Health Care Facilities and Bioterrorism Preparedness A Template for Healthcare Facilities

Presented by Ohio Department of Health Bureau of Environmental Health Bureau of Infectious Disease Control Disaster Preparedness and Response Program Bioterrorism Surveillance and Epidemiology Program

Introduction n The Association for Professionals in Infection Control and Epi (APIC) along with the Center for Disease Control and Prevention (CDC) created template n The Bioterrorism Readiness Plan is offered as a tool for planning and to facilitate preparation of bioterrorism readiness for individual institutions.

Telephone notification numbers necessary for a readiness plan n Internal contacts n Infection control n Epidemiologist n Administration/ Public Affairs n External contacts n Local & State Health Department n Local EMS n Local Law Enforcement n Local EMA Agency n Regional Poison Control n CDC Hospital Infections Program

Reporting Requirements and Contact Information n If a bioterrorism event is suspected, local emergency response systems should be activated. n Prompt communication is essential.

Detection of Outbreaks n Unannounced (covert) events n Announced (overt) events n Possibility of bioterrorism event should be ruled out with assistance of the FBI and state health officials.

Detection Criteria (continued) n Syndrome-based May be necessary to initiate response based on the recognition of high- risk syndromes n Epidemiological Epi principles used to assess whether patient’s presentation is typical of endemic disease or is an unusual event that should raise concern.

Four Potential Bioterrorism Agents n Anthrax (bacteria) n Botulism (toxin) n Plague (bacteria) n Smallpox (virus)

Some More Bio Agents... n Q Fever n Tularemia n Brucellosis n Viral Hemorrhagic Fevers n Viral Encephalitis n Staphylococcal enterotoxin B (SEB)

Transmission Type: Natural n Direct Contact (skin-skin, etc.) –Anthrax (animal to human) –like STD’s or common cold n Direct Large Droplet Spread (  1 m projection) –Pneumonic Plague (secondary) –like Influenza (also droplet nuclei)

Transmission Type: Natural n Indirect Vehicle-borne –Brucellosis (milk, meat) –Hep A (water) –Anthrax (meat) n Indirect Vector-borne –Bubonic plague (fleas) –like Lyme disease (ticks)

Transmission Type: Natural n Airborne Droplet Nuclei (Particles  5 microns) (Particles  5 microns) –Q fever –Smallpox (also direct and fomites) –like Tuberculosis n Airborne Dust –Hantaviruses –Aspergillosis

Transmission Type: BioT n Aerosolized –Anthrax –Smallpox –Q Fever –Tularemia –Plague n Foodborne –Ricin –Botulinum

PRIMARY PREVENTION Pre-Exposure (DPRP) n Immunization (Active) n Drug Prophylaxis n Training and Education

SECONDARY PREVENTION Incubation Period (DPRP) n Diagnosis (Class or Agent Specifics) n Passive Immunization (Immune Serum) n Pre-Treatment (Drugs)

TERTIARY PREVENTION Crisis Management of Overt Disease (DPRP) n Diagnosis n Treatment n Communication

Infection Control Practices for Patient Management n Two-Tier Precautions n Patient Placement n Patient Transport n Cleaning, Disinfecting, and Sterilization of Equipment and Environment n Discharge Management n Post-Mortem care

Isolation Precautions n All patients in healthcare facilities should be managed using Standard Precautions. n Some patients will need Transmission Based Precautions.

Standard Precautions n Handwashing n Gloves n Masks/Eye Protection or Face Shields n Gowns

Patient Placement n Infection control practices should be followed in small-scale events. n Large-scale events should incorporate triage & isolation strategies. –Grouping patients with similar syndromes. –The IC Committee should establish cohorting sites.

Patient Transport n Should be limited to movement that is essential to provide patient care. n Should reduce the opportunities for transmission of microorganisms within healthcare facilities.

Cleaning, Disinfecting, and Sterilization of Equipment and Environment n Standard Precautions should be generally applied for the management of patient-care equipment and environmental control. n Each facility should have guidelines in place for proper treatment of equipment and a contaminated environment.

Discharge Management n Ideally, patients should be declared noninfectious. n Home care may be considered (and may be DESIRABLE.)

Post-mortem Care n Inform pathology departments and clinical labs of a potentially infectious outbreak prior to submitting specimens for exam or disposal. n All autopsies should be performed using Standard Precautions. n Instructions for funeral directors should be developed and incorporated into the Bioterrorism Readiness Plan.

Post Exposure Management n Decontamination of Patients and Environment n Prophylaxis & Post-exposure immunization n Triage & Management of Large Scale Exposures or Suspected Exposures n Psychological Aspects of Bioterrorism

Decontamination of Patients & Environment n Goal = reduce extent of external contamination of the patient & contain contamination to prevent further spread. n Decontamination should only be used in instances of gross contamination. n Decisions regarding DECON needs should be in consultation with state and local health departments and in advance.

Decontamination (continued) n There is no likelihood for re-aerosolization of a bio agent off a patient and little risk associated with cutaneous exposure. –Shower with soap and water –Clean water, saline solution or commercial ophthalmic solutions are recommended for rinsing eyes. –Potentially harmful practices, such as bathing patients with bleach solutions should be AVOIDED

Prophylaxis and Post-exposure Immunization n Recommendations for prophylaxis are subject to change. n So are the treatment recommendations! n STAY TUNED!!!

Triage & Management of Large Scale Exposures / Suspected Exposures n Establish lines of communication and authority (ICS!) n Plan to cancel non-ER services and procedures. n ID sources for supply of TX resources (e.g., vaccines, immune globulin, antibiotics, botulinum anti-toxin) n Plan for efficient evaluation & discharge of patients (existing patients and incoming victims.)

Triage & Management of Large Scale Exposures / Suspected Exposures n Determine availability & sources for additional medical equipment & supplies. n Plan for allocation or re-allocation of scarce equipment. n ID ability to manage a sudden increase in the number of cadavers on site.

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

Strategies to address fears n Patient & general public fears –Explain risks, offering careful but rapid treatment and support. –Treat anxiety in unexposed persons who experience somatic symptoms. n Healthcare worker fears –Provide Bioterrorism readiness training. –Invite active, involvement in the bioterrorism readiness planning process. –Encourage participation in disaster drills.

Laboratory Support & Confirmation n Obtain diagnostic samples n Lab criteria for processing potential bioterrorism agents n Transport requirements

Laboratory Criteria for Processing Potential Bioterrorism Agents: 4 Levels n Level A: Clinical laboratories- minimal identification of agents. n Level B: County/State/ other labs- ID, confirmation, susceptibility testing.

Laboratory Criteria for Processing Potential Bioterrorism Agents: 4 Levels n Level C: State & other large facility labs with advanced capacity for testing-some molecular technologies. n Level D: CDC or select Dept. of Defense labs-Bio Safety Level 3 & 4 labs with special surge capacity & advanced molecular typing techniques.

Transport Requirements n Must be coordinated with local & state health departments & the FBI. n A chain of custody document should accompany the specimen from the moment of collection.

Patient, Visitor, & Public Info. n Methods & channels of communication used to inform public should be planned in advance. n Decide how communication & action across agencies will be accomplished (ICS!)

Anthrax n Description of Agent/Syndrome n Preventive Measures n Infection Control Practices for Patient Management n Post Exposure Management n Laboratory Support & Confirmation n Patient, Visitor & Public Information

Description of Anthrax n Etiology n Clinical Features n Modes of transmission n Incubation Period n Period of Communicability

Preventive Measures: Anthrax n A: Vaccine availability- limited n B: Immunization recommendations- administered to select military personnel. No routine vaccination of civilians.

Infection Control Practices for Patient Management: Anthrax n Isolation Precautions n Patient Placement n Patient Transport n Cleaning Equipment n Discharge n Post-mortem Care

Post Exposure Management: Anthrax n Decontamination of Patient/Environment –Contaminated clothing should be removed. –Shower with soap & water. –Decontaminate surfaces with approved solution. n Prophylaxis & Post- exposure Immunization –Recommendations are subject to change. –Should be initiated upon confirmation of an anthrax exposure.

Post Exposure Management (cont’d) n Triage & management of large scale: advance planning should include ID of –Sources of prophylactic antibiotics –Location, personnel needs & protocols for administering prophylactic post-exposure care to large number of individuals –Follow-up information & other public communication services. –How to obtain additional ventilators

Laboratory Support & Confirmation: Anthrax n A: Diagnositc Samples n B: Laboratory selection n C: Transportation requirements

Patient, Visitor & Public Information: Anthrax n Fact sheets should be prepared to explain: – that people recently exposed are not contagious & antibiotics are available for prophylactic therapy along with the anthrax vaccine. –Dosing information with side effects should be explained clearly –Decontamination procedures

Botulism n Description of Agent/Syndrome n Preventive Measures n Infection Control Practices for Patient Management n Post Exposure Management n Laboratory Support & Confirmation n Patient, Visitor & Public Information

Description of Botulism n Etiology n Clinical Features n Mode of Transmission n Incubation Period n Period of Communicability

Prevention Measures: Botulism n A: Vaccine availability n B: Immunization Recommendation

Infection Control Practices for Patient Management: Botulism n Isolation Precautions n Patient Placement n Patient Transport n Cleaning Equipment n Discharge Management n Post-mortem Care

Post Exposure Management: Botulism n A: Decontamination of patients/environment n B: Prophylaxis & post-exposure immunization n C: Triage & management of large scale exposures/potential exposures

Laboratory Support & Confirmation: Botulism Diagnostic Samples –a.) limited value in diagnosis of botulism –b.) detection is possible from serum, stool or gastric secretions Laboratory Selection - handling coordinated with local & state health departments & the FBI Transport Requirements - chain of custody document should accompany the specimen from the moment of collection.

Fact sheets should be prepared, including: n Emphasis botulism toxin is not contagious person-person n Clear description of symptoms n Instructions to report for evaluation if symptoms for evaluation if symptoms develop develop Patient, Visitor & Public Information: Botulism

Smallpox n Description of Agent/Syndrome n Preventive Measures n Infection Control Practices for Patient Management n Post Exposure Management n Laboratory Support & Confirmation n Patient, Visitor, & Public Information

Description of Smallpox & Preventive Measures n Etiology n Clinical Features n Mode of Transmission n Incubation Period n Period of Communicability n Vaccine Availability n Immunization Recommendations

Infection Control Practices for Patient Management: Smallpox n Isolation Precautions n Patient Placement n Patient Transport n Cleaning, disinfection, & sterilization of equipment & environment n Post-mortem Care

Post-Exposure Management & Laboratory Support & Confirmation n Decontamination of patients & environment n Prophylaxis & post- exposure immunization n Triage & Management of large scale exposure n Diagnostic Sample n Laboratory Selection n Transport Requirements

Patient, Visitor & Public Information: Smallpox n Fact sheets should include: –clear description of symptoms –where to report for evaluation & care if such symptoms are recognized. –details of type & duration of isolation

IN Summary... n INVITATIONAL FORUM on HOSPITAL PREPARENESS for MASS CASUALTIES –Chicago, March 2000 by AHA –Attendees Grouped Needs into FOUR Broad Categories : n Community Wide Preparedness n Staffing n Communications n Public Policy

Community Wide Preparedness n SUSTAINED Demand to be expected n Hospital Viewed as VITAL RESOURCE with 24/7 capabilities n Prior Hospital Preparedness focused on narrow band of disaster n Planning usually has not factored in “hospital as victim” n REALISTIC Response not necessarily being addressed

STAFFING n RESERVE STAFF –retired –career changed –admin –QUIT duplicating count (e.g., temp) n TEMPORARY PRIVILEGES –Licensure –Credentialing

COMMUNICATIONS n Backup and Redundant n Regular Briefings for Press and Media n Community Wide Systems for Patient Location with Single POC

PUBLIC POLICY n There must be vehicle for monies –Frist-Kennedy legislation –Stafford Act, FEMA n Approach should be understood as GENERAL strengthening of system for any disaster response

CUT The End... n QUESTIONS? n CONCERNS ?