Plan Policy/procedure number: 400-PE-MIC-160 Issued: 7/21/04 Revised: _________________________________________________________________________________________________________ III. AGENTS IN LEVEL A PROTOCOLS – CONSULT REFERENCE BOOKS FOR DETAILED INFORMATION FOR CULTURE AND IDENTIFICATION. A. Bacillus anthracis – anthrax is a zoonotic disease transmissible to humans through handling or consumption of contaminated animal products, or though inhalation of spores from animal products. There are three forms: cutaneous, gastrointestinal, and inhalation. The organism can be isolated from blood, sputum, lesions, stool, CSF, and nasal swabs (early). If recovered, contact State Laboratory and send out report as, “Bacillus species: Sent to State Laboratory to rule out B. anthracis.” It may be presumptively identified as follows: 1. 2. 3. 4. 5. 6. B. Brucella species – B. abortus, B melitensis, B. suis, and B. canis. A zoonotic disease transmissible to humans, it is rare in the US, although endemic in some countries. Transmission is from unpasturized dairy products or direct skin contact. It is an acute disease of fever, sweating, malaise, headache, muscle and back pain. It may be isolated from blood and bone marrow and from tissue biopsies of spleen and liver. The aerosols are highly infectious (most common laboratory acquired infection). If recovered, send out report as, “Suspect Brucella species: sent to State Laboratory.” It may be presumptively identified as follows: 1. 2. 3. 4. 5. 6. C. Large, box-car shaped, encapsulated, aerobic, spore-forming, gram positive/variable bacilli. Colonies have a ground glass appearance, tenacious. Non-motile (most Bacillus sp. are positive). Non-hemolytic, but lecithinase positive. Susceptible to penicillin. Catalase positive. Non-spore-forming, faintly staining gram negative coccobacilli. Aerobic, small, non-hemolytic, slightly yellow colonies. Grows well in infusion broth. Positive for catalase, oxidase, H2S, and rapidly urease positive. Susceptible to penicillin. Satellite test negative. Yersinia pestis. Plague: a zoonotic disease acquired by humans from the bite of a flea, direct contact with contaminated tissue, and by inhalation of bacteria-laden droplets. There are three forms: bubonic, septicemic, and pneumonic. It may be isolated from bubo, spleen, liver, blood, and sputa. If recovered, send out report as, “Suspect Yersinia peestis (plague bacillus): sent to State Laboratory.” It may be presumptively identified as follows: 1. Pleomorphic, bi-polar staining, non-spore-forming, non-motile, gram negative coccobacilli in single or short chains; clumped growth in broth (stalactite pattern). 2. Gray white to slight yellow; opaque, 1 mm id diameter at 48 hours, fried egg morphology as colony ages, hammered coppery shiny surface; oxidase negative; catalase positive. 3. May be slightly hemolytic on BAP. D. Francisella tularensis is a highly infectious zoonotic plague-like disease transmissible to humans; widely enzootic in North America and other countries. Transmission is from exposure to the bite of an infected vector (ticks, flies, and mosquitoes) or by handling, ingesting, or inhaling infectious material. An ulcer usually forms at the bite site. There will be a sudden onset of chills, fever, headache, body aches, and malaise. It may be recovered from ulcers, lymph nodes, biopsies, eyes, and sputa. Clinical manifestations include glandular, ulceroglandular, oculoglandular, oropharyngeal, systemic, and pneumonic. If recovered, send out report as, “Suspect Francisella tularensis: sent to State Laboratory.” It will generally not be recovered our laboratory unless the microbiologist is told to culture for it. It requires enriched media and a prolonged incubation of 2-14 days. E. Clostridium botulinum – botulism. This is a neuroparalytic illness resulting from the action of the toxin produced by this organism. Diagnosis is made clinically based on the patient’s history and physical findings. Signs and symptoms include dry mouth, double vision, droopy eyelids, dilated pupils, progressive descending muscle weakness and paralysis, respiratory weakness, and death. Toxin testing is performed on stool, serum, and suspect foods. Page 2 of 3 Russell County Hospital Policy/procedure name: Microbiology Bioterrorism Plan Policy/procedure number: 400-PE-MIC-160 Issued: 7/21/04 Revised: _________________________________________________________________________________________________________ F. Human poxvirus infections (small pox, et al). If present, the patient will present with disseminated vesicular lesions. If suspected, contact the State Laboratory and ensure the CDC is also notified! Collect vesicular fluid as drops on slides and send slides to CDC in non-breakable, sealed holders. G. Viral hemorrhagic fevers – arenaviruses, bunyaviruses, filoviruses, flaviviruses. Collect acute and convalescent (21 days) serum specimens. Post-mortem: send paraffin tissue blocks of lung, kidney, and spleen. IV. CONTACT INFORMATION: If a bioterrorism agent is suspected, notify the laboratory director and the infection control nurse immediately. Contact the Division of Laboratory Services before shipping isolates and/or clinical specimens. Division Of Laboratory Services Dept of Health Services 100 Sower Blvd Frankfort, Kentucky 40601 1-502-564-4446 or 888-9REPORT (after hours) IV. V. SHIPPING INSTRUCTIONS: Our laboratory stocks shipping containers that consist of absorbent packing material, an inner container, and an outer container, along with labels. Specimens must be triple packaged and properly labeled. See appended detailed instructions from CDC for specific requirements. A. The primary receptacle must be watertight, sealed with masking tape, and wrapped in absorbent packing material. B. The secondary receptacle must also be watertight and wrapped in absorbent packing material. It must be labeled with the name, address, and telephone number of the shipper and with an itemized list of contents. It must also have a biohazard label affixed to it. A Shipper’s Declaration of Goods must be filled out completely and must contain an emergency contact. C. The outer container may be a cardboard box that is sealed and labeled with the shipper’s information, a biohazard label, and an infectious substance label. D. Ship via FedEx or UPS, but do not ship via a passenger aircraft. REFERENCES. A. Bioterrorism information from www.cdc.gov. B. “Bioterrorism – A Plan of Action: Bioterrorism Preparedness For Clinical Laboratories” manual provided by the Kentucky State Laboratory in Frankfort, KY. C. Download from Kentucky Cabinet for Human Resources: www.chs.ky.gov/chs/cabinetinfo. Page 3 of 3