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Bioterrorism Event Internal Contacts: Infection Control - 933-1683 Safety and Security - 933-1198 External Contacts: Local Health Department - 636/789-3372 State Health Department - 573/751-6001 Bioterrorism Emergency Number, CDC Emergency Response Office: 770/488-7100 CDC Hospital Infections Program: 404/639-6413 SECTION 2: PURPOSE Potential Agents Four diseases with recognized bioterrorism potential: ANTHRAX (see section A; pg. 1) BOTULISM (see section B; pg. 5) PLAGUE (see section C; pg. 7) SMALLPOX (see section D; pg. 9) Bioterrorism may occur as covert events, in which persons are unknowingly exposed and an outbreak is suspected only upon recognition of unusual disease clusters or symptoms. SECTION 3: PROCEDURE AGENT-SPECIFIC RECOMMENDATIONS A. Anthrax 1. Description of Agent/Syndrome a. Etiology Anthrax is an acute infectious disease caused by Bacillus anthracis, a spore forming gram-positive bacillus. Associated disease occurs most frequently in sheep, goats, and cattle, which acquire spores through ingestion of contaminated soil. Humans can become infected through skin contact, ingestion, or inhalation of B. anthracis Page 2 JEFFERSON MEMORIAL HOSPITAL POLICY/PROCEDURE SUBJECT: Bioterrorism Event DISTRIBUTION: All Departments SECTION 3: PROCEDURE (CONTINUED) spores from infected animals or animal products (as in “woolsorter's disease” from exposure to goat hair). Person-to-person transmission of inhalational disease does not occur. Direct exposure to vesicle secretions of cutaneous anthrax lesions may result in secondary cutaneous infection. b. Clinical features Three forms: pulmonary, cutaneous, or gastrointestinal, depending on the route of exposure. Pulmonary · Non-specific prodrome of flu-like symptoms follows inhalation of infectious spores. · Possible brief interim improvement. · Two to four days after initial symptoms, abrupt onset of respiratory failure and hemodynamic collapse, possibly accompanied by thoracic edema and a widened mediastinum on chest radiograph suggestive of mediastinal lymphadenopathy and hemorrhagic mediastinitis. · Gram-positive bacilli on blood culture, usually after the first two or three days of illness. · Treatable in early prodromal stage. Mortality remains extremely high despite antibiotic treatment if it is initiated after onset of respiratory symptoms. Cutaneous · Local skin involvement after direct contact with spores or bacilli. · Commonly seen on the head, forearms or hands. · Localized itching, followed by a papular lesion that turns vesicular, and within 2-6 days develops into a depressed black eschar. · Usually non-fatal if treated with antibiotics. Gastro-intestinal · Abdominal pain, nausea, vomiting, and fever following ingestion of contaminated food, usually meat. · Bloody diarrhea, hematemesis. · Gram-positive bacilli on blood culture, usually after the first two or three days of illness. · Usually fatal after progression to toxemia and sepsis. Page 3 JEFFERSON MEMORIAL HOSPITAL POLICY/PROCEDURE SUBJECT: Bioterrorism Event DISTRIBUTION: All Departments SECTION 3: PROCEDURE (CONTINUED) c. Modes of Transmission The spore form of B. anthracis is durable. As a bioterrorism agent, it could be delivered as an aerosol. The modes of transmission for anthrax include: · Inhalation of spores. · Cutaneous contact with spores or spore-contaminated materials. · Ingestion of contaminated food. d. Incubation period The incubation period following exposure to B. anthracis ranges from 1 day to 8 weeks (average 5 days), depending on the exposure route and dose: · 2-60 days following pulmonary exposure. · 1-7 days following cutaneous exposure. · 1-7 days following ingestion. e. Period of communicability Transmission of anthrax infections from person-to-person is unlikely. Airborne transmission does not occur, but direct contact with skin lesions may result in cutaneous infection. 2. Infection Control Practices for Patient Management Symptomatic patients with suspected or confirmed infections with B. anthracis should be managed according to current guidelines specific to their disease state. Recommend-ations for chemotherapy are beyond the scope of this policy. a. Isolation precautions Standard Precautions are used for the care of patients with infections associated with B. anthracis. Standard Precautions include the routine use of gloves for contact with nonintact skin, including rashes and skin lesions. b. Patient placement Private room placement for patients with anthrax is not necessary. Airborne transmission of anthrax does not occur. Skin lesions may be infectious, but requires direct skin contact only. c. Patient transport Standard Precautions should be used for transport and movement of patients with B. anthracis infections. d. Cleaning, disinfection, and sterilization of equipment and environment Principles of Standard Precautions should be generally applied for the management of patient-care equipment and for environmental control. Page 4 JEFFERSON MEMORIAL HOSPITAL POLICY/PROCEDURE SUBJECT: Bioterrorism Event DISTRIBUTION: All Departments SECTION 3: PROCEDURE (CONTINUED) e. Discharge management No special discharge instructions are indicated. Home care providers should be taught to use Standard Precautions for all patient care (e.g., dressing changes). f. Post-mortem care Standard Precautions should be used for post-mortem care. Standard Precautions include wearing appropriate personal protective equipment, including masks and eye protection, when generation of aerosols or splatter of body fluids is anticipated. 3. Post Exposure Management a. Decontamination of patients/environment The risk for re-aerosolization of B. anthracis spores appears to be extremely low in setting where spores were released intentionally or were present at low or high levels. In situations where the threat of gross exposure to B. anthracis spores exists, cleansing of skin and potentially contaminated fomites (e.g. clothing or environmental surfaces) may be considered to reduce the risk for cutaneous and gastrointestinal forms of disease. The plan for decontaminating patients exposed to anthrax includes the following: · Instruct patients to remove contaminated clothing and store in labeled, plastic bags. · Handle clothing minimally to avoid agitation. · Instruct patients to shower thoroughly with soap and water (and providing assistance if necessary). · Instruct personnel regarding Standard Precautions and wearing appropriate barriers (e.g. gloves, gown, and respiratory protection) when handling contaminated clothing or other contaminated fomites. · Decontaminate environmental surfaces using and EPA-registered, facility-approved sporicidal/germicidal agent or 0.5% hypochlorite solution (one part household bleach added to nine parts water). b. Prophylaxis and post-exposure immunization Recommendations for prophylaxis are subject to change. Up-to-date recommenda-tions should be obtained in consultation with local and state health departments and CDC. Prophylaxis should be initiated upon confirmation of an anthrax exposure. 4. Patient, Visitor, and Public Information People recently exposed to B. anthracis are not contagious, and antibiotics are available for prophylactic therapy along with the anthrax vaccine. Decontamination procedures, Page 5 JEFFERSON MEMORIAL HOSPITAL POLICY/PROCEDURE SUBJECT: Bioterrorism Event DISTRIBUTION: All Departments SECTION 3: PROCEDURE (CONTINUED) i.e., showering thoroughly with soap and water; and environmental cleaning, i.e. with 0.5% hypochlorite solution (one part household bleach added to nine parts water) is recommended. B. Botulism 1. Description of Agent/Syndrome a. Etiology Closridium botulinum is an anaerobic gram-positive bacillus that produces a potent neurotoxin, botulinum toxin. Foodborne botulism is the most common form of disease in adults. An inhalational form of botulism is also possible. Botulinum toxin exposure may occur in both forms as agents of bioterrorism. b. Clinical features Foodborne botulism is accompanied by gastrointestinal symptoms. Inhalational botulism and foodborne botulism are likely to share other symptoms including: · Responsive patient with absence of fever. · Symmetric cranial neuropathies (drooping eyelids, weakened jaw clench, difficulty swallowing or speaking). · Blurred vision and diplopia due to extra-ocular muscle palsies. · Symmetric descending weakness in a proximal to distal pattern (paralysis of arms first, followed by respiratory muscles, then legs). · Respiratory dysfunction from respiratory muscle paralysis or upper airway obstruction due to weakened glottis. · No sensory deficits. c. Mode of transmission Botulinum toxin is generally transmitted by ingestion of toxin-contaminated food. Aerosolization of botulinum toxin has been described and may be a mechanism for bioterrorism exposure. d. Incubation period · Neurologic symptoms of foodborne botulism begin 12 - 36 hours after ingestion. · Neurologic symptoms of inhalational botulism begin 24 - 72 hours after aerosol exposure. e. Period of communicability Botulism is not transmitted from person to person. Page 6 JEFFERSON MEMORIAL HOSPITAL POLICY/PROCEDURE SUBJECT: Bioterrorism Event DISTRIBUTION: All Departments SECTION 3: PROCEDURE (CONTINUED) 2. Infection Control Practices for Patient Management Symptomatic patients with suspected or confirmed botulism should be managed according to current guidelines. Recommendations for therapy are beyond the scope of this policy. For up-to-date information and recommendations for therapy, contact CDC or state health department. a. Isolation precautions Standard Precautions are used for the care of patients with botulism b. Patient placement Patient-to-patient transmission of botulism does not occur. c. Patient transport Standard Precautions should be used for transport and movement of patients with botulism. d. Cleaning, disinfection, and sterilization of equipment and environment Principles of Standard Precautions should be generally applied to the management of patient-care equipment and environmental control. e. Discharge management No special discharge instructions are indicated. f. Post-mortem care Standard Precautions should be used for post-mortem care. 3. Post Exposure Management Suspicion of even single cases of botulism should immediately raise concerns of an outbreak potentially associated with shared contaminated food. In collaboration with CDC and local/state health departments, attempts should be made to locate the contaminated food source and identify other persons who may have been exposed. Any individuals suspected to have been exposed to botulinum toxin should be carefully monitored for evidence of respiratory compromise. a. Decontamination of patients/environment Contamination with botulinum toxin does not place persons at risk for dermal exposure or risk associated with re-aerosolization. Therefore, decontamination of patients is not required. 4. Patient, Visitor, and Public Information People exposed to botulinum toxin are not contagious. Page 7 JEFFERSON MEMORIAL HOSPITAL POLICY/PROCEDURE SUBJECT: Bioterrorism Event DISTRIBUTION: All Departments SECTION 3: PROCEDURE (CONTINUED) C. Plague 1. Description of Agent/Syndrome a. Etiology Plague is an acute bacterial disease caused by the gram-negative bacillus Yersinia pestis, which is usually transmitted by infected fleas, resulting in lymphatic and blood infections (bubonic and septicemia plague). A bioterrorism-related outbreak may be expected to be airborne, causing a pulmonary variant, pneumonic plague. b. Clinical features · Fever, cough, chest pain. · Hemoptysis. · Muco-purulent or watery sputum with gram-negative rods on gram stain. · Radiographic evidence of bronchopneumonia. c. Modes of transmission · Plague is normally transmitted from an infected rodent to man by infected fleas. · Bioterrorism-related outbreaks are likely to be transmitted through dispersion of an aerosol. · Person-to-person transmission of pneumonic plague is possible via large aerosol droplets. d. Incubation period The incubation period for plague is normally 2-8 days if due to fleaborne transmission. The incubation period may be shorter for pulmonary exposure (1-3 days). e. Period of communicability Patients with pneumonic plague may have coughs productive of infectious particle droplets. Droplet precautions, including the use of a mask for patient care, should be implemented until the patient has completed 72 hours of antimicrobial therapy. 2. Infection Control Practices for Patient Management Symptomatic patients with suspected or confirmed plague should be managed according to current guidelines. Recommendations for specific therapy are beyond the scope of this policy. For up-to-date information and recommendations for therapy, contact CDC or state health department. Page 8 JEFFERSON MEMORIAL HOSPITAL POLICY/PROCEDURE SUBJECT: Bioterrorism Event DISTRIBUTION: All Departments SECTION 3: PROCEDURE (CONTINUED) a. Isolation precautions For pneumonic plague, Droplet Precautions should be used in addition to Standard Precautions · Droplet Precautions are used for patients known or suspected to be infected with microorganisms transmitted by large particle droplets, generally larger than 5u in size, that can be generated by the infected patient during coughing, sneezing, talking, or during respiratory-care procedures. · Droplet Precautions require healthcare providers and others to wear a surgical-type mask when within 3 feet of the infected patient. · Droplet Precautions should be maintained until patient has completed 72 hours of antimicrobial therapy. b. Patient Placement Patients suspected or confirmed to have pneumonic plague require Droplet Precautions. Patient placement recommendations for Droplet Precautions include: · Placing infected patient in a private room. · Cohort in symptomatic patients with similar symptoms and the same presumptive diagnosis (i.e. pneumonic plague) when private rooms are not available. · Maintaining spatial separation of at least 3 feet between infected patients and others when cohorting is not achievable. · Avoiding placement of patient requiring Droplet Precautions in the same room with an immunocompromised patient. c. Patient transport · Limit the movement and transport of patients on Droplet Precautions to essential medical purposes only. · Minimize dispersal of droplets by placing a surgical-type mask on the patient when transport is necessary. d. Cleaning, disinfection, and sterilization of equipment and environment Principles of Standard Precautions should be generally applied to the management of patient-care equipment for environmental control. e. Discharge management Generally, patients with pneumonic plague should not be discharged from a healthcare facility until no longer infectious (completion of 72 hours of antimicrobial therapy) and would require no special discharge instructions. f. Post-mortem care Standard Precautions and Droplet Precautions should be used for post-mortem care. Page 9 JEFFERSON MEMORIAL HOSPITAL POLICY/PROCEDURE SUBJECT: Bioterrorism Event DISTRIBUTION: All Departments SECTION 3: PROCEDURE (CONTINUED) 3. Post Exposure Management a. Decontamination of patients/environment The risk for re-aerosolization of Y. pestis from the contaminated clothing of exposed persons is low. In situations where there may have been gross exposure to Y. pestis, decontamination of skin and potential contaminated fomites (e.g. clothing or environmental surfaces) may be considered to reduce the risk for cutaneous or bubonic forms of the disease. The plan for decontaminating patients include: · Instructing patients to remove contaminated clothing and storing in labeled, plastic bags. · Handling clothing minimally to avoid agitation. · Instructing to patients to shower thoroughly with soap and water (and providing assistance if necessary). · Instructing personnel regarding Standard Precautions and wearing appropriate barriers (e.g. gloves, gown, face shield) when handling contaminated clothing or other contaminated fomities. · Performing environmental surface decontamination using an EPA-registered, facility-approved sporicidal/germicidal agent or 0.5% hypochlorite solution (one part household bleach added to nine parts water). b. Prophylaxis Recommendations for prophylaxis are subject to change. Up-to-date recommendations should be obtained in consultation with local and state health departments and CDC. 4. Patient, Visitor, and Public Information a. Droplet Precautions Decontamination by showering thoroughly with soap and water is also recommended. D. Smallpox 1. Description of Agent/Syndrome a. Etiology Smallpox is an acute viral illness caused by the variola virus. Smallpox is a bioterrorism threat due to its potential to cause severe morbidity in a nonimmune population and because it can be transmitted via the airborne route. A single case is considered a public health emergency. Page 10 JEFFERSON MEMORIAL HOSPITAL POLICY/PROCEDURE SUBJECT: Bioterrorism Event DISTRIBUTION: All Departments SECTION 3: PROCEDURE (CONTINUED) b. Clinical features Acute clinical symptoms of smallpox resemble other acute viral illnesses, such as influenza. Skin lesions appear, quickly progressing from macules to papules to vesticles. Other clinical symptoms to aid in identification of smallpox include: · 2-4 day, non-specific prodrome of fever, myalgias. · Rash most prominent on face and extremities (including palms and soles) in contrast to the truncal distribution of varicella. · Rash scabs over in 1-2 weeks. · In contrast to the rash of varicella, which arises in “crops”, variola rash has a synchronous onset. c. Mode of transmission Smallpox is transmitted via both large and small respiratory droplets. Patient-to-patient transmission is likely from airborne and droplet exposure, and by contact with skin lesions or secretions. Patients are considered more infectious if coughing or they have a hemorrhagic form of smallpox. d. Incubation period The incubation period for smallpox is 7-17 days; the average is 12 days. e. Period of communicability Unlike varicella, which is contagious before the rash is apparent, patients with smallpox become infectious at the onset of the rash and remain infectious until their scabs separate (approximately 3 weeks). · Vaccination against smallpox does not reliably confer lifelong immunity. Even previously vaccinated persons should be considered susceptible to smallpox. 2. Infection Control Practices for Patient Management Symptomatic patients with suspected or confirmed smallpox should be managed according to current guidelines. Recommendations for specific therapy are beyond the scope of this policy. For up-to-date information and recommendations for therapy, contact the CDC or state health department. a. Isolation precautions For patients with suspected or confirmed smallpox, both Airborne and Contact Precautions should be used in addition to Standard Precautions. · Airborne Precautions are used for patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small particle residue, 5u or smaller in size) of evaporated droplets containing microorganisms that can remain suspended in air and can be widely dispersed by air currents. Page 11 JEFFERSON MEMORIAL HOSPITAL POLICY/PROCEDURE SUBJECT: Bioterrorism Event DISTRIBUTION: All Departments SECTION 3: PROCEDURE (CONTINUED) · Airborne Precautions require healthcare providers and others to wear respiratory protection (N95 particulate respirator mask) when entering the patient room. · Contact Precautions are used for patients known or suspected to be infected or colonized with epidemiologically important organisms that can be transmitted by direct contact with the patient or indirect contact with potentially contaminated surfaces in the patient's care area. · Contact precautions require healthcare providers and others to: Þ Wear clean gloves upon entry into patient room. Þ Wear gown for all patient contact and for all contact with the patient's environment. Gown must be removed before leaving the patient's room. Þ Wash hands using an antimicrobial agent. b. Patient placement Patients suspected or confirmed with smallpox require placement in rooms that meet the ventilation and engineering requirements for Airborne Precautions, which include: · Monitored negative air pressure in relation to the corridor and surrounding areas. · A door that must remain closed. Patient placement in a private room is preferred. However, in the event of a large outbreak, patients who have active infections with the same disease (i.e., smallpox) may be cohorted in rooms that meet appropriate ventilation and airflow requirements for Airborne Precautions. c. Patient transport · Limit the movement and transport of patients with suspected or confirmed smallpox to essential medical purposes only. · When transport is necessary, minimize the dispersal of respiratory droplets by placing a mask on the patient, if possible. d. Cleaning, disinfection, and sterilization of equipment and environment A component of Contact Precautions is careful management of potentially contaminated equipment and environmental surfaces. · When possible, noncritical patient care equipment should be dedicated to a single patient (or cohort of patients with the same illness). · If use of common items is unavoidable, all potentially contaminated, reusable equipment should not be used for the care of another patient until it has been appropriately cleaned and reprocessed. Page 12 JEFFERSON MEMORIAL HOSPITAL POLICY/PROCEDURE SUBJECT: Bioterrorism Event DISTRIBUTION: All Departments SECTION 3: PROCEDURE (CONTINUED) e. Discharge management In general, patients with smallpox will not be discharged from a healthcare facility until determined they are no longer infectious. Therefore, no special discharge instructions are required. f. Post-mortem care Airborne and Contact Precautions should be used for post-mortem care. 4. Post Exposure Management a. Decontamination of patients/environment · Patient decontamination after exposure to smallpox is not indicated. · Items potentially contaminated by infectious lesions should be handled using Contact Precautions. b. Prophylaxis and post-exposure immunization Recommendations for prophylaxis are subject to change. Up-to-date recommendations should be obtained in consultation with local and state health departments and CDC 5. Patient, Visitor, and Public Information Extreme measures such as burning or boiling potentially exposed materials should be discouraged. |
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