Pre-Event Planning
Evaluating your facility
Plan of Action
Emergency management plan
Mitigation
Preparedness
Response
Recovery
Identifying a Problem
Most common features of an outbreak
caused by a bioterrorism agent
Influenza-like illness
Viral exanthem: rash/fever
Gastrointestinal complaints
Surveillance Methods
Databases
Mainframe systems
Admissions
Emergency department
Microbiology
Surveillance Methods
Mainframe systems
Laboratory
Pathology
Radiology
Pharmacy
Surveillance Methods
Access to system
Report distribution
Computer access
Patient electronic medical record
HIPAA concerns ?
Confirming the Diagnosis
Coordination of surveillance plan
Review of symptoms
Gathering data
Communication with internal and
external resources
Facilities/Environmental
Isolation Rooms
Negative Pressure
Alternatives
Transportation Routes
Lockdown
Disinfectants
PPE
Laboratory Support
Level of involvement
Level
Level
Level
Level
A: Initial work- r/o BT agents
B: County/state- agent confirmation
C: Large state lab/ advanced labs
D: CDC/DOD labs
Laboratory Support
BSL levels
1:
2:
3:
4:
General office
Biosafety cabinets
Negative airflow
“Moon suits”
Specimen Collection
Collection
Preparation
Media
Preservation
Shipping
Notification
Febrile, Vesicular
Rash Illness
Algorithm for
Evaluating Patients
for Smallpox
Patient with
Acute, Generalized
Vesicular or Pustular Rash Illness
Institute Airborne & Contact Precautions
Alert Infection Control on Admission
Low Risk for Smallpox
Moderate Risk of Smallpox
High Risk for Smallpox
(see criteria below)
(see criteria below)
(see criteria below)
ID and/or Derm Consultation
VZV +/- Other Lab Testing
as indicated
ID and/or Derm Consultation
Alert Infx Control &
Local and State Health Depts
History and Exam
Highly Suggestive
of Varicella
Diagnosis
Uncertain
Varicella Testing
Optional
Test for VZV
and Other Conditions
as Indicated
Non-Smallpox
Diagnosis Confirmed
Report Results to Infx Control
No Diagnosis Made
Ensure Adequacy of Specimen
ID or Derm Consultant
Re-Evaluates Patient
Smallpox Response Team
Collects Specimens and
Advises on Management
Cannot R/O Smallpox
Contact Local/State Health Dept
Testing at CDC
NOT Smallpox
Further Testing
SMALLPOX
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
Lab Methods for Confirmation of
Orthopoxvirus Diagnosis
PCR related methods for DNA identification, (e.g., realtime PCR)
Electron microscopy
Histopathology
Culture
Serology
Antigen detection (IFA, EIA ag capture)
IgM capture
Neutralization antibodies
IgG ELISA
Negative Stain Electron Microscopy
Vaccinia
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/ responseplan/files/guide-d.pdf
Specimens for Vaccinia-Related
Disease: Vesicular Rash
Lesion ‘roofs’ and crusts
Vesicular fluids:
Touch prep
EM grid
Biopsy
Serum
Others (e.g., CSF)
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
Vaccinia lesion on foot
Lifting a crust or ‘roof’ from the skin
Applying microscope slide to lesion
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
Centers for Disease Control and
Prevention
Yersinia pestis:
Specimen Selection
Specimen selection is important
Bubonic - bubo - lymph node aspirate
Septicemic - blood - Obtain three sets
10-30 minutes apart
Pneumonic
Sputum/throat
Bronchial washings
Centers for Disease Control and
Prevention
Yersinia pestis:
Specimen inoculation
Inoculate routine plating media
and make thin smear for DFA
Use Wayson only if DFA is
unavailable
Centers for Disease Control and
Prevention
Laboratory Confirmation
By State Health Dept., CDC and Military
labsAntigen detection
PCR
IgM enzyme immunoassay
Immuno-staining
Level A Lab Procedures
Yersinia pestis
Gram stain
Wayson stain
Growth characteristics on agar
Growth characteristics in broth
Centers for Disease Control and
Prevention
Yersinia pestis
Gram stain
Small, gram-negative
bipolar-stained
coccobacilli
Must confirm by DFA and mouse inoculation
Centers for Disease Control and
Prevention
Gram Negative Coccobacilli
Most likely
Acinetobacter
Actinobacillus
H. aphrophilus
Bordetella
spp.
Pasturella spp.
Least likely
DF-3
Brucella spp.
Francisella
spp.
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
Centers for Disease Control and
Prevention
Transportation
Communications
Security
Transportation is More than…
Communications is More
than…
Security is More than…
Transportation
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
Anticipate Transportation
Needs:
Transfer agreements with lower levels
of care:
Which patients?
What facilities?
How…what means of transportation?
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
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
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
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 noninjured individuals
Communications
Communications Mission
Organize and coordinate internal and
external communications
Act as custodian of all
logged/documented communications
Anticipate Communication
Needs:
Provisions for normal system overloaded or
inoperable:
Telephone
Page
Cellular
Fax
Alternative arrangements:
Telephone trees
Pay phones
Walkie-talkies
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
Internal Communication
Systems and equipment
Train staff to repair equipment
Availability of replacement parts
Telephone lines buried, marked and
protected
Internal Communication
Keep written records
Radio transmitter/receivers equipped to
operate on multiple frequencies
Potentially use closed circuit TV or
broadcast one-way messages
Internal Communications:
Patient Records
Updating and keeping track of patient
records essential
Triage tags
Medical records
Registration
History
Treatment
Communications:
Staff 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
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
External Communications:
Law enforcement or military
EMS dispatch/services
Public utilities
Radio operations
Public safety communication services
Health Department
Security
Security Mission
Ensure any activity is done with
maximum security
Provide personal security to staff,
patients, visitors and property
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
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
Security
Entry route for staff, supplies etc
Personnel identification policy
Establish ambulance entry and exit routes
Secure triage, ER, morgue and other sensitive
areas
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
Security
Secure food, water, medical and blood
reserves
Credentialing/screening process of
volunteers
Initiate contact with fire, police agencies
through communication liaison when
necessary
Anticipate, Plan and Practice
Isolation Guidelines
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
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
PLAGUE
For pneumonic plague, Droplet
Precautions until 72 hours of antimicrobial 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
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
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
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
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 postmortem care
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
VHF
Cleaning, disinfection, sterilization
Meticulous cleaning daily of all surfaces and
equipment in patient’s room
Disinfectant discarded before exiting patient’s 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
VHF
Cleaning, disinfection, sterilization
continued
Cleaning bucket and mop handle to remain
in patient’s room.
Contact and Airborne Precautions
for post-mortem care
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
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 postmortem care
Precautions
Patient
Placement
Patient
Transport
Cleaning,
sterilization
Postmortem
Anthrax
Standard
No special
Standard
Precautions
Facility policy
Standard
Botulism
Standard
No special
Standard
Precautions
Facility policy
Standard
Brucellosis
Standard
No special
Standard
Precautions
Facility policy
Standard
Essential
purposes
Patient wears
mask
Facility policy
Standard
+ Droplet
Meticulous
Special
treatment of
mop head and
water
Airborne +
Contact
Disease
Plague
Droplet for
pneumonic
Private room or
cohort, leave
three feet if no
private rooms
Smallpox
Airborne +
Contact
Negative pressure
Doors closed
Transfer plans
May cohort
Essential
purposes
Patient wears
mask
Patient covered
Q Fever
Standard
No special
Standard
Precautions
Facility policy
Standard
Tularemia
Standard
No special
Standard
Precautions
Facility policy
Standard