2. Bioterrorism Readiness Plan Shands Hospital at the University of Florida 2001

3. Tokyo Train Station

4. Aerial view of anthrax production facility

5. Where and when will bioterrorism hit next?

6. Biological Weapons?????

7. Bioterrorism Readiness Planning Subcommittee  Sub committee of Infection Prevention and Control Committee  Chair: Kenneth Rand, MD  Multidisciplinary Membership

8. 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

9. 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

10. 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

11. 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

12. 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.

13. 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

14. Bioterrorism Readiness Plan Communication Network Individual Shands Operator Infection Control & Safety and Security Director-On-Call Public Health Local and State Authorities ( EMS, Police, Fire Departments) FBI CDC Administration DEPTSDEPTS Public Relations

15. Maximum Containment Lab

16. 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

17. 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

18. 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

19. 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

20. Bioterrorism Readiness Plan Section II: Agent Specific Recommendations  Anthrax  Botulinum Toxin  Plague  Smallpox  Ricin

21. Anthrax

22.  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

23. Anthrax: Mode of Transmission for Bioterrorism  Spore is durable  Delivered as an aerosol= inhale spores  Ingestion of contaminated food  Cutaneous contact with spores or spore- contaminated material

25. Anthrax time curve after incident

26. 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

27. 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

28. Anthrax Chest Xray Note the widened mediastinum

29. 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

30. Cutaneous Anthrax

31. Lymph node tissue infected with anthrax is shown in this picture.

32. Anthrax Preventive Measures  Standard Precautions  Antibiotic Therapy  Ciprofloxacin  Levofloxacin  Ofloxacin  Doxycycline  Amoxicillin for exposed children  Vaccination

33. Botulism

34.  Clostridium botulism  Present in soil and marine sediment  Foodborne botulism most common disease  Inhalation botulism may also occur

35. 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

36. 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

37. 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

38. 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

39. Life cycle of plague

40. 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

41. Lung biopsy from pneumonic plague

42. 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

43. 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

44. Last known person with smallpox in the world Public Health Quarantine Sign

45. 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

46. Smallpox in Child

47. Progression of Smallpox Lesion

48. 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

50. 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

51. Time curve of smallpox after incident

52. 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

53. 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

54. Durability of smallpox

55. Smallpox vaccination

56. Ricin  Causative agent: A biological toxin derived from the castor plant and castor oil.  Toxin inhibits protein synthesis  Exposure routes:  inhalation  percutaneous  ingestion

57. 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

58. 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

59. 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