Health Care Facilities and Bioterrorism Preparedness

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Health Care Facilities and Bioterrorism
Preparedness

• A Template for Healthcare Facilities

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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

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Introduction

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

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Telephone notification numbers necessary for a
readiness plan

• External contacts
• Local State Health Department
• Local EMS
• Local Law Enforcement
• Local EMA Agency
• Regional Poison Control
• CDC Hospital Infections Program

• Internal contacts
• Infection control
• Epidemiologist
• Administration/ Public Affairs

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Reporting Requirements and Contact Information

• If a bioterrorism event is suspected, local
  emergency response systems should be activated.
• Prompt communication is essential.

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Detection of Outbreaks

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

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Detection Criteria (continued)

• Syndrome-based
• May be necessary to initiate response based on
  the recognition of high-risk syndromes

• Epidemiological
• Epi principles used to assess whether patients
  presentation is typical of endemic disease or is
  an unusual event that should raise concern.

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Four Potential Bioterrorism Agents

• Anthrax (bacteria)
• Botulism (toxin)
• Plague (bacteria)
• Smallpox (virus)

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Some More Bio Agents...

• Q Fever
• Tularemia
• Brucellosis
• Viral Hemorrhagic Fevers
• Viral Encephalitis
• Staphylococcal enterotoxin B (SEB)

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Transmission Type Natural

• Direct Contact (skin-skin, etc.)
• Anthrax (animal to human)
• like STDs or common cold
• Direct Large Droplet Spread (? 1 m projection)
• Pneumonic Plague (secondary)
• like Influenza (also droplet nuclei)

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Transmission Type Natural

• Indirect Vehicle-borne
• Brucellosis (milk, meat)
• Hep A (water)
• Anthrax (meat)
• Indirect Vector-borne
• Bubonic plague (fleas)
• like Lyme disease (ticks)

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Transmission Type Natural

• Airborne Droplet Nuclei
• (Particles ? 5 microns)
• Q fever
• Smallpox (also direct and fomites)
• like Tuberculosis
• Airborne Dust
• Hantaviruses
• Aspergillosis

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Transmission Type BioT

• Aerosolized
• Anthrax
• Smallpox
• Q Fever
• Tularemia
• Plague
• Foodborne
• Ricin
• Botulinum

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PRIMARY PREVENTION Pre-Exposure (DPRP)

• Immunization (Active)
• Drug Prophylaxis
• Training and Education

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SECONDARY PREVENTIONIncubation Period (DPRP)

• Diagnosis (Class or Agent Specifics)
• Passive Immunization (Immune Serum)
• Pre-Treatment (Drugs)

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TERTIARY PREVENTIONCrisis Management of Overt
Disease (DPRP)

• Diagnosis
• Treatment
• Communication

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Infection Control Practices for Patient Management

• Two-Tier Precautions
• Patient Placement
• Patient Transport
• Cleaning, Disinfecting,
  and Sterilization of Equipment
  and Environment
• Discharge Management
• Post-Mortem care

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Isolation Precautions

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

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Standard Precautions

• Handwashing
• Gloves
• Masks/Eye Protection or Face Shields
• Gowns

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Patient Placement

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

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Patient Transport

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

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Cleaning, Disinfecting, and Sterilization of
Equipment and Environment

• Standard Precautions should be generally applied
  for the management of patient-care equipment and
  environmental control.
• Each facility should have guidelines in place for
  proper treatment of equipment and a contaminated
  environment.

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Discharge Management

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

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Post-mortem Care

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

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Post Exposure Management

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

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Decontamination of Patients Environment

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

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Decontamination (continued)

• 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
  

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Prophylaxis and Post-exposure Immunization

• Recommendations for prophylaxis are subject to
  change.
• So are the treatment recommendations!
• STAY TUNED!!!

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Triage Management of Large Scale Exposures /
Suspected Exposures

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

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Triage Management of Large Scale Exposures /
Suspected Exposures

• Determine availability sources for additional
  medical equipment supplies.
• Plan for allocation or re-allocation of scarce
  equipment.
• ID ability to manage a sudden increase in the
  number of cadavers on site.

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Psychological aspects of bioterrorism

• Following a bioterrorism-related event, fear
  panic can be expected from both patients and
  healthcare providers.

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Strategies to address fears

• Patient general public fears
• Explain risks, offering careful but rapid
  treatment and support.
• Treat anxiety in unexposed persons who experience
  somatic symptoms.

• Healthcare worker fears
• Provide Bioterrorism readiness training.
• Invite active, involvement in the bioterrorism
  readiness planning process.
• Encourage participation in disaster drills.

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Laboratory Support Confirmation

• Obtain diagnostic samples
• Lab criteria for processing potential
  bioterrorism agents
• Transport requirements

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Laboratory Criteria for Processing Potential
Bioterrorism Agents 4 Levels

• Level A Clinical laboratories-minimal
  identification of agents.
• Level B County/State/ other labs- ID,
  confirmation, susceptibility testing.

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Laboratory Criteria for Processing Potential
Bioterrorism Agents 4 Levels

• Level C State other large facility labs with
  advanced capacity for testing-some molecular
  technologies.
• Level D CDC or select Dept. of Defense labs-Bio
  Safety Level 3 4 labs with special surge
  capacity advanced molecular typing techniques.

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Transport Requirements

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

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Patient, Visitor, Public Info.

• Methods channels of communication used to
  inform public should be planned in advance.
• Decide how communication action across agencies
  will be accomplished (ICS!)

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Anthrax

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

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Description of Anthrax

• Etiology
• Clinical Features
• Modes of transmission
• Incubation Period
• Period of Communicability

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Preventive Measures Anthrax

• A Vaccine availability- limited
• B Immunization recommendations-administered to
  select military personnel. No routine
  vaccination of civilians .

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Infection Control Practices for Patient
Management Anthrax

• Isolation Precautions
• Patient Placement
• Patient Transport
• Cleaning Equipment
• Discharge
• Post-mortem Care

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Post Exposure Management Anthrax

• Decontamination of Patient/Environment
• Contaminated clothing should be removed.
• Shower with soap water.
• Decontaminate surfaces with approved solution.

• Prophylaxis Post-exposure Immunization
• Recommendations are subject to change.
• Should be initiated upon confirmation of an
  anthrax exposure.

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Post Exposure Management (contd)

• 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

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Laboratory Support Confirmation Anthrax

• A Diagnositc Samples
• B Laboratory selection
• C Transportation requirements

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Patient, Visitor Public Information Anthrax

• 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

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Botulism

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

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Description of Botulism

• Etiology
• Clinical Features
• Mode of Transmission
• Incubation Period
• Period of Communicability

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Prevention Measures Botulism

• A Vaccine availability
• B Immunization Recommendation

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Infection Control Practices for Patient
Management Botulism

• Isolation Precautions
• Patient Placement
• Patient Transport
• Cleaning Equipment
• Discharge Management
• Post-mortem Care

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Post Exposure Management Botulism

• A Decontamination of patients/environment
• B Prophylaxis post-exposure immunization
• C Triage management of large scale
  exposures/potential exposures

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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.

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Patient, Visitor Public Information Botulism

• Fact sheets should be prepared, including
• Emphasis botulism toxin is not contagious
  person-person
• Clear description of symptoms
• Instructions to report
• for evaluation if symptoms
• develop

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Smallpox

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

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Description of Smallpox Preventive Measures

• Etiology
• Clinical Features
• Mode of Transmission
• Incubation Period
• Period of Communicability

• Vaccine Availability
• Immunization Recommendations

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Infection Control Practices for Patient
Management Smallpox

• Isolation Precautions
• Patient Placement
• Patient Transport
• Cleaning, disinfection, sterilization of
  equipment environment
• Post-mortem Care

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Post-Exposure Management Laboratory Support
Confirmation

• Decontamination of patients environment
• Prophylaxis post-exposure immunization
• Triage Management of large scale exposure

• Diagnostic Sample
• Laboratory Selection
• Transport Requirements

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Patient, Visitor Public Information Smallpox

• 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

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IN Summary...

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

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Community Wide Preparedness

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

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STAFFING

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

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COMMUNICATIONS

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

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PUBLIC POLICY

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

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CUT The End...

• QUESTIONS?
• CONCERNS ?