PreEvent Planning

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Pre-Event Planning

• Evaluating your facility

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Plan of Action

• Emergency management plan
• Mitigation
• Preparedness
• Response
• Recovery

3
Identifying a Problem

• Most common features of an outbreak caused by a
  bioterrorism agent
• Influenza-like illness
• Viral exanthem rash/fever
• Gastrointestinal complaints

4
Surveillance Methods

• Databases
• Mainframe systems
• Admissions
• Emergency department
• Microbiology

5
Surveillance Methods

• Mainframe systems
• Laboratory
• Pathology
• Radiology
• Pharmacy

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Surveillance Methods

• Access to system
• Report distribution
• Computer access
• Patient electronic medical record
• HIPAA concerns ?

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Confirming the Diagnosis

• Coordination of surveillance plan
• Review of symptoms
• Gathering data
• Communication with internal and external
  resources

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Facilities/Environmental

• Isolation Rooms
• Negative Pressure
• Alternatives
• Transportation Routes
• Lockdown
• Disinfectants
• PPE

9
Laboratory Support

• Level of involvement
• Level A Initial work- r/o BT agents
• Level B County/state- agent confirmation
• Level C Large state lab/ advanced labs
• Level D CDC/DOD labs

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Laboratory Support

• BSL levels
• 1 General office
• 2 Biosafety cabinets
• 3 Negative airflow
• 4 Moon suits

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Specimen Collection

• Collection
• Preparation
• Media
• Preservation
• Shipping
• Notification

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Febrile, Vesicular Rash Illness Algorithm for
Evaluating Patients for Smallpox
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Smallpox Diagnosis

• Traditional confirmatory methods
• Electron microscopy of vesicle fluid
• Rapidly confirms if orthopoxvirus
• Culture on chick membrane or cell culture
• Slow, specific for variola
• Newer rapid tests
• Available only at reference labs (e.g. CDC)
• PCR, RFLP

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Lab Methods for Confirmation of Orthopoxvirus
Diagnosis

• PCR related methods for DNA identification,
  (e.g., real-time PCR)
• Electron microscopy
• Histopathology
• Culture
• Serology
• Antigen detection (IFA, EIA ag capture)
• IgM capture
• Neutralization antibodies
• IgG ELISA

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Negative Stain Electron Microscopy
Vaccinia
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Specimen Collection

• Vaccinia and variola specimen collection
  essentially the same
• Check CDC website for
• Recent updates in orthopox specimen collection
  specifics
• Appropriate infection control practices
• Shipping criteria
• Laboratories
• www.bt.cdc.gov/agent/smallpox/ response-plan/files
  /guide-d.pdf

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Specimens for Vaccinia-Related Disease Vesicular
Rash

• Lesion roofs and crusts
• Vesicular fluids
• Touch prep
• EM grid
• Biopsy
• Serum
• Others (e.g., CSF)

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Specimen procurement/handling

• By recently successfully immunized person
• Appropriate PPE (gowns, gloves, mask, protective
  eyewear)
• Open vesicle with blunt end of blade
• Collect with cotton swab
• Place swab into sealed vacuum blood tube
• Place tube in larger jar, tape lid

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Vaccinia lesion on foot
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Lifting a crust or roof from the skin
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Applying microscope slide to lesion
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Handling VHF Specimens

• Sample for serology - 10-12 ml
• ship on dry ice
• Tissue for immunohistochemistry
• formalin-fixed or paraffin block
• ship at room temperature
• Tissue for PCR/virus isolation
• ante-mortem, post-mortem ship on dry ice
• Ship serum cold or on dry ice in a plastic tube

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Yersinia pestisSpecimen Selection

• Specimen selection is important
• Bubonic - bubo - lymph node aspirate
• Septicemic - blood - Obtain three sets 10-30
  minutes apart
• Pneumonic
• Sputum/throat
• Bronchial washings

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Yersinia pestisSpecimen inoculation

• Inoculate routine plating media and make thin
  smear for DFA
• Use Wayson only if DFA is unavailable

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Laboratory Confirmation

• By State Health Dept., CDC and Military labs-
• Antigen detection
• PCR
• IgM enzyme immunoassay
• Immuno-staining

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Level A Lab ProceduresYersinia pestis

• Gram stain
• Wayson stain
• Growth characteristics on agar
• Growth characteristics in broth

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Yersinia pestisGram stain

• Small, gram-negative bipolar-stained coccobacilli

Must confirm by DFA and mouse inoculation
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Gram Negative Coccobacilli

• Most likely
• Acinetobacter
• Actinobacillus
• H. aphrophilus
• Bordetella spp.
• Pasturella spp.

• Least likely
• DF-3
• Brucella spp.
• Francisella spp.

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Level A Lab Procedures Francisella tularensis

• This is a dangerous, highly virulent organism and
  it should not be manipulated at the bench, but
  under a controlled environment
• Gram stain
• Growth characteristics in broth
• Growth characteristics in agar

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TransportationCommunicationsSecurity
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Transportation is More than
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Communications is More than
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Security is More than
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Transportation
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Transportation Mission

• Organize and coordinate the transportation of all
  casualties, ambulatory and non-ambulatory
• Arrange for the transportation of human and
  material resources to and from the facility

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Anticipate Transportation Needs

• Transfer agreements with lower levels of care
• Which patients?
• What facilities?
• Howwhat means of transportation?

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Anticipate Transportation Needs

• Transporting discharged patients (or getting
  family members to pick them up)
• Limited or no access to facility
• Difficulty contacting families
• Secure private ambulance/cabs for discharged
  patients

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Anticipate Transportation Needs

• Plan for transportation of staff and supplies to
  and from your organization
• Off sight gathering locations
• Private vehicle vs. group (bus/van)
  transportation
• Non essential employees?
• Housekeeping

39
Anticipate Transportation Needs

• Provisions
• Agreements in place to have vendors send supplies
  without actual request
• Need for identification system of suppliers to
  pass through police or security checkpoints

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Transportation

• Utilize personnel from labor pool as patient
  transporters
• Assemble stretchers and wheelchairs in proximity
  to ambulance off loading and triage area
• Identify transportation needs of walking
  decontaminated or non-injured individuals

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Communications
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Communications Mission

• Organize and coordinate internal and external
  communications
• Act as custodian of all logged/documented
  communications

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Anticipate Communication Needs

• Provisions for normal system overloaded or
  inoperable
• Telephone
• Page
• Cellular
• Fax
• Alternative arrangements
• Telephone trees
• Pay phones
• Walkie-talkies

44
Anticipate Communication Needs

• Organized runner or messenger system
• Area layout maps
• Established communications with local emergency
  medical services or management agencies
• Plans to keep staff informed

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Internal Communication

• Systems and equipment
• Train staff to repair equipment
• Availability of replacement parts
• Telephone lines buried, marked and protected

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Internal Communication

• Keep written records
• Radio transmitter/receivers equipped to operate
  on multiple frequencies
• Potentially use closed circuit TV or broadcast
  one-way messages

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Internal CommunicationsPatient Records

• Updating and keeping track of patient records
  essential
• Triage tags
• Medical records
• Registration
• History
• Treatment

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CommunicationsStaff Information

• Frequent communications of accurate information
• What has happened
• How many patients to expect and when
• How organization will help meet needs
• Recognize healthcare workers needs to contact
  families
• Call trees
• Designated phone number

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External Communications

• Establish communication lines with community and
  national disaster agencies
• Employees, medical staff and volunteers
• Family members, friends and visitors
• Community office of emergency management

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External Communications

• Law enforcement or military
• EMS dispatch/services
• Public utilities
• Radio operations
• Public safety communication services
• Health Department

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Security
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Security Mission

• Ensure any activity is done with maximum security
• Provide personal security to staff, patients,
  visitors and property

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Anticipate Security Needs

• Nuclear, biological, chemical and explosive
• Internal vs. external
• Internal
• Damage to structure
• Evacuation while minimizing passage through
  contaminated areas
• Damage to support systems water or electric
• External
• Prevailing winds
• Evaluate need to turn off air conditioning, seal
  windows

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Security

• Personnel trained
• Early recognition
• Procedure to lock down or minimize access and
  egress
• Direct exposed foot traffic to decontamination
• Direct families/friends to centralized area
• Direct media to designated spokesperson

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Security

• Entry route for staff, supplies etc
• Personnel identification policy
• Establish ambulance entry and exit routes
• Secure triage, ER, morgue and other sensitive
  areas

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Security

• Maintain effective crowd control
• Maintain chain of evidence for any criminal or
  other investigation
• Provide vehicular and pedestrian traffic control
• Parking and decontamination issues

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Security

• Secure food, water, medical and blood reserves
• Credentialing/screening process of volunteers
• Initiate contact with fire, police agencies
  through communication liaison when necessary

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Anticipate, Plan and Practice
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Isolation Guidelines
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ANTHRAX

• Use Standard Precautions
• Patient Placement
• Private rooms not necessary
• Skin lesions may be infectious by direct contact
• Patient Transport
• Use Standard Precautions
• Cleaning, disinfection, sterilization
• Use facility procedures for surfaces, equipment
• Bleach
• Standard Precautions for post-mortem care

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BOTULISM

• Use Standard Precautions
• Patient Placement
• No person-to-person transmission
• Patient Transport
• Use Standard Precautions
• Cleaning, disinfection, sterilization
• Use facility procedures for surfaces, equipment
• Standard Precautions for post-mortem care

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PLAGUE

• For pneumonic plague, Droplet Precautions until
  72 hours of anti-microbial therapy completed
• Patient Placement
• Place infected patients in private room
• Cohort symptomatic patients with similar symptoms
  when private rooms not available
• Maintain at least three feet between infected
  patients and others when cohorting is not
  possible
• Avoid placing patients requiring Droplet
  Precautions with immunocompromised patients

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PLAGUE

• Patient Transport
• Transport for essential purposes only
• Patient should wear surgical mask
• Cleaning, disinfecting, sterilization
• Use facility procedures for surfaces, equipment
• Standard plus Droplet Precautions for post-mortem
  care

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SMALLPOX

• Airborne and Contact Precautions
• Patient Placement
• Monitored negative pressure room
• Doors must remain closed
• Facilities without negative pressure rooms should
  have plans for transfer of patients
• Cohorting maybe be used in outbreaks

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SMALLPOX

• Patient Transport
• Transport for emergencies only
• Patient must wear surgical mask and be completely
  covered
• Cleaning, disinfection, sterilization
• Ensure management of contaminated surfaces and
  equipment
• Airborne and Contact Precautions for post-mortem
  care
• Glass vials or tubes should not be used for
  laboratory specimens

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TULAREMIA

• Use Standard Precautions
• Patient placement
• No person-to-person transmission
• Patient transport
• Use Standard Precautions
• Cleaning, disinfection, sterilization
• Use facility procedures for surfaces, equipment
• Standard Precautions for post-mortem care

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VIRAL HEMORRHAGIC FEVERS (VHF)

• Use Airborne Precautions
• If negative pressure room not available, use HEPA
  filtration unit
• Face shields in addition to N95 respirators
• Patient Placement
• Monitored Negative pressure room
• Cohort patients with similar symptoms
• Patient transport
• Transport for essential purposes only
• In elevator, all personnel should wear PPE
• Patient must wear surgical mask and be completely
  covered

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VHF

• Cleaning, disinfection, sterilization
• Meticulous cleaning daily of all surfaces and
  equipment in patients room
• Disinfectant discarded before exiting patients
  room
• Reusable cloths and mop heads should not be
  reused and sent for disinfection/laundering
• All reusable equipment to be cleaned and
  disinfected before taking from room
• Curtains and linens should be changed when soiled
  or on discharge

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VHF

• Cleaning, disinfection, sterilization continued
• Cleaning bucket and mop handle to remain in
  patients room.
• Contact and Airborne Precautions for post-mortem
  care

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BRUCELLOSIS

• Use Standard Precautions
• Patient placement
• Not transmitted person-to-person
• Patient transport
• Use Standard Precautions
• Cleaning, disinfection, sterilization
• Use facility procedures for surfaces, equipment
• Standard Precautions for post-mortem care

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Q FEVER

• Use Standard Precautions
• Patient placement
• No person-to-person transmission
• Patient transport
• Use Standard Precautions
• Cleaning, disinfection, sterilization
• Use facility procedures for surfaces, equipment
• Standard Precautions for post-mortem care

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