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Texas: Bioterrorism Response for Healthcare Professionals

Lauren Robertson, BA, MPT

Sharon Sanders, RN

Susan Walters Schmid, BA, MA, PhD (candidate)

Wild Iris Medical Education is an approved provider (#0007) of continuing education by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS).
This course is appropriate for EMTs, paramedics, and first responders.

At the end of the day it is medical care that will be needed. Jerome Hauer, Office of Public Health Emergency Preparedness, DHHS

Managing a mass casualty or bioterrorism situation is no job for a single provider organization. This is, in fact, the responsibility of "the community"—an as yet ill-defined composite that, at a minimum, includes emergency medical services, fire, police, the public health system, local municipalities and government authorities, and local hospitals and other health care organizations. JCAHO, 2003

Bioterrorism is the act of using bacteria, toxins, or viruses to cause human disease, to harm people, or to elicit widespread fear or intimidation for political or ideological goals. Biological warfare (BW) agents are microorganisms that infect humans, livestock, or crops and cause an incapacitating or fatal disease. Symptoms of illness do not appear immediately but only after a delay, or "incubation period," that may last for days to weeks (MIIS, 2007). From a scientific and medical perspective, bioterrorism can be viewed as a variation of the problem of emerging infectious diseases, the only difference being that increased virulence or intentional release is a deliberate act. The United States public health system and primary healthcare providers must be prepared to address various biological agents, including pathogens that are rarely seen in this country.

In September 2002 the Texas Department of Health (TDH) [now the Department of State Health Services (DSHS)] contracted with the Texas Institute for Health Policy Research (Institute) to manage the Disaster Response Project. The project's goal was to develop a document that could be used by all Texas acute-care facilities to help them prepare to respond to an act of bioterrorism, and to identify hurdles to implementing their programs. The project, which received funding from the Health Resources Services Administration (HRSA) of the federal government, was completed in January 2003 (TIH, 2004). The second edition of that report is available from the Institute's website.

COVERT vs. OVERT BIOTERRORISM

The intentional release of biological agents can be either covert or overt. A covert release is unannounced and hidden, and may go unnoticed for days or even weeks. The presence of ill persons may be the first sign of a release, and the infected persons may have inadvertently infected others. An infected person may seek medical care anywhere within the healthcare system, possibly at a distance from the release area.

An overt release is immediately apparent and may even be announced. In an overt release, the healthcare system and public health officials may be overwhelmed by requests for information and treatment. Hospitals, clinics, emergency responders, and communication systems will be pressed into immediate service. An overt release has the potential to cause widespread panic.

Whether the release is covert or overt, healthcare providers need to be alert to illness patterns and diagnostic clues that indicate an unusual infectious disease outbreak associated with intentional release of a biological agent. Healthcare professionals need to be on the outlook for increases in unexpected or unexplained illnesses and know how to activate the public health response system if an outbreak is suspected (CDC, 2001). Well-trained and educated first responders, first receivers (emergency room doctors and nurses), and public health personnel are essential to an organized and successful response.

BIOLOGICAL WEAPONS

Biological agents have long been used as weapons during times of war and conflict. They are sometimes called the "poor man's weapon" because they are less expensive to produce, store, and transport than conventional weapons. Although biological weapons are relatively easy to produce, pharmaceutical knowledge is necessary to produce high-quality agents.

As weapons, biological agents have many drawbacks. They can be unpredictable and ineffective as weapons and are easily destroyed by heat or exposure to air. They tend to be slow-acting, are of little use during a surprise attack, and have the potential for affecting friendly forces. Toxins such as botulin, ricin, and animal venoms—although not infectious—tend to be more effective than pathogenic microbes because they act more quickly and have a shorter incubation period before the onset of symptoms.

Many countries have recognized the need to end the use of biological and chemical weapons and during the twentieth century several international attempts were made to contain their use. In 1925, under the auspices of the League of Nations, 132 countries signed the Protocol for the Prohibition of the Use in War of Asphyxiating, Poisonous or Other Gases, and of Bacteriological Methods of Warfare. This agreement banned the use of biological weapons but did not prohibit their production, development, and stockpiling (CNS, 2004). Known as the Geneva Convention, the agreement had some notable weaknesses, namely, it did not cover civil or internal conflicts, and many signatories reserved the right to retaliate in kind if biological weapons were used against them.

In 1975, building on the Geneva Convention, the Biological and Toxins Weapons Convention (BTWC) was ratified by the United Nations. The goal of the BTWC was to end the development, production, stockpiling, and use of microbial or biological weapons worldwide. Many offensive biological weapons programs were dismantled after the ratification of the BTWC in 1975. As of 2005, the BTWC had been signed by 171 countries, and 155 of those countries have also ratified or acceded to the treaty (CNS, 2006). However, several countries are known to have had offensive biological weapons programs well into the 1990s—most notably Iraq, the former Soviet Union, and at least thirteen other countries (Inglesby et al., 2002). Like the Geneva Convention, the BTWC has its own weaknesses, including the lack of a provision to verify compliance. Compliance depends on voluntary reporting and state-based oversight. The increase of non-state-based conflicts has made it difficult for the United Nations to monitor international violations. As of June 2005, twenty-three countries have yet to sign the BTWC (BTWC, 2005).

RECOGNIZING ILLNESS DUE TO A BIOLOGICAL RELEASE

Healthcare providers, clinical laboratory personnel, infection control professionals, and public health departments play critical and complementary roles in the recognition and response to illness caused by the intentional release of biological agents. Syndrome descriptions, epidemiologic clues, and laboratory recommendations provide basic guidance that can improve recognition of these events (CDC, 2001).

Since September 11, 2001, state and local health departments have initiated activities to improve recognition, reporting, and response, ranging from enhancing communications to conducting special surveillance projects. This includes active tracking for changes in the number of hospital admissions, emergency department visits, and occurrence of specific syndromes. Bioterrorism preparedness activities and work with emerging infectious diseases have helped public health agencies prepare for the intentional release of a biological agent (CDC, 2001).

The release of a biological agent may not have an immediate impact because of the delay between exposure and illness onset, and outbreaks associated with intentional releases may resemble naturally occurring outbreaks. Nevertheless, healthcare workers should be familiar with indications of intentional release of a biological agent and know when, and to whom, to report a suspected outbreak. This includes unusual clustering of illness, patients presenting with clinical signs and symptoms that suggest an infectious disease outbreak, unusual age distribution for common diseases, and a large number of cases of acute flaccid paralysis with prominent bulbar palsies, which is suggestive of a release of botulinum toxin (CDC, 2001). The most common features of an outbreak caused by bioterrorist agents include:

• A rapid increase (hours to days) in the number of previously healthy persons with similar symptoms seeking medical treatment.
• A cluster of previously healthy persons with similar symptoms who live, work, or recreate in a common geographical area.
• An unusual clinical presentation.
• An increase in reports of dead animals.
• Lower incident rates in those persons who are protected (eg, confined to home; no exposure to large crowds).
• An increase number of patients who expire within 72 hours after admission to the hospital.
• Any person with a history of recent (past 2–4 weeks) travel to a foreign country who presents with symptoms of high fever, rigors, delirium, rash (not characteristic of measles or chickenpox), extreme myalgias, prostration, shock, diffuse hemorrhagic lesions or petechiae; and/or extreme dehydration due to vomiting or diarrhea with or without blood loss (TIH, 2004).

A number of factors affect the potential public health impact of an intentionally released biological agent. The quality of the infectious agent and the infectious dose needed to cause an outbreak will affect the type and scope of the medical response. The incubation period of a disease organism can be anywhere from 1 to 42 days, making it potentially difficult to pinpoint the time and location of the release (CNS, 2007).

Mortality and duration are important factors to consider from a public health perspective (CNS, 2007). Plague has a rapid onset and is potentially fatal within 12 to 24 hours if untreated. Botulism toxin has a rapid onset and requires immediate supportive treatment. Smallpox can be treated effectively with a vaccination within 2 to 3 days of symptom onset.

How long an organism remains in the environment and how widely it was disbursed impacts the public health response (CNS, 2007). Most viruses and bacteria die shortly after exposure to air but some bacterial spores such as anthrax may be able to survive for several hours or longer.

Finally, the contagiousness of an organism and the availability of a vaccine or medical treatment are of primary concern (CNS, 2007). Smallpox and plague are highly contagious and have the potential for causing widespread panic. In the case of smallpox, which was believed to be eradicated, not enough vaccine exists should a widespread outbreak occur. Anthrax and plague, despite their potential for causing serious illness and death, are effectively treated with antibiotics.

CATEGORIES OF BIOLOGICAL DISEASES AND AGENTS

Any nation or group with an advanced pharmaceutical industry can produce biological weapons. More than thirty microbes have been identified as having potential for use as a biological weapon. The Centers for Disease Control and Prevention (CDC) defines three categories of biological diseases and agents based on their ease of dissemination, morbidity and mortality, potential for panic and social disruption, and requirements for public health preparedness (CDC, 2007).

Category A Diseases or Agents

Category A diseases or agents are high priority and include organisms that pose a risk to national security. They can be massed produced, transported, and disseminated with relative ease.

Category A diseases or agents:

• Are easily disseminated or transmitted from person to person.
• Cause high mortality rates.
• Have the potential for major public health impact.
• May cause panic and social disruption.
• Require special action for public health preparedness. (CDC, 2007)

Category A diseases or agents include:

• Anthrax (Bacillus anthracis)
• Botulism (Clostridium botulinum toxin)
• Plague (Yersinia pestis)
• Smallpox (variola major)
• Tularemia (Francisella tularensis)
• Viral hemorrhagic fevers (filoviruses [eg, Ebola, Marburg], and arenaviruses [eg, Lassa, Machupo]) (CDC, 2007).

Category B Diseases or Agents

Category B diseases or agents are the second highest priority and:

• Are moderately easy to disseminate.
• Result in moderate morbidity rates and low mortality rates.
• Require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance. (CDC, 2007).

Category B diseases or agents include:

• Brucellosis (Brucella species)
• Epsilon toxin of Clostridium perfringens
• Food safety threats (eg, Salmonella species, Escherichia coli O157:H7, and Shigella)
• Glanders (Burkholderia mallei)
• Melioidosis (Burkholderia pseudomallei)
• Psittacosis (Chlamydia psittaci)
• Q fever (Coxiella burnetii)
• Ricin toxin from Ricinus communis (castor beans)
• Staphylococcal enterotoxin B
• Typhus fever (Rickettsia prowazekii)
• Viral encephalitis (alphaviruses [eg, Venezuelan equine encephalitis, eastern and western equine encephalitis])
• Water safety threats (eg, Vibrio cholerae, Cryptosporidium parvum) (CDC, 2007).

Category C Diseases or Agents

Category C diseases or agents are the third highest priority and include emerging pathogens that could be engineered for mass dissemination in the future because of availability, ease of production and dissemination, and potential for high morbidity and mortality rates and major health impact. Category C diseases or agents include emerging infectious diseases such as Nipah virus and hantavirus (CDC, 2007).

CLINICAL FEATURES OF HIGH-PRIORITY AGENTS

Four category-A diseases have been the focus of CDC's efforts to educate the healthcare community about bioterrorism potential: anthrax, botulism, plague, and smallpox. The CDC does not prioritize these agents in any order of importance or likelihood of use. Other agents with bioterrorism potential include those that cause tularemia and viral hemorrhagic fevers (category A), brucellosis, Q fever, viral encephalitis, and disease associated with staphylococcal enterotoxin B (category B). Other important category B agents include any organism that threatens the water or food supply.

Anthrax

Anthrax is a bacterium that forms spores, which are the infectious component of the organism. In the absence of an intentional release, anthrax infection is extremely rare. In nature, anthrax occurs in sheep, cattle, horses, and pigs. Anthrax commonly causes disease in herbivores, which are infected after eating soil contaminated with spores (Inglesby et al., 2002). Spores are transmitted to humans by handling or ingesting contaminated animals or animal products or by handling spore-infested soil. Inoculation is through broken skin and mucous membranes, by inhalation, or more rarely by ingestion (Tierney, McPhee & Papadakis, 2004). There are three clinical forms of anthrax: inhalation, cutaneous, and gastrointestinal.

Inhalation anthrax is rare but accounts for the majority of anthrax fatalities. There have been no naturally occurring cases of inhalation anthrax reported in the United States since 1976. Inhalation anthrax develops in two stages. The first stage occurs on average 10 days after exposure, although initial symptoms can be delayed for up to 6 weeks after exposure. In the first stage, nonspecific flu-like symptoms, fever, dyspnea, cough, congestion, and anterior chest discomfort occur. Approximately 2 to 4 days after initial symptoms—sometimes after a brief period of improvement—respiratory failure, sepsis, and hemodynamic collapse occur. Thoracic edema and a widened mediastinum may be present on chest radiograph. Gram-positive bacilli can grow on blood culture, usually 2 to 3 days after onset of illness. Inhalation anthrax is not contagious person to person. Treatment is for 60 days with ciprofloxacin, rifampin, and clindamycin, in the intensive-care unit.

Cutaneous anthrax is the most commonly occurring form of anthrax worldwide, with approximately 2,000 cases reported annually. If left untreated, there is an approximately 20% fatality rate, which drops to less than 1% if treated with ciprofloxacin, doxycycline, or penicillin for 60 days. Symptoms appear within two weeks of exposure. Cutaneous anthrax infection occurs when the anthrax spore comes into contact with the skin—particularly on exposed areas of the hands, arms, or face. An area of local edema becomes a pruritic macule or papule, which enlarges and ulcerates after 1 to 2 days. Small, 1- to 3-mm vesicles may surround the ulcer. A painless, depressed, black eschar, usually with surrounding local edema, subsequently develops. The syndrome also may include lymphangitis and painful lymphadenopathy (CDC, 2001).

Gastrointestinal anthrax, which has not been reported in the United States, occurs 2 to 5 days after ingesting the anthrax spore in contaminated meat. As with the other forms of anthrax, fever is present in addition to diffuse abdominal pain and tenderness, nausea, and vomiting. Ulcerative lesions may cause bowel perforation (Tierney et al., 2004). As with the other forms of anthrax, doxycycline, ciprofloxacin (or another antibiotic in its class) and amoxicillin are used for 60 days for treatment.

TABLE 1

ANTHRAX

Type of anthrax	Signs and symptoms
Inhalation anthrax	nonspecific flu-like symptoms fever dyspnea cough congestion anterior chest discomfort
Cutaneous anthrax	local edema becomes a pruritic macule or papule, which enlarges and ulcerates after 1–2 days lymphangitis and painful lymphadenopathy
Gastrointestinal anthrax	fever diffuse abdominal pain and tenderness nausea vomiting bloody diarrhea ulcerative lesions may cause bowel perforation

"Weapons grade" anthrax (high spore count, uniform spore size, and low electrostatic charge), of the type used in the anthrax attacks in the United States following the destruction of the World Trade Center in New York, is difficult and expensive to produce. By contrast, lower-grade anthrax is more easily obtained from livestock vaccination programs but is not a significant risk to humans (Inglesby et al., 2002).

Botulism

Botulism neurotoxin is an extremely potent organism found in soil that causes respiratory paralysis and death if left untreated. Less than 1 microgram causes fatality in adults. The spore is formed by Clostridium botulinum and causes paralysis by inhibiting the release of acetycholine at the neuromuscular junction. There are 30 to 50 case of foodborne botulism reported each year in the United States.

Clinical features in adults include symmetric cranial neuropathies, such as drooping eyelids, weakened jaw clench, difficulty swallowing or speaking, blurred vision or diplopia, symmetric descending weakness in a proximal to distal pattern, and respiratory dysfunction from respiratory muscle paralysis or upper-airway obstruction without sensory deficits. In infants, symptoms can include loss of head control and limb weakness, respiratory distress, constipation, lethargy, and loss of gag reflex.

Food-borne botulism can be contracted by ingesting botulism from infected canned, smoked, or vacuum-packed foods. Inhalational botulism has a similar clinical presentation; however, the gastrointestinal symptoms that accompany foodborne botulism may be absent (CDC, 2001).

Treatment is supportive, and in the case of respiratory failure mechanical ventilation may be necessary. Antitoxin is effective in reducing the severity of symptoms, if administered early, A supply of antitoxin against botulism is maintained by the CDC and state health departments should contact CDC to arrange for a clinical consultation by phone, and (if indicated) the release of the antitoxin. Botulism can be prevented by the administration of neutralizing antibody in the bloodstream. Passive immunity can be provided by equine botulinum antitoxin or by specific human hyperimmune globulin, while endogenous immunity can be induced by immunization with botulinum toxoid (CDC, 2006).

Plague (Yersinia pestis)

Plague is an acute and potentially fatal bacterial infection that affects humans and animals and is caused by Y. pestis. Plague usually presents as 1 of 5 principal clinical syndromes: bubonic, pneumonic, septicemic, plague meningitis, or pharyngeal. Plague is a naturally occurring disease that has been endemic in the United States since 1900. Approximately 5 to 15 cases occur per year, with the greatest concentration of cases in Arizona, Colorado, and New Mexico (CDC, 2004b).

An immediate and coordinated public health and medical response would be required in the event of the intentional use of plague. Therefore, any case of plague should be reported to the state health department immediately. Reporting is especially important when a case of plague occurs outside of a typically affected area (CDC, 2004b).

With bubonic plague the infection is transmitted by the bite of an infected flea or exposure to infected material through a break in the skin. Bubonic plague cannot be transmitted from person to person. If bubonic plague is not treated, the bacteria can spread through the bloodstream and infect the lungs, causing a secondary infection of pneumonic or septicemic plague (CDC, 2004b).

Pneumonic plague is a pulmonary infection that occurs upon inhalation of plague bacteria. Pneumonic plague can be transmitted person to person through respiratory droplets with direct close contact, and without early treatment in less than 24 hours, pneumonic plague almost universally leads to respiratory failure, shock, and rapid death (CDC, 2004b).

Infection via inhalation of infective respiratory droplets or aerosols is rare with naturally occurring plague in the United States, but is the most likely route of transmission in a bioterrorist event. If Y. pestis were to be used as a bioweapon, it would be most dangerous if released as an aerosol. An aerosol release would be expected to result in an outbreak of the pneumonic form of plague and it may also cause the less common pharyngeal plague and ocular plague (CDC, 2004b).

The primary form of septicemic plague results from direct inoculation and multiplication of plague bacilli in the bloodstream, while the secondary form is a development of untreated pneumonic or bubonic plague (CDC, 2004b).

CLINICAL FEATURES

Bubonic Plague

• Incubation Period: 2–6 days.
• Symptoms
• Lymphadenopathy and fever are both early symptoms of bubonic plague.
• Patients develop buboes, which are grossly enlarged, extremely tender lymph nodes draining at the respective site of inoculation.
• Progression of Disease: If bubonic plague is not treated, the bacteria can spread through the bloodstream causing septicemia or it can infect the lungs, causing a secondary case of pneumonic plague. Rarely, it can progress to meningitis. (CDC, 2004b).

Pneumonic

• Incubation Period: 2–4 days with range of 1–6 days.
• Symptoms
• Acute onset of fever, chills, malaise, and myalgias associated with progressive lethargy.
• A productive cough of copious watery mucoid sputum that may be bloody.
• Associated chest pain and increasing dyspnea.
• Progression of disease: As the disease progresses, adult respiratory distress syndrome (ARDS) characterized by refractory pulmonary edema, may occur. Signs of shock, including hypotension and eventual multi-organ failure, may also occur. Without early detection and treatment in less than 24 hours, pneumonic plague is almost universally fatal (CDC, 2004b).

Septicemic Plague

• Incubation Period: Occurs when plague bacteria multiply in the blood. Most commonly, septicemic plague presents as a complication of pneumonic or bubonic plague, but primary septicemic plague can occur.
• Symptoms: Acute onset of fever, chills, prostration, abdominal pain, nausea, and vomiting.
• Progression of Disease: As the disease progresses, purpura may develop, as well as possible disseminated intravascular coagulation (DIC). Eventually, hypotension and other signs of shock appear. Septicemic plague is often fatal even when treated (CDC, 2004b).

Smallpox (variola)

Smallpox is a highly infectious and virulent disease caused by the variola virus. It is marked by fever and a distinctive, progressive skin rash. The name smallpox is derived from the Latin word for "spotted" and refers to the raised bumps that appear on the face and body of an infected person. There is no specific treatment for smallpox, and the only prevention is vaccination.

There are two clinical forms of smallpox: variola major and variola minor. Variola major is the most common and most severe form of smallpox. It produces an extensive rash and high fever. Historically, variola major has an overall fatality rate of about 30%. Variola minor is a less-common and less-severe form of smallpox, with death rates historically of 1% or less.

Human-to-human transmission normally occurs by inhalation of large virus-containing airborne droplets of saliva from an infected person. Infectious virus particles are released by the sloughing of oropharyngeal lesions. Smallpox can also be spread through direct contact with infected bodily fluids or contaminated objects such as bedding or clothing.

The acute clinical symptoms of smallpox resemble other acute viral illnesses, such as influenza, beginning with a 2- to 4-day nonspecific prodrome of fever and myalgias before rash onset. Several clinical features can help clinicians differentiate varicella (chickenpox) from smallpox. The rash of varicella is most prominent on the trunk and develops in successive groups of lesions over several days, resulting in lesions in various stages of development and resolution. In comparison, the vesicular/pustular rash of smallpox is typically most prominent on the face and extremities, and lesions develop at the same time (CDC, 2001).

The only weapons against smallpox are vaccination and patient isolation. Vaccination before exposure, or within 2 to 3 days after exposure, affords almost complete protection against disease. Vaccination as late as 4 to 5 days after exposure may protect against death. The smallpox vaccine is derived from the vaccinia virus, which is another pox-type virus. Vaccinia is related to smallpox, but is milder and does not contain the smallpox virus. The vaccinia vaccine helps the body develop immunity to smallpox.

Responding to an incident of bioterrorism requires a multi-agency and multidisciplinary approach. The response depends on the magnitude of the event, but at a minimum should include after-action reviews, follow-up medical care, analysis of economic repercussions and workforce disruption, decontamination, post-exposure prophylaxis and vaccination, waste management, storage and disposition of corpses, infectious disease concerns, psychosocial impacts, environmental concerns, and diversion of resources and personnel from low-impact to high-impact areas. Close working relationships and mutual-aid agreements and with emergency management and medical agencies, law enforcement and fire departments, neighboring communities, volunteer groups, private businesses, and appropriate academic institutions are critical (CDC, 2005a).

CDC Division of State and Local Readiness

One of five divisions of the Coordinating Office for Terrorism Preparedness and Emergency Response (COTPER), the Division of State and Local Readiness is primarily responsible for the administration of the Cooperative Agreement for Public Health Emergency Preparedness to state and local health departments. (CDC, 2005c).

In 1999, CDC/ATSDR began a program of providing technical assistance and funding to state, local and territorial public health departments to develop public health infrastructure, capacity, and plans to respond to events of terrorism and related public health emergencies. In 2002, shortly after the events of September 11 and the anthrax attacks, this program grew rapidly into the Agency's State and Local Preparedness Program housed within the newly formed Office of Terrorism Preparedness and Emergency Response. Given national security interest in public health preparedness, the State and Local Preparedness Program's Cooperative Agreement has grown significantly in importance and now includes 62 grantees (CDC, n.d.).

Also housed within the Division of State and Local Readiness is the Centers for Public Health Preparedness (CPHP) program, an important resource for development, delivery, and evaluation of preparedness education. The CPHP program has participating centers throughout the United States, including ones at Texas A&M University and at the University of Texas at Houston. (See Resources for further information.)

State health departments are responsible for implementing a plan, including accessing the Laboratory Response Network for Biological Terrorism, to collect and transport specimens and to store them appropriately before laboratory analysis. They are also responsible for reporting immediately to the Centers for Disease Control and Prevention (CDC) if the results of an investigation suggest release of a biological agent and for requesting help when necessary (CDC, 2001).

Mass Prophylaxis

Effective public health response to a bioterrorist attack or other disease outbreak hinges on the ability to recognize the outbreak, mobilize supplies of needed materials to affected populations in a timely manner, and provide ongoing medical care for affected individuals. Dispensing of antibiotics and/or vaccines is a cornerstone of any mass prophylaxis campaign against outbreaks of preventable disease (Hupert et al., 2004).

In the event of a bioterrorist attack or disease outbreak, medications can be distributed in two ways: by delivering the medication to a person's home or by setting up a centrally located dispensing/vaccination center (DVC). Factors such as the size and nature of the release of disease-causing agents and the availability of local and federal resources and personnel will determine whether the initial response consists of the establishment of one, several, or many dozen DVCs. The stockpiling and distribution components of a public health emergency response plan need to be similarly scalable to maintain a reliable and adequate supply of antibiotics, vaccines, and other medical materiel to these DVCs (Hupert et al., 2004).

Strategic National Stockpile

The Strategic National Stockpile (SNS) is a national repository of antibiotics, chemical antidotes, antitoxins, life-support medications, IV administration supplies, airway maintenance supplies, and medical/surgical items. It is managed jointly by the Department of Homeland Security (DHS) and Department of Health and Human Services (DHHS). The SNS program works with governmental and nongovernmental partners to upgrade the nation's public health capacity for responding to a national emergency and manages and distributes SNS assets. It supplements and re-supplies state and local public health agencies within 12 hours of federal deployment (CDC, 2005b). These federal resources are intended to build on the local and regional first-response infrastructure (that is, personnel and planning, but not necessarily stockpiles) for carrying out mass prophylaxis (Hupert et al., 2004).

Clinical Laboratories

In 1999 the Centers for Disease Control and Prevention (CDC) established the Laboratory Response Network (LRN). The LRN's purpose is to run a network of labs that can respond to biological and chemical terrorism, and other public health emergencies. The LRN has grown since its inception. It now includes state and local public health, veterinary, military, and international labs (CDC, 2006b).

The LRN structure for bioterrorism includes three levels of labs designated as national, reference, or sentinel. A lab's designation depends on the types of tests it can perform and how it handles infectious agents to protect workers and the public (CDC, 2006b).

National labs have unique resources to handle highly infectious agents and the ability to identify specific agent strains (CDC, 2006b).

Reference labs can perform tests to detect and confirm the presence of a threat agent. These labs ensure a timely local response in the event of a terrorist incident. Rather than having to rely on confirmation from labs at CDC, reference labs are capable of producing conclusive results. This allows local authorities to respond quickly to emergencies (CDC, 2006b).

Sentinel labs represent the thousands of hospital-based labs that are on the front lines. Sentinel labs have direct contact with patients. In an unannounced or covert terrorist attack, patients provide specimens during routine patient care. Sentinel labs could be the first facility to spot a suspicious specimen. A sentinel laboratory's responsibility is to refer a suspicious sample to the right reference lab (CDC, 2006b).

The Texas Department of State Health Services (DSHS) will assume responsibility as the lead agency should a bioterrorism event occur anywhere in Texas. Report immediately any instance of a biological threat to your local health department or directly to the DSHS. (See Resources for specific contact information.)

HEALTHCARE ORGANIZATIONS

Healthcare organizations will play a central role should a bioterrorism event occur in the United States. In January 2001 the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) (now known as The Joint Commission) implemented revised standards to improve the ability of healthcare organizations to deal with infectious disease outbreaks and bioterrorism events. They modified earlier standards in three ways:

1. The concept of simple emergency preparedness was changed to emergency management.
2. Healthcare organizations must adopt an "all-hazards approach" to planning.
3. Accredited organizations must conduct annual, community-wide practice drills if the organization's all-hazards assessment identifies a credible community threat. (JCAHO, 2001)

Despite the fact that billions of dollars have been allocated for homeland security, hospitals are struggling to keep up with the new standards. The JCAHO has referred to the demand for hospitals to take the lead in the emergency management of bioterrorism events as an "unfunded mandate" (JCAHO, 2003). In many communities, underfunded healthcare organizations are barely able to keep up with the daily demands of healthcare services in their respective communities. To help hospitals meet the new requirements for disaster preparedness, and to contain costs, JCAHO recommends the following:

1. Enlist the community in preparing the local response.
2. Focus on the key aspects of the preparedness system that will preserve the ability of community healthcare resources to care for patients, protect staff, and serve the public.
3. Establish accountabilities, oversight, leadership, and sustainment of community preparedness systems (JCAHO, 2003).

In any type of emergency, including a bioterrorism event, a healthcare organization should focus on four areas of planning:

• Mitigation: activities taken before an event that will lessen the probability or effects of the incident. Hospitals need to consider what they can do to lessen the impact on their facility in the event of a large-scale outbreak.
• Preparedness: efforts taken to enhance the response capabilities so as to effectively handle a large number of patients presenting for treatment. Preparedness includes the creation of plans that will protect staff, patients, and the facility, while serving the community.
• Response: the activities that occur during an event to improve the outcome through a well-developed plan that activates needed resources within the emergency response system.
• Recovery: includes short- and long-term measures to bring the system back to normal operation (TIH, 2004).

BEST PRACTICES FOR HOSPITAL-BASED FIRST RECEIVERS

Healthcare workers risk occupational exposures to biological materials when a hospital receives contaminated patients, particularly during mass-casualty events. Hospital employees, who may be termed first receivers, work at a site away from where the hazardous release occurred. This means that their exposures are limited to the substances transported to the hospital on the skin, hair, clothing, or personal effects of the victims. The location and limited source of contaminant distinguishes first receivers from first responders such as firefighters, law enforcement, and ambulance service personnel, who typically respond to the incident site (OSHA, 2005).

Worst-case scenarios take into account challenges associated with communication, resources, and victims. During mass-casualty emergencies, hospitals can anticipate little or no warning before victims begin arriving. First receivers can anticipate that information regarding the hazardous agents may not be available immediately. Hospitals also can anticipate a large number of self-referred victims (as many as 80% of the total number of victims) and should assume victims will not have been decontaminated prior to arriving at the hospital (OSHA, 2005).

An employee's role and the hazards that an employee might encounter dictate the level of training that must be provided to any individual first receiver. Personal protective equipment (PPE) selection must be based on a hazard assessment that carefully considers both of these factors, along with the steps taken to minimize the extent of the employee's contact with hazardous substances (OSHA, 2005).Surge capacity, triage, decontamination, security, and disposal of contaminated wastewater must also be addressed.

Surge Capacity

In the event of a mass-casualty event, healthcare organizations must be able to increase their services quickly in response to the crisis. This is called an organization's "surge capacity," or the "the ability to expand care capabilities in response to sudden or prolonged demand" (JCAHO, 2003). Staffing levels, education and training, decontamination capabilities, vaccination programs for direct caregivers, volunteer resources, and stockpiling of supplies must be assessed. In most cases, routine care must be continued.

The ability of the organization to "degrade gracefully" must be considered. A healthcare organization should plan for a reduction in services as the number of patients climb. The goal is to engineer and manage failures and thus to avoid "catastrophic failure" (JCAHO, 2003). During a state of emergency, it may be impossible to follow normal practice guidelines. JCAHO recommends that hospitals and oversight agencies "provide for waiver of regulatory requirements under conditions of extreme emergency" (JCAHO, 2003).

Triage

Pre-decontamination triage serves three purposes. It:

• Distinguishes contaminated individuals from other patients arriving at the hospital by identifying symptoms and victim's proximity to a known chemical release.
• Identifies victims who require immediate stabilization before they enter the decontamination system.
• Identifies injuries or critical pre-hospital treatment materials that will require special handling inside the decontamination system (OSHA, 2005).

Post-decontamination triage for medical treatment should occur in the hospital post-decontamination zone, after victims are inspected and found to be free of contamination. Some hospitals combine decontamination and initial medical treatment (such as antidotes), which means either the healthcare worker attempts medical triage while wearing PPE (preferred) or the worker is at risk of exposure from victims who have not been adequately decontaminated (OSHA, 2005).

Decontamination Activities

Hospitals must identify spaces that will support decontamination activities (including equipment storage) and ensure operations can continue in the event one area of the hospital becomes contaminated. Hospitals planning additions or remodeling projects have a unique opportunity to design spaces appropriately. Other hospitals should use creative planning to identify existing architectural features that they can use to their advantage. Nonambulatory victims can require a substantial proportion of first receivers' time and efforts. First receivers are likely to experience the greatest exposure while assisting these victims (OSHA, 2005).

Because victims often will not present to a hospital immediately following exposure to a biological agent, decontamination will not be necessary in most cases (Texas Dept. of Health, 2003). If decontamination is necessary, numerous agencies and organizations recommend a shower time of approximately five minutes for contaminated victims brought to a hospital. Despite the fact that there is no empirical data, operational procedures deem this time as adequate. Numerous agencies and programs recommend the use of water and a liquid soap with good surfactant properties (such as hand dishwashing detergent) to decontaminate victims during emergencies and mass casualties involving hazardous substances (OSHA, 2005).

Isolation and Lockdown

Hospitals can use a variety of methods to limit unauthorized access to the emergency department until the victims have been decontaminated. The methods range from a guard with a key at the door to sophisticated keycard systems controlled at a central command center. The more complex systems tend to be associated with urban or recently modernized hospitals and are intended for use in any type of disturbance. Hospitals intend to use these methods if situations suggest that an unruly crowd will force its way into the hospital (OSHA, 2005).

Security

Site security helps maintain order and control traffic around the decontamination facility and the hospital entrances. Security officers might need to control a contaminated individual to prevent other staff from becoming exposed and to protect equipment. Security officers also ensure contaminated victims do not bypass the decontamination hospital or enter the ED without passing inspection. In cases of civil disturbance, properly identified security officers protect the decontamination facility and staff so normal operations can continue (OSHA, 2005).

Personal Protective Equipment

Hospitals should select personal protective equipment (PPE) such as respirators, suits, gloves, and face and eye protection based on a hazard assessment that identifies the hazards to which employees might be exposed. Under OSHA's Personal Protective Equipment Standard, or the parallel State Plan standards, all employers, including hospitals, must certify in writing that the hazard assessment has been performed. For first-receiver PPE, hospitals may base the hazard assessment on OSHA's Best Practices document. Hospitals likely to respond to incidents involving a specific hazard should adjust the PPE accordingly (OSHA, 2005).

OSHA's Personal Protective Equipment Standard also requires that employees be provided with equipment that fits appropriately. Some hospitals assign a set of protective equipment to a specific individual. The equipment is stored in a container marked with the individual's name. Other hospitals maintain general supplies of PPE, storing sets of equipment by size. In this case, the packages are clearly marked only with the size. Each first receiver tries on equipment to determine what size group fits best, then, during an emergency, the employee can quickly locate an appropriate PPE set (OSHA, 2005).

Personal protective equipment selection for first receivers has been a topic of extensive discussion. At the root of this discussion is the need for hospitals to provide adequate protection for the reasonably anticipated worst-case employee-exposure scenario, despite having limited information regarding the nature of the substance with which victims may be contaminated. This lack of information challenges hospitals' abilities to conduct the hazard assessments on which PPE selection must be based (OSHA, 2005).

Infection Control

Heightened awareness by infection control (IC) professionals facilitates recognition of the release of a biological agent. Infection control professionals are involved with many aspects of hospital operations, and several departments, and with counterparts in other hospitals. As a result, they may recognize changing patterns or clusters in a hospital or in a community that might otherwise go unrecognized (CDC, 2001).

Infection control professionals should set up a clinical syndrome-monitoring system for hospital departments most likely to be involved in a bioterrorism event. At a minimum, this should include monitoring:

• Emergency department diversions due to increased visits to the ED or to CCU bed unavailability.
• Increases in the number of patients with influenza-like illness, rash with fever, gastroenteritis (vomiting and/or diarrhea), and acute asthma attacks.
• Unexplained deaths occurring in otherwise healthy persons, especially if there is clinical evidence suggestive of an infectious disease process.
• Increases in the number of persons with sepsis or septic shock (TIH, 2004).

Infection control professionals should ensure that hospitals have current telephone numbers for notification of both internal and external contacts and that they are distributed to the appropriate personnel. They should work with clinical microbiology laboratories, on- or off-site, that receive specimens for testing from their facility to ensure that cultures from suspicious cases are evaluated appropriately (CDC, 2001).

Wastewater Management

Wastewater from decontamination showers can contain low-level concentrations of the substance(s) with which victims are contaminated. Given the opportunity to plan for decontamination activities (by designing and installing or purchasing decontamination facilities, developing procedures, and preparing staff), hospitals should consider the management of decontamination shower water as part of the plan (OSHA, 2005).

Decontaminating Surfaces and Equipment

The hospital emergency management plan should include procedures for cleaning equipment and surfaces during and after an incident. Cleaning should be performed by properly protected and trained employees. Items that cannot be decontaminated safely should be processed for appropriate disposal. It is unlikely that portable gear could be adequately decontaminated after an incident involving a persistent or highly toxic agent (OSHA, 2005).

REPORTING AN INCIDENT OF BIOTERRORISM

In the event that an incident of bioterrorism occurs in your community, you should know what to report and to whom the report should be sent. First reporters should start at the healthcare organization or hospital level by reporting to the department supervisor, laboratory, and infection control department. Then contact the local health/regional departments, which will contact the Texas Department of State Health Services and the CDC. In 2003 the CDC published recommended practices for early detection and reporting of a terrorist event. Successful reporting of a bioterrorism event results from good planning, education, and awareness, and regular standardized testing before an occurrence.

Telephone Reporting

Telephone should be the primary means for immediate reporting because it is the most direct, rapid, and easy-to-use method. A trained public health professional should be able to handle up to 80% of incoming queries. Standards should be established to ensure a reliable and immediate response to notifiable diseases and health conditions. The time from initial receipt of the call to a response by the health-department on-call physician should not exceed 30 minutes. If the telephone system fails, health departments must have an alternative for receiving urgent reports (CDC, 2003).

Texas Reporting
Texas Department of State Health Services, Austin, Texas
(512) 458-7111 OR 888-963-7111
Public Health Preparedness Unit
(512) 458-7219

Education and Awareness

Information on disease reporting requirements should be communicated to clinicians and laboratories. Multiple outreach mechanisms should be used to disseminate educational information. The target audience for education and awareness materials needs to be defined. Disease reporting requirements should reach appropriate medical personnel and laboratories at least annually. The process for reporting other diseases of immediate public health importance will help a given jurisdiction establish a system for reporting cases due to terrorism agents (CDC, 2003).

Testing

For testing of the 24/7 reporting system regular, formal, unannounced standardized system testing should be implemented. Testing should be conducted at least annually and should test:

• Existence/use of standard protocols.
• Whether the call connects.
• Who you reach.
• How quickly you reach a public health physician.
• How quickly consultation is initiated.
• Review of the call response (recording or listening in).
• Back-up and surge capacity. (CDC, 2003)

During the first 24 hours of most emergencies and disasters, specific functions and tasks are divided into three response time frames: immediate, intermediate, and extended. The order in which these activities are undertaken may vary according to the specific incident. Because emergency response is a dynamic process, these activities may be repeated at various stages of the response. In most instances, health department officials will not take the lead in responding to an incident. The health department should function as part of a larger overall emergency response effort.

In the first hours following a bioterrorism event, public health officials should assess the situation and initiate the appropriate response. Try to determine how many people are threatened, affected, exposed, injured, or dead. Determine what public health functions and what geographical areas have been impacted and assess if medical and healthcare facilities been affected. Contact key health personnel within your health department who  have emergency response roles and responsibilities.

Ensure that contact has been established with appropriate personnel within your health department and initiate risk communication activities. Remember to communicate public health messages in an appropriate language to persons with limited English proficiency. A public health information "hotline" can be established to address requests for information from the public. Public messages in a crisis should employ the STARCC principle: Simple, Timely, Accurate, Relevant, Credible, Consistent (Reynolds, 2002).

Posted January 24, 2008

Expires January 15, 2010

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