Download Microbiology Bioterrorism Plan

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)
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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.
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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.
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