Bioterrorism Readiness Plan

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

2. Tokyo Train Station

3. Aerial view of anthrax production facility

4. Where and when will bioterrorism hit next?

5. Biological Weapons?????

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

7. 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 Multidisciplinary Membership

8. 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

9. 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

10. 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

11. Bioterrorism Readiness PlanBasic 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.

12. 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

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

14. Maximum Containment Lab

15. Bioterrorism Readiness PlanStaff 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

16. Bioterrorism Readiness PlanSection 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

17. Bioterrorism Readiness PlanSection 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

18. Bioterrorism Readiness PlanSection 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

19. Bioterrorism Readiness PlanSection II: Agent Specific Recommendations • Anthrax • Botulinum Toxin • Plague • Smallpox • Ricin

20. Anthrax

21. 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

22. 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

24. Anthrax time curve after incident

25. InhalationAnthrax • 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

26. AnthraxClinical 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

27. Anthrax Chest Xray Note the widened mediastinum

28. AnthraxClinical 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

29. Cutaneous Anthrax

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

31. AnthraxPreventive Measures • Standard Precautions • Antibiotic Therapy • Ciprofloxacin • Levofloxacin • Ofloxacin • Doxycycline • Amoxicillin for exposed children • Vaccination

32. Botulism

33. Botulism • Clostridium botulism • Present in soil and marine sediment • Foodborne botulism most common disease • Inhalation botulism may also occur

34. BotulismClinical 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

35. 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

36. 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

37. 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

38. Life cycle of plague

39. PlagueClinical 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

40. Lung biopsy from pneumonic plague

41. 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

42. PlaguePreventive 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

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

44. 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

45. Smallpox in Child

46. Progression of Smallpox Lesion

47. SmallpoxClinical 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

49. 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

50. Time curve of smallpox after incident