All Hazards Emergency Preparedness: The Role of Medical Technologists

1. All Hazards Emergency Preparedness:The Role of Medical Technologists

2. Medical Technologists (MT) Work in many settings, including : Physician office laboratories Community hospital laboratories Reference laboratories State and public health laboratories Military hospital laboratories National Institutes of Health (NIH) laboratories Centers for Disease Control and Prevention (CDC) laboratories

4. Role in EmergencyPreparedness Laboratories must be actively involved as contingency plans are designed, especially those regarding infection control, maintenance/generation of electrical power, computer information systems integrity and acquisition of necessary operating supplies.

6. Biological Warfare Agents Agents that could be weaponized2 : Bacterial Bacillus anthracis [Anthrax] Yersinia pestis [Plague] Francisella tularensis [Tularemia] Viral Variola major Virus [Smallpox] Hemorrhagic Fever Viruses [Ebola, Marburg, Lassa] Toxins Clostridium botulinum Toxin

7. Biological Warfare Terrorists most likely to use methods that result in the airborne release of biological agents for maximum damage Symptoms may mimic other illnesses at first Could delay recognition event has occurred Communication and epidemiological scrutiny key to recognition and response

8. Laboratory Response Network [LRN] Sentinel (Local) Labs Recognize pathogen ! Refer sample to Reference Labs Send confirmatory testing results to local/regional authorities to formulate threat response Refer sample to National Labs (CDC) Definitive identity of pathogen

9. Biological Warfare : Sentinel Laboratories LEVEL A : local hospitals, some public health & military labs Do not test environmental, animal, food or water specimens for select agents Responsible for visual recognition of organisms on clinical plate media, gram stains, and diagnostic testing necessary for presumptive ID of the organism as a suspicious isolate Follow hospital notification policies via appropriate channels�public health authorities make final decisions as to whether samples are referred to reference labs for confirmation, whether a threat exists, and if (when) it is appropriate to notify law enforcement.

10. Biological Warfare : Local & State Reference Laboratories LEVEL B - Local & State Public Health Laboratories Biosafety levels 2 & 3 (BSL 2,3) Identification/susceptibility testing of isolates Refer to Level C & D labs LEVEL C � Select State Health Laboratories with advanced testing capability Biosafety level 3 (BSL 3) Molecular typing/ toxigenicity testing of isolates Refer to Level D labs

11. Biological Warfare : National Laboratories Level D � ex. Centers for Disease Control and Prevention (CDC) Performs advanced genetic analysis and direct analysis of biological agents requiring Biosafety level 4 precautions Develops new tests for detection of agents, lab protocols, educational materials, archives isolates for later studies, etc The Federal Bureau of Investigation (FBI) has ultimate responsibility to declare that a bioterrorism event has occurred.

12. Role in Disaster Recovery Pre-meditated Disasters: Biological Warfare Work in designated sentinel hospital laboratories screening for organisms used as bioweapons, performing other testing as required by physicians to provide quality care to disaster victims. May serve as an infection control officer to prevent institutionalized spread of infection Interact cooperatively both with and within other agencies in the Laboratory Response Network (LRN) to refer suspicious isolates for further testing to laboratories with higher biosafety level capabilities.

13. Chemical Warfare Agents Agents that could be weaponized : Choking agents Phosgene (CG), Diphosgene (DP) Chlorine (Cl), Chloropicrin (PS) Cyanide gas/cyanide compounds Hydrocyanic acid (AC), Cyanogen chloride (CK) Blistering agents Sulfur mustard (HD), Nitrogen mustard (HN) Lewisite (L), Phosgene oxime (CX) Nerve agents Tabun (GA), Soman (GD) Sarin (GB), GF, VX agents

14. Role in Disaster Recovery Pre-meditated Disasters :Chemical Warfare Analyze plasma from suspected chemical warfare victims for rapid drops in acetylcholinesterase (red blood cell) and butyrylcholinesterase (plasma) enzyme activity � indicating acute exposure to nerve agents Analyze body fluids from victims looking for sulfur mustard and/or its metabolites � indicating exposure to blistering agents Perform arterial blood gas analysis, to functionally assess patient for exposure to choking agents such as chlorine Perform plasma and/or whole blood cyanide levels looking for exposure to either cyanide gas or various cyanide salts Perform other testing as required by physicians to provide quality care to disaster victims.

15. Radiological Agents Types of ionizing emissions Alpha particles Large, positively charged, do not penetrate clothing Beta particles High energy electrons, do not penetrate clothing Neutrons Particles are not charged, but have the capacity to cause more tissue damage than gamma rays by interacting with nuclei of other atoms present. Gamma rays High energy, capable of penetrating the body

16. Dirty Bombs Combine radioactive materials with explosive devices in an effort to disperse radiation into the surrounding environment. Radioactive material from medical & industrial sources considered easiest for would-be terrorists to access. All emit ?-radiation. (Cobalt-60, Cesium-137 & Strontium-90)

17. Dirty Bombs Disperse radioactivity, levels decrease rapidly as distance increases from the blast. Few would receive lethal doses of radiation Anyone within the blast area should be triaged and monitored for radiation sickness, those closest to the blast will have greater need of medical attention Outside the blast area, persons should not need treatment for radiation exposure Estimated that more psychological than physical damage would be done

18. Acute Radiation Syndromes Presentations Hematopoietic Gastrointestinal Neurologic Cardiovascular Outcome Considerations Dose of radiation exposure How much of the body was exposed Age & pre-existing health conditions of the patient Accessibility to treatment

19. Role in Disaster Recovery Pre-meditated Disasters :Nuclear Warfare Perform complete blood counts (CBC) with differential and absolute lymphocyte counts � significant radiation exposure can cause early drops in blood cell counts � especially lymphocytes by as much as 50% Perform 24-hour urine/fecal analysis for detection of radioactivity � determines whether radioactive material has been inhaled or ingested Perform serum amylase � exposure to greater than 50 rads to the body or parotid glands causes a significant rise in this enzyme Perform HLA blood & tissue typing for peripheral blood stem cell transplant (adults) or cord blood transplant (children) and red blood cell (RBC) and/or platelet transfusions for patients having received high doses of radiation; other testing as required for quality patient care.

20. References JOURNALS Ecker, D.J et al, The Microbial Rosetta Stone Database: A Compilation of Global and Emerging Infectious Microorganisms and Bioterrorist Threat Agents, BioMed Central (BMC) Microbiology @ http://www.pubmedcentral.gov/articlerender.fcgi?tool=pmcentrez&artid=1127111 last accessed 2.13.2006. Jortani, S.A., Snyder, J.W. and Valdes, R. The Role of the Clinical Laboratory in Managing Chemical or Biological Terrorism, Clinical Chemistry 46:1883-1893, 2000.@ http://www.clinchem.org/cgi/content/full/46/12/1883 last accessed 2.13.2006.

21. References JOURNALS Luckey, TD, Nuclear Triage and the Dirty Bomb, Radiation Protection Management, 20 (1): 11-17, 2003 McKinney, W. Paul et al, Educating Health Professionals to Respond to Bioterrorism, Public Health Reports, 2005 Supplement, Volume 120, 42-47 Shapiro, D.S. Surge Capacity for Response to Bioterrorism in Hospital Clinical Microbiology Laboratories, J.Clin Microbiol 41(12):5372-5376, December 2003 @ http://www.pubmedcentral.gov/articlerender.fcgi?tool=pmcentrez&artid=308964 Last accessed 2.10.2006.

22. References JOURNALS Snyder, J. Role of the Hospital-Based Microbiology Laboratory in Preparation for and Response to a Bioterrorism Event, J. Clin Microbiol 41(1):1-4, January 2003 @ http://www.pubmedcentral.gov/articlerender.fcgi?tool=pmcentrez&artid=149646 Last accessed 2.10.2006. Streichert, Laura C. et al, Using Problem�Based Learning as a Strategy for Cross-Discipline Emergency Preparedness Training, J Public Health Management Practice, 2005, November (Suppl), S95-S99.

23. References JOURNALS 8. Westphal, Robert G. et al, Development of an On-line Bioterrorism Preparedness Course, J Public Health Management Practice, 2005, November (Suppl), S132-S134. WEBSITES 1. Berger, ME et al, Hospital Triage in the First 24 Hours after a Nuclear or Radiological Disaster, Oak Ridge Institute for Science and Education REAC/TS @ http://www.orau.gov/reacts/triage.pdf Last accessed 2.13.2006

24. References WEBSITES 2. Facts about the Laboratory Response Network @ http://www.bt.cdc.gov/lrn/factsheet.asp Last accessed 2.13.2006 3. Gum, RM, Hoyle, JD and Selanikio, JD, Chemical Warfare Mass Casualty Management @ http://www.emedicine.com/emerg/topic895.htm Last accessed 4.2.2006. 4. Jagminas, L and Erdman, DP, Evaluation of a Chemical Warfare Victim @ http://www.emedicine.com/emerg/topic892.htm Last accessed 4.3.2006..

25. References WEBSITES (continued) 5. Jagminas, L and Mothershead, JL, Biological Warfare Mass Casualty Management @ http://www.emedicine.com/emerg/topic896.htm Last accessed 4.3.2006 Jagminas, L, Evaluation of a Biological Warfare Victim @ http://www.emedicine.com/emerg/topic891.htm Last accessed 4.3.2006. 7. Pemberton, L and Pemberton, JD et al, Nuclear Radiation Exposure @ http://www.emedicine.com/emerg/topic934.htm Last accessed 4.2.2006.

26. References OTHER PUBLICATIONS State of Maryland, Department of Health and Mental Hygiene Laboratories Administration, Guide to Public Health Laboratory Services, Laboratories Administration, 201 West Preston Street, Baltimore, MD 21201, July 2000. Centers for Disease Control and Prevention, Information on Testing and Referral for Agents of Bioterrorism in Clinical Laboratories, CD derived from CDC website http://www.bt.cdc.gov on October 2001. United States Army Medical Research Institute of Chemical Defense, Medical Management of Chemical Casualties Handbook, 2nd Edition, September, 1995 @ http://www.fas.org/nuke/guide/usa/doctrine/army/mmcch/index.html Last accessed 4.2.2006.