Download Bioterrorism Readiness Plan

Bioterrorism
Readiness Plan
Shands Hospital at the University of Florida
2001
Tokyo Train Station
Aerial view of anthrax production
facility
Where and when will
bioterrorism hit next?
Biological
Weapons?????
Bioterrorism Readiness
Planning Subcommittee
Sub committee of Infection Prevention
and Control Committee
Chair: Kenneth Rand, MD
Multidisciplinary Membership
Multidisciplinary Membership
Infection Control Staff
Hospital Epidemiologist
Physicians
• Infectious Disease Physicians
• Emergency Medicine Chief
and other ER Physicians
• Surgeons
Emergency Department
Nurse Manager
Safety Director
Public Relations
Respiratory Care
Laboratory
Facilities Operations
Public Health
Administrator & other
agencies
Materials Management
Administration
Bioterrorism Readiness Plan
Purpose
To be a:
Reference on bioterrorism
A practical and realistic institutional response for
a real or suspected bioterrorism attack
Plan that incorporates local and state health
agencies recommendations
 A branch of existing disaster preparedness and
other emergency plans
Bioterrorism Readiness Plan
Components
Infection Control Activities
Laboratory Policies
Public Inquiry
Disease Specific Information
Appendix
FBI Field Offices
Telephone Directory of State and Territorial
Public Health Directors
Relevant Websites
Indications of a Possible
Bioterrorism Event
Unusual illness in a population
Large number of ill persons with similar disease
Large numbers of cases of unexplained diseases or death
Higher morbidity or mortality in association with a
common disease or syndrome
Single case of unusual agent
No illness in persons not exposed to common ventilation
system
Threat received indicating exposure
Bioterrorism Readiness Plan
Basic Premises
In a case of suspected/real bioterrorism
related event or outbreak
 All personnel are responsible for immediately
reporting suspected event.
The Shands Disaster Plan shall be activated in
conjunction with this Bioterrorism Readiness
Plan.
Bioterrorism Readiness Plan
Authority to rapidly implement prevention and control
measures
Administration
Director On Call
Infection Prevention and Control
Hospital Epidemiologist
Chairman
Director or designee
Safety and Security
Director or designee
Bioterrorism Readiness Plan
Communication Network
Shands
Operator
Individual
Administration
Director-On-Call
Infection Control & Safety and Security
Public Health
FBI
Public Relations
CDC
Local and State Authorities
( EMS, Police, Fire Departments)
D
E
P
T
S
Maximum Containment Lab
Bioterrorism Readiness Plan
Staff Education
Initial special program to introduce plan
Video tape and module
Ongoing education incorporated into
orientation and annual Infection Control and
Safety programs
Bioterrorism Preparedness Drills
Bioterrorism Readiness Plan
Section I: General Recommendation for any
Suspected Event
Reporting Requirements and Contact Information
Internal
External
Potential Agents
Syndrome Based
Epidemiologic Features
Patient, Visitor and Public Information
Pharmacy
Bioterrorism Readiness Plan
Section I: General Recommendation for any Suspected
Event: Infection Control Practices
Isolation
Patient Placement
Patient Transport
Cleaning, Disinfection and Sterilization
Discharge Management
Post-mortem Care
Post Exposure Management
Decontamination of Patients and Environment
Prophylaxis and post-exposure management
Triage
Psychological Aspects of Bioterrorism
Bioterrorism Readiness Plan
Section I: General Recommendation for any Suspected
Event:
Infection Control Practices
Laboratory Support and Confirmation
Obtaining diagnostic samples
Criteria for processing
Transportation of clinical specimens
Management and handling of criminal investigation
specimens
Bioterrorism Readiness Plan
Section II:
Agent Specific Recommendations
Anthrax
Botulinum Toxin
Plague
Smallpox
Ricin
Anthrax
Anthrax
Transmission:
Inhalation
Ingestion
Skin contact
Associated with infected animals such as sheep, goats,
and cattle (Woolsorter’s disease)
 No person to person transmission of inhalation
anthrax
 Direct exposure to cutaneous anthrax lesions may
result in secondary cutaneous infections
Anthrax: Mode of Transmission for
Bioterrorism
Spore is durable
Delivered as an aerosol= inhale spores
Ingestion of contaminated food
Cutaneous contact with spores or sporecontaminated material
Anthrax time curve after incident
Inhalation
Anthrax
Incubation Period
Range 1 day to 8 weeks (average 5 days)
• 2-60 days following pulmonary exposure
• 1-7 days following cutaneous exposure
• 1-7 days following ingestion
Period of Communicability
No person to person for inhalation
Anthrax
Clinical Features
Pulmonary
• Non-specific flu-like symptoms
• 2-4 days after symptoms
– Abrupt onset of respiratory failure
Widened mediastinum on chest x-ray
• High mortality almost 100% if treatment
initiated after onset of respiratory symptoms
Anthrax Chest Xray
Note the
widened
mediastinum
Anthrax
Clinical Features
Cutaneous Anthrax (skin contact)
• Commonly seen on head, forearms and hands
• papular lesion that turns vesicular within 2-6 days
• usually non-fatal if treated with antibiotics and a 25%
mortality rate if untreated
Gastro-intestinal Anthrax (ingestion)
• bloody diarrhea, hematemesis
• + blood cultures after 2-3 days
• usually fatal ( almost 100% mortality) after progression to
toxemia and sepsis
Cutaneous Anthrax
Lymph node tissue infected with anthrax is
shown in this picture.
Anthrax
Preventive Measures
Standard Precautions
Antibiotic Therapy
Ciprofloxacin
Levofloxacin
Ofloxacin
Doxycycline
Amoxicillin for exposed children
Vaccination
Botulism
Botulism
Clostridium botulism
Present in soil and marine sediment
Foodborne botulism most common disease
Inhalation botulism may also occur
Botulism
Clinical Features
GI symptoms for food borne disease
Responsive patient with absence of fever
Symmetric cranial neuropathies
Blurred vision
Symmetric descending weakness in a proximal
to distal pattern
Respiratory dysfunction
Botulism: Mode of Transmission
Mode of Transmission
Ingestion of toxin-contaminated food
Aerosolization of toxin
Incubation Period
Neurologic symptoms from food borne
botulism begin 12-36 hours after ingestion
Neurologic symptoms of inhalation botulism
begin 24-72 hours after aerosol exposure
Not transmitted person to person
Botulism: Exposure Management
Preventative Measures
Vaccine
• takes 3 injections at 0,2, and 12 weeks
• routine vaccination not recommended
• used by Department of Defense
Standard Precautions
Prophylaxis and Post exposure immunization
Trivalent botulinum antitoxin
Patients may require mechanical ventilation
Assess vent availability
Plague
Causative agent:
Yersinia pestis, a gram-negative bacillus
usually zoonotic disease of rodents
 usually transmitted by infected fleas
• resulting in lymphatic and blood infections
– Bubonic plague
– Septicemia plague
Bioterrorism exposure are expected to be
airborne resulting in a pulmonary variant,
pneumonic plague
Life cycle of plague
Plague
Clinical Features
Pneumonic Plague
Fever, cough, chest pain
Hemoptysis
Muco-purulent or watery sputum with GNRs
in gram stain
X-ray with evidence of bronchopneumonia
Bubonic Plague - skin and tissue disease
form
Lung biopsy from pneumonic
plague
Plague
Transmission
Normally from an infected rodent to man by infected flea
Bioterrorism-related = dispersion of an aerosol
Person to person transmission of pneumonic plague is possible
via large aerosol droplets
Communicability
Via Productive cough
Droplet Precautions until 72 hours after initiation of effective
antimicrobial therapy
Incubation: 2-8 days due to fleaborne disease or 1-3 days for
pulmonary exposure
Plague
Preventive Measures
Droplet Precautions
Private Room or cohort, doors closed but no special
ventilation needed
Maintain isolation for 72 hours after effective
antimicrobial therapy has been initiated
Vaccine not practical since requires multiple doses over
several weeks and post exposure immunity has no utility
Post exposure Prophylaxis
Doxycycline
Ciprofloxacin
Last known person with smallpox
in the world
Public Health Quarantine Sign
Smallpox
Causative agent:Variola virus
Eradicated clinical smallpox from world
Two WHO labs store virus
Severe morbidity if released into non-immune
population
single case is considered a public health emergency
Can be aerosolized or contaminated items can
be used to deploy this virus as a biological
warfare agent
Smallpox in Child
Progression of Smallpox Lesion
Smallpox
Clinical Features
Acute viral illness with skin lesions
quickly progressing from macules to papules to vesicles
2-4 days = prodrome of non-specific fever and
myalgias
Rash most prominent on face and extremities
including palms and soles in contrast to truncal
distribution of varicella
Rash scabs in 1-2 weeks
Variola rash has a synchronous onset in contrast to
varicella’s “crops” of lesions
Smallpox
Mode of transmission:
airborne, droplet and contact.
Patients are most infectious if they are coughing or
have hemorrhagic form
Person to person spread
Incubation Period = 7-17 days (ave. = 12 days)
Period of Communicability = Variola becomes
infectious at onset of rash and continues to be
infectious until their scabs separate which is
approximately 3 weeks
Time curve of smallpox after
incident
Smallpox
Preventive Measures
STRICT ISOLATION
Negative air pressure room, doors must remain
closed, verify ventilation
Mask, gown and glove for entry into room
Limit transport
Handle all surfaces and supplies as
contaminated
Smallpox
Preventive Measures
Live virus intradermal vaccine
Vaccinia virus is used for vaccine
does not confer lifelong immunity
Must be given within 7 days post exposure to
be effective
Durability of smallpox
Smallpox vaccination
Ricin
Causative agent:
A biological toxin derived from the castor
plant and castor oil.
Toxin inhibits protein synthesis
Exposure routes:
inhalation
percutaneous
ingestion
Ricin
Clinical Features
Weakness, fever, cough and pulmonary edema
occur within 18 hours after inhalation exposure
Progressing to respiratory distress and death from
hypoxemia within 36-72 hours
Diagnosis: signs and symptoms found in large
number of a geographically clustered group
ELISA : acute and convalescent titers in serum
Ricin
Treatment:
supportive including treatment for pulmonary
edema and gastric decontamination
Prophylaxis: None available
Prevention
Protective mask to prevent inhalation
Standard Precautions
• Weak hypochlorite solution (0.1% sodium
hypochlorite) and/or soap and water can
decontaminate skin surfaces
Steps in Preparing for a
Bioterrorism Event
Know how to locate
policy
Review Executive
Summary of Plan for
inclusion in Disaster
Manual
Access Specific
Departmental Policies
ER
Pharmacy
Use Information
Sheets for Patients and
Public
Learn about
bioterrorism by
completing module.
Get your questions
answered by experts
Coordinate plan with
state and local
authorities