Health Care Facilities and Health Care Facilities and Bioterrorism PreparednessBioterrorism Preparedness

A Template for Healthcare A Template for Healthcare FacilitiesFacilities

Presented byPresented by

Ohio Department of HealthOhio Department of HealthBureau of Environmental Health Bureau of Environmental Health

Bureau of Infectious Disease ControlBureau of Infectious Disease Control

Disaster Preparedness and Response Disaster Preparedness and Response ProgramProgram

Bioterrorism Surveillance and Bioterrorism Surveillance and Epidemiology ProgramEpidemiology Program

IntroductionIntroduction

The Association for Professionals in The Association for Professionals in Infection Control and Epi (APIC) along Infection Control and Epi (APIC) along with the Center for Disease Control with the Center for Disease Control and Prevention (CDC) created and Prevention (CDC) created templatetemplate

The Bioterrorism Readiness Plan is The Bioterrorism Readiness Plan is offered as a tool for planning and to offered as a tool for planning and to facilitate preparation of bioterrorism facilitate preparation of bioterrorism readiness for individual institutions.readiness for individual institutions.

Telephone notification numbers Telephone notification numbers necessary for a readiness plannecessary for a readiness plan

Internal Internal contactscontacts

Infection controlInfection control EpidemiologistEpidemiologist Administration/ Administration/

Public AffairsPublic Affairs

External contactsExternal contacts

Local & State Health Local & State Health DepartmentDepartment

Local EMSLocal EMS Local Law EnforcementLocal Law Enforcement Local EMA AgencyLocal EMA Agency Regional Poison Regional Poison

ControlControl CDC Hospital CDC Hospital

Infections ProgramInfections Program

Reporting Requirements Reporting Requirements and Contact Informationand Contact Information

If a bioterrorism If a bioterrorism event is event is suspected, local suspected, local emergency emergency response response systems should systems should be activated.be activated.

Prompt Prompt communication communication is essential.is essential.

Detection of OutbreaksDetection of Outbreaks

Unannounced (covert) Unannounced (covert) eventsevents

Announced (overt) Announced (overt) eventsevents

Possibility of Possibility of bioterrorism event bioterrorism event should be ruled out should be ruled out with assistance of the with assistance of the FBI and state health FBI and state health officials.officials.

Detection Criteria Detection Criteria (continued)(continued)

Syndrome-Syndrome-basedbased

May be necessary May be necessary to initiate to initiate response based response based on the recognition on the recognition of high-risk of high-risk syndromessyndromes

EpidemiologicalEpidemiological

Epi principles used to Epi principles used to assess whether assess whether patient’s patient’s presentation is presentation is typical of endemic typical of endemic disease or is an disease or is an unusual event that unusual event that should raise concern.should raise concern.

Four Potential Bioterrorism Four Potential Bioterrorism AgentsAgents

Anthrax (bacteria)Anthrax (bacteria) Botulism (toxin)Botulism (toxin) Plague (bacteria)Plague (bacteria) Smallpox (virus)Smallpox (virus)

Some More Bio Agents...Some More Bio Agents...

Q FeverQ Fever TularemiaTularemia BrucellosisBrucellosis Viral Hemorrhagic Viral Hemorrhagic

FeversFevers Viral EncephalitisViral Encephalitis Staphylococcal Staphylococcal

enterotoxin B (SEB)enterotoxin B (SEB)

Transmission Type: Transmission Type: NaturalNatural

Direct Contact (skin-skin, etc.)Direct Contact (skin-skin, etc.)– Anthrax (animal to human)Anthrax (animal to human)– like STD’s or common coldlike STD’s or common cold

Direct Large Droplet Spread (Direct Large Droplet Spread ( 1 m 1 m projection)projection)– Pneumonic Plague (secondary)Pneumonic Plague (secondary)– like Influenza (also droplet nuclei)like Influenza (also droplet nuclei)

Transmission Type: NaturalTransmission Type: Natural

Indirect Vehicle-borneIndirect Vehicle-borne– Brucellosis (milk, meat)Brucellosis (milk, meat)– Hep A (water)Hep A (water)– Anthrax (meat)Anthrax (meat)

Indirect Vector-borneIndirect Vector-borne– Bubonic plague (fleas)Bubonic plague (fleas)– like Lyme disease (ticks)like Lyme disease (ticks)

Transmission Type: NaturalTransmission Type: Natural

Airborne Droplet NucleiAirborne Droplet Nuclei

(Particles (Particles 5 microns) 5 microns) – Q feverQ fever– Smallpox (also direct and fomites)Smallpox (also direct and fomites)– like Tuberculosislike Tuberculosis

Airborne DustAirborne Dust– HantavirusesHantaviruses– AspergillosisAspergillosis

Transmission Type: Transmission Type: BioTBioT AerosolizedAerosolized

– AnthraxAnthrax– SmallpoxSmallpox– Q FeverQ Fever– TularemiaTularemia– PlaguePlague

FoodborneFoodborne– RicinRicin– BotulinumBotulinum

PRIMARY PREVENTION PRIMARY PREVENTION Pre-Exposure (DPre-Exposure (DPPRP)RP)

Immunization (Active)Immunization (Active)

Drug ProphylaxisDrug Prophylaxis

Training and EducationTraining and Education

SECONDARY PREVENTIONSECONDARY PREVENTIONIncubation Period (DIncubation Period (DPRPRP)P)

Diagnosis (Class or Agent Diagnosis (Class or Agent Specifics)Specifics)

Passive Immunization (Immune Passive Immunization (Immune Serum)Serum)

Pre-Treatment (Drugs)Pre-Treatment (Drugs)

TERTIARY PREVENTIONTERTIARY PREVENTIONCrisis Management of Overt Crisis Management of Overt

Disease (DPDisease (DPRRP)P) DiagnosisDiagnosis

TreatmentTreatment

CommunicationCommunication

Infection Control Practices for Infection Control Practices for Patient ManagementPatient Management

Two-Tier PrecautionsTwo-Tier Precautions Patient PlacementPatient Placement Patient TransportPatient Transport Cleaning, Disinfecting, Cleaning, Disinfecting,

and Sterilization of Equipment and Sterilization of Equipment and Environment and Environment

Discharge ManagementDischarge Management Post-Mortem carePost-Mortem care

Isolation PrecautionsIsolation Precautions

All patients in All patients in healthcare facilities healthcare facilities should be managed should be managed using using Standard Standard Precautions.Precautions.

Some patients will Some patients will need need Transmission Transmission Based Based Precautions.Precautions.

Standard PrecautionsStandard Precautions

HandwashingHandwashing GlovesGloves Masks/Eye Masks/Eye

Protection or Protection or Face ShieldsFace Shields

GownsGowns

Patient PlacementPatient Placement Infection control practices should be Infection control practices should be

followed in small-scale events.followed in small-scale events. Large-scale events should Large-scale events should

incorporate triage & isolation incorporate triage & isolation strategies.strategies.– Grouping patients with similar Grouping patients with similar

syndromes.syndromes.– The IC Committee should establish The IC Committee should establish

cohorting sites.cohorting sites.

Patient TransportPatient Transport

Should be limited to Should be limited to movement that is movement that is essential to provide essential to provide patient care.patient care.

Should reduce the Should reduce the opportunities for opportunities for transmission of transmission of microorganisms microorganisms within healthcare within healthcare facilities.facilities.

CleaningCleaning, , Disinfecting, and Disinfecting, and Sterilization of Equipment and Sterilization of Equipment and

EnvironmentEnvironment

Standard Precautions should be Standard Precautions should be generally applied for the management generally applied for the management of patient-care equipment and of patient-care equipment and environmental control.environmental control.

Each facility should have guidelines in Each facility should have guidelines in place for proper treatment of equipment place for proper treatment of equipment and a contaminated environment. and a contaminated environment.

Discharge ManagementDischarge Management

Ideally, patients Ideally, patients should be should be declared declared noninfectious.noninfectious.

Home care may Home care may be considered be considered (and may be (and may be DESIRABLE.)DESIRABLE.)

Post-mortem CarePost-mortem Care

Inform pathology departments and clinical Inform pathology departments and clinical labs of a potentially infectious outbreak prior labs of a potentially infectious outbreak prior to submitting specimens for exam or to submitting specimens for exam or disposal.disposal.

All autopsies should be performed using All autopsies should be performed using Standard Precautions.Standard Precautions.

Instructions for funeral directors should be Instructions for funeral directors should be developed and incorporated into the developed and incorporated into the Bioterrorism Readiness Plan.Bioterrorism Readiness Plan.

Post Exposure Post Exposure ManagementManagement

Decontamination of Patients and Decontamination of Patients and EnvironmentEnvironment

Prophylaxis & Post-exposure Prophylaxis & Post-exposure immunizationimmunization

Triage & Management of Large Scale Triage & Management of Large Scale Exposures or Suspected ExposuresExposures or Suspected Exposures

Psychological Aspects of BioterrorismPsychological Aspects of Bioterrorism

Decontamination of Decontamination of Patients & EnvironmentPatients & Environment

Goal =Goal = reduce extent of external reduce extent of external contamination of the patient & contain contamination of the patient & contain contamination to prevent further spread.contamination to prevent further spread.

Decontamination should Decontamination should onlyonly be used in be used in instances of gross contamination.instances of gross contamination.

Decisions regarding DECON needs should Decisions regarding DECON needs should be in consultation with state and local be in consultation with state and local health departments and health departments and in advancein advance..

Decontamination Decontamination (continued)(continued)

There is no likelihood for re-aerosolization There is no likelihood for re-aerosolization of a bio agent off a patient and little risk of a bio agent off a patient and little risk associated with cutaneous exposure. associated with cutaneous exposure. – Shower with soap and waterShower with soap and water– Clean water, saline solution or commercial Clean water, saline solution or commercial

ophthalmic solutions are recommended for ophthalmic solutions are recommended for rinsing eyes.rinsing eyes.

– Potentially harmful practices, such as Potentially harmful practices, such as bathing patients with bleach solutions bathing patients with bleach solutions should be AVOIDEDshould be AVOIDED

Prophylaxis and Post-Prophylaxis and Post-exposure Immunizationexposure Immunization

Recommendations Recommendations for prophylaxis are for prophylaxis are subject to change.subject to change.

So are the So are the treatment treatment recommendations!recommendations!

STAY TUNED!!!STAY TUNED!!!

Triage & Management of Large Triage & Management of Large Scale Exposures / Suspected Scale Exposures / Suspected

ExposuresExposures Establish lines of communication and Establish lines of communication and

authority (ICS!)authority (ICS!) Plan to cancel non-ER services and Plan to cancel non-ER services and

procedures.procedures. ID sources for supply of TX resources (e.g., ID sources for supply of TX resources (e.g.,

vaccines, immune globulin, antibiotics, vaccines, immune globulin, antibiotics, botulinum anti-toxin)botulinum anti-toxin)

Plan for efficient evaluation & discharge of Plan for efficient evaluation & discharge of patients (existing patients and incoming patients (existing patients and incoming victims.)victims.)

Triage & Management of Large Triage & Management of Large Scale Exposures / Suspected Scale Exposures / Suspected

ExposuresExposures

Determine availability & sources for Determine availability & sources for additional medical equipment & additional medical equipment & supplies.supplies.

Plan for allocation or re-allocation of Plan for allocation or re-allocation of scarce equipment. scarce equipment.

ID ability to manage a sudden ID ability to manage a sudden increase in the number of cadavers on increase in the number of cadavers on site.site.

Psychological aspects of Psychological aspects of bioterrorismbioterrorism

Following a Following a bioterrorism-bioterrorism-related event, related event, fear & panic can fear & panic can be expected from be expected from both patients and both patients and healthcare healthcare providers.providers.

Strategies to address fearsStrategies to address fears

Patient & general Patient & general public fearspublic fears– Explain risks, offering Explain risks, offering

careful but rapid careful but rapid treatment and support.treatment and support.

– Treat anxiety in Treat anxiety in unexposed persons unexposed persons who experience who experience somatic symptoms.somatic symptoms.

Healthcare worker Healthcare worker fearsfears– Provide Bioterrorism Provide Bioterrorism

readiness training.readiness training.– Invite active, Invite active,

involvement in the involvement in the bioterrorism readiness bioterrorism readiness planning process.planning process.

– Encourage Encourage participation in participation in disaster drills. disaster drills.

Laboratory Support & Laboratory Support & ConfirmationConfirmation

Obtain diagnostic Obtain diagnostic samplessamples

Lab criteria for Lab criteria for processing processing potential potential bioterrorism agentsbioterrorism agents

Transport Transport requirementsrequirements

Laboratory Criteria for Processing Laboratory Criteria for Processing Potential Bioterrorism Agents: Potential Bioterrorism Agents: 4 4

LevelsLevels

Level A:Level A: Clinical laboratories- Clinical laboratories-minimal identification of agents.minimal identification of agents.

Level B:Level B: County/State/ other County/State/ other labs- ID, confirmation, labs- ID, confirmation, susceptibility testing.susceptibility testing.

Laboratory Criteria for Processing Laboratory Criteria for Processing Potential Bioterrorism Agents: Potential Bioterrorism Agents: 4 4

LevelsLevels

Level C:Level C: State & other large facility State & other large facility labs with advanced capacity for labs with advanced capacity for testing-some molecular technologies.testing-some molecular technologies.

Level D:Level D: CDC or select Dept. of CDC or select Dept. of Defense labs-Bio Safety Level 3 & 4 Defense labs-Bio Safety Level 3 & 4 labs with special surge capacity & labs with special surge capacity & advanced molecular typing advanced molecular typing techniques.techniques.

Transport RequirementsTransport Requirements Must be coordinated Must be coordinated

with local & state with local & state health departments health departments & the FBI.& the FBI.

A chain of custody A chain of custody document should document should accompany the accompany the specimen from the specimen from the moment of moment of collection.collection.

Patient, Visitor, & Public Patient, Visitor, & Public Info.Info.

Methods & channels Methods & channels of communication of communication used to inform used to inform public should be public should be planned in advance.planned in advance.

Decide how Decide how communication & communication & action across action across agencies will be agencies will be accomplished accomplished (ICS!)(ICS!)

AnthraxAnthrax

Description of Agent/SyndromeDescription of Agent/Syndrome Preventive MeasuresPreventive Measures Infection Control Practices for Infection Control Practices for

Patient ManagementPatient Management Post Exposure ManagementPost Exposure Management Laboratory Support & ConfirmationLaboratory Support & Confirmation Patient, Visitor & Public InformationPatient, Visitor & Public Information

Description of Description of AnthraxAnthrax

EtiologyEtiology Clinical FeaturesClinical Features Modes of Modes of

transmissiontransmission Incubation PeriodIncubation Period Period of Period of

CommunicabilityCommunicability

Preventive Measures: Preventive Measures: AnthraxAnthrax

A: Vaccine A: Vaccine availability- limited availability- limited

B: Immunization B: Immunization recommendations-recommendations-administered to administered to select military select military personnel. No personnel. No routine vaccination routine vaccination of civilians .of civilians .

Infection Control Practices Infection Control Practices for Patient Management: for Patient Management:

AnthraxAnthrax

Isolation PrecautionsIsolation Precautions Patient PlacementPatient Placement Patient TransportPatient Transport Cleaning EquipmentCleaning Equipment DischargeDischarge Post-mortem CarePost-mortem Care

Post Exposure Management:Post Exposure Management: AnthraxAnthrax

Decontamination of Decontamination of Patient/EnvironmenPatient/Environmentt– Contaminated Contaminated

clothing should be clothing should be removed.removed.

– Shower with soap & Shower with soap & water.water.

– Decontaminate Decontaminate surfaces with surfaces with approved solution.approved solution.

Prophylaxis & Prophylaxis & Post-exposure Post-exposure ImmunizationImmunization– Recommendations Recommendations

are subject to are subject to change.change.

– Should be initiated Should be initiated upon confirmation upon confirmation of an anthrax of an anthrax exposure.exposure.

Post Exposure Post Exposure Management (cont’d)Management (cont’d)

Triage & management of large Triage & management of large scale: advance planning should scale: advance planning should include ID ofinclude ID of– Sources of prophylactic antibioticsSources of prophylactic antibiotics– Location, personnel needs & protocols for Location, personnel needs & protocols for

administering prophylactic post-exposure administering prophylactic post-exposure care to large number of individualscare to large number of individuals

– Follow-up information & other public Follow-up information & other public communication services.communication services.

– How to obtain additional ventilatorsHow to obtain additional ventilators

Laboratory Support & Laboratory Support & Confirmation: Confirmation: AnthraxAnthrax

A: Diagnositc A: Diagnositc SamplesSamples

B: Laboratory B: Laboratory selectionselection

C: Transportation C: Transportation requirementsrequirements

Patient, Visitor & Public Patient, Visitor & Public Information: Information: AnthraxAnthrax

Fact sheets should be prepared to Fact sheets should be prepared to explain: explain: – that people recently exposed are that people recently exposed are notnot

contagious & antibiotics are available contagious & antibiotics are available for prophylactic therapy along with the for prophylactic therapy along with the anthrax vaccine.anthrax vaccine.

– Dosing information with side effects Dosing information with side effects should be explained clearlyshould be explained clearly

– Decontamination proceduresDecontamination procedures

BotulismBotulism

Description of Agent/SyndromeDescription of Agent/Syndrome Preventive MeasuresPreventive Measures Infection Control Practices for Infection Control Practices for

Patient ManagementPatient Management Post Exposure ManagementPost Exposure Management Laboratory Support & ConfirmationLaboratory Support & Confirmation Patient, Visitor & Public InformationPatient, Visitor & Public Information

Description of Description of BotulismBotulism

EtiologyEtiology Clinical FeaturesClinical Features Mode of TransmissionMode of Transmission Incubation PeriodIncubation Period Period of CommunicabilityPeriod of Communicability

Prevention Measures: Prevention Measures: BotulismBotulism

A: Vaccine availabilityA: Vaccine availability B: Immunization B: Immunization

RecommendationRecommendation

Infection Control Practices Infection Control Practices for Patient Management: for Patient Management:

BotulismBotulism

Isolation PrecautionsIsolation Precautions Patient PlacementPatient Placement Patient TransportPatient Transport Cleaning EquipmentCleaning Equipment Discharge ManagementDischarge Management Post-mortem CarePost-mortem Care

Post Exposure Post Exposure Management: Management: BotulismBotulism

A: Decontamination of A: Decontamination of patients/environmentpatients/environment

B: Prophylaxis & post-exposure B: Prophylaxis & post-exposure immunizationimmunization

C: Triage & management of large C: Triage & management of large scale exposures/potential scale exposures/potential exposuresexposures

Laboratory Support & Laboratory Support & Confirmation: Confirmation: BotulismBotulism

Diagnostic SamplesDiagnostic Samples – a.) limited value in diagnosis of botulism a.) limited value in diagnosis of botulism – b.) detection is possible from serum, stool or b.) detection is possible from serum, stool or

gastric secretionsgastric secretions

Laboratory SelectionLaboratory Selection - handling - handling coordinated with local & state health coordinated with local & state health departments & the FBIdepartments & the FBI

Transport RequirementsTransport Requirements - chain of - chain of custody document should accompany the custody document should accompany the specimen from the moment of collection.specimen from the moment of collection.

Fact sheets should be prepared, including: Fact sheets should be prepared, including: Emphasis botulism toxin is not contagious person-personEmphasis botulism toxin is not contagious person-person Clear description of symptomsClear description of symptoms Instructions to reportInstructions to report

for evaluation if symptomsfor evaluation if symptoms

developdevelop

Patient, Visitor & Public Patient, Visitor & Public Information: Information: BotulismBotulism

SmallpoxSmallpox

Description of Agent/SyndromeDescription of Agent/Syndrome Preventive MeasuresPreventive Measures Infection Control Practices for Infection Control Practices for

Patient ManagementPatient Management Post Exposure ManagementPost Exposure Management Laboratory Support & ConfirmationLaboratory Support & Confirmation Patient, Visitor, & Public InformationPatient, Visitor, & Public Information

Description of Description of SmallpoxSmallpox & & Preventive MeasuresPreventive Measures

EtiologyEtiology Clinical FeaturesClinical Features Mode of Mode of

TransmissionTransmission Incubation PeriodIncubation Period Period of Period of

CommunicabilityCommunicability

Vaccine Vaccine AvailabilityAvailability

Immunization Immunization RecommendationRecommendationss

Infection Control Practices for Infection Control Practices for Patient Management:Patient Management:

SmallpoxSmallpox

Isolation PrecautionsIsolation Precautions Patient PlacementPatient Placement Patient TransportPatient Transport Cleaning, disinfection, & Cleaning, disinfection, &

sterilization of equipment & sterilization of equipment & environmentenvironment

Post-mortem CarePost-mortem Care

Post-Exposure Management & Post-Exposure Management & Laboratory Support & Laboratory Support &

ConfirmationConfirmation

Decontamination of Decontamination of patients & patients & environmentenvironment

Prophylaxis & post-Prophylaxis & post-exposure exposure immunizationimmunization

Triage & Triage & Management of Management of large scale large scale exposureexposure

Diagnostic Diagnostic Sample Sample

Laboratory Laboratory SelectionSelection

Transport Transport RequirementsRequirements

Patient, Visitor & Public Patient, Visitor & Public Information: Information: SmallpoxSmallpox

Fact sheets should Fact sheets should include:include:– clear description of clear description of

symptomssymptoms– where to report for where to report for

evaluation & care if evaluation & care if such symptoms are such symptoms are recognized.recognized.

– details of type & details of type & duration of isolation duration of isolation

IN Summary...IN Summary...

INVITATIONAL FORUM on HOSPITAL INVITATIONAL FORUM on HOSPITAL PREPARENESS for MASS CASUALTIESPREPARENESS for MASS CASUALTIES – Chicago, March 2000 by AHAChicago, March 2000 by AHA– Attendees Grouped Needs into FOUR Broad Attendees Grouped Needs into FOUR Broad

CategoriesCategories: : Community Wide PreparednessCommunity Wide Preparedness StaffingStaffing CommunicationsCommunications Public PolicyPublic Policy

Community Wide Community Wide PreparednessPreparedness

SUSTAINED Demand to be SUSTAINED Demand to be expectedexpected

Hospital Viewed as VITAL Hospital Viewed as VITAL RESOURCE with 24/7 RESOURCE with 24/7 capabilitiescapabilities

Prior Hospital Preparedness Prior Hospital Preparedness focused on narrow band of focused on narrow band of disasterdisaster

Planning usually has not Planning usually has not factored in “hospital as factored in “hospital as victim”victim”

REALISTIC Response not REALISTIC Response not necessarily being necessarily being addressedaddressed

STAFFINGSTAFFING RESERVE STAFFRESERVE STAFF

– retiredretired– career changedcareer changed– adminadmin– QUIT duplicating QUIT duplicating

count (e.g., temp)count (e.g., temp) TEMPORARY TEMPORARY

PRIVILEGESPRIVILEGES– Licensure Licensure – CredentialingCredentialing

COMMUNICATIONSCOMMUNICATIONS Backup and Backup and

RedundantRedundant

Regular Briefings Regular Briefings for Press and Mediafor Press and Media

Community Wide Community Wide Systems for Patient Systems for Patient Location with Single Location with Single POCPOC

PUBLIC POLICYPUBLIC POLICY

There must be vehicle for moniesThere must be vehicle for monies– Frist-Kennedy legislationFrist-Kennedy legislation– Stafford Act, FEMA Stafford Act, FEMA

Approach should be understood as Approach should be understood as GENERAL strengthening of system GENERAL strengthening of system for any disaster responsefor any disaster response

CUT CUT The End...The End...

QUESTIONSQUESTIONS??

CONCERNS CONCERNS ??