A bioterrorism attack is the deliberate release of viruses, bacteria, or other germs (agents) used to cause illness or death in people, animals, or plants. These agents are typically found in nature, but it is possible that they could be changed to increase their ability to cause disease, make them resistant to current medicines, or to increase their ability to be spread into the environment. Biological agents can be spread through the air, through water, or in food. Terrorists may use biological agents because they can be extremely difficult to detect and do not cause illness for several hours to several days. Some bioterrorism agents, like the smallpox virus, can be spread from person to person and some, like anthrax, cannot.

“Preparedness plan for Bioterrorism Attack” considering 2 scenarios:
i.Patients undergoing treatment – infected with the Bioterrorism agent
ii. When a community or a large number of people is affected by the Bioterrorism attack, the hospital needs to take part in the management of an epidemic outbreak.

Roles and responsibilities

A. Role of the command center

• Provide initial notification to the local health department;
• Communicate with the local health department as the number of victims increase or the number of patients
• exceed the number of available resources (staffing and beds);
• Estimate the number of victims likely to require health care in a bioterrorist event;
• Coordinate hospital admissions of patients who require isolation (smallpox, plague, and viral hemorrhagic fever);
• Coordinate hospital discharge of patients currently in negative pressure rooms with non-bioterrorist related infectious diseases such as tuberculosis;
• Determine the need for additional personal protective equipment including N-95 respirators;
• Communicate information to staff, visitors, current patients, and the media;
• Coordinate the procurement of additional life support equipment such as adult, pediatric, and neonate respirators;
• Coordinate the procurement of antibiotics and antitoxins;
• Brief the Incident Commander;
• Develop the incident status report; and
• Participate in scheduled meetings

B. Role of the infection control officer

• The ICO is responsible for managing the day-to-day activities of the hospital-wide infection surveillance, prevention, and control program. Because the role is highly visible in the hospital and surveillance for infections is a primary function, the ICO is in a unique position to detect rapid or subtle increases in patients admitted with unusual clinical presentations.
• Frequent rounds and surveillance in Critical Care Units, Emergency Department, and other patient care units is vital to the early recognition of a bioterrorism event. The medical record of patients admitted with unusual infectious disease symptoms should be reviewed. The ICO should, at a minimum, review microbiology reports and ED discharge diagnoses several times each week. It is essential that the ICO develop a syndrome or disease monitoring system for those departments that are likely to be the first affected by a bioterrorism event. The monitoring system should include a method of communicating with the ICO when a threshold of the following events is exceeded:

 

• Emergency room diversions due to increase utilization or ICU bed unavailability;
• Increase in the number of patients with influenza-like illness, a rash with fever, gastroenteritis (vomiting and/or diarrhea), and acute asthma attack;
• Unexplained deaths occurring in otherwise healthy persons, especially if there is clinical evidence suggestive of an infectious disease process; and
• Increase in the number of persons with sepsis or septic shock.

1. Phase 1 – Mitigation

Four common diseases with recognized bioterrorism potential are anthrax, botulism, plague, and smallpox. These are not prioritized in any order of importance or likelihood of use.
However there are other agents also associated with bioterrorism potential, including those that cause tularemia, brucellosis, Q fever, viral hemorrhagic fevers, and viral encephalitis, and disease associated with staphylococcal enterotoxin B. Since the prevention may not be solely possible by the hospital itself, early detection and notifying the local health authorities would prevent the larger impact of the infectious disease.

2. Phase 2 – Preparedness

• Establishing networks of communication and lines of authority required to coordinate onsite care.
• Planning for cancellation of non-emergency services and procedures.
• Identifying sources able to supply available vaccines, immune globulin, antibiotics, and botulinum anti-toxin (with assistance from local and state health departments).
• Planning for the efficient evaluation and discharge of patients.
• Developing discharge instructions for patients determined to be non-contagious or in need of additional on-site care, including details regarding if and when they should return for care or if they should seek medical follow-up.
• Determining availability and sources for additional medical equipment and supplies (e.g., ventilators) that may be needed for urgent large-scale care.o Planning for the allocation or re-allocation of scarce equipment in the event of a large scale event (e.g., duration of ventilator support of terminally afflicted individuals).
• With assistance from the Pathology service, identifying the institution’s ability to manage a sudden increase in the number of cadavers on site.

Training and education

Physicians, nurses, technicians, and administrative personnel should be trained in all aspects of the hospital bioterrorism response plan during new employee orientation and at least annually. Drills and exercises should be conducted periodically to assess the level of staff preparedness. The hospital bioterrorism response plan should be evaluated and revised annually, based on the results of internal and external drills and as new information becomes available.

3. Phase 3 – Response

A. Detection of outbreaks caused by agents of bioterrorism

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. Bioterrorism may also occur as announced events, in which persons are warned that an exposure has occurred. Bioterrorism Readiness Plan given here includes details for the management of both types of scenarios: suspicion of a bioterrorism outbreak potentially associated with a covert event and announced bioterrorism events or threats.

a) Syndrome-based criteria

Rapid response to a bioterrorism-related outbreak requires prompt identification of its onset. Because of the rapid progression to illness and potential for dissemination of some of these agents, it may not be practical to await diagnostic laboratory confirmation. Instead, it will be necessary to initiate a response based on the recognition of high-risk syndromes. Potential Bioterrorism Disease Syndromes are listed in Annexure I

b) Epidemiologic features

Epidemiologic principles must be used to assess whether a patient’s presentation is typical of an endemic disease or is an unusual event that should raise concern. Features that should alert healthcare providers to the possibility of a bioterrorism-related outbreak include:

• A rapidly increasing disease incidence (e.g. within hours or days) in a normally healthy population.
• An epidemic curve that rises and falls during a short period of time.
• An unusual increase in the number of people seeking care, especially with fever, respiratory, or gastrointestinal complaints.
• An endemic disease rapidly emerging at an uncharacteristic time or in an unusual pattern.
• Lower attack rates among people who had been indoors, especially in areas with filtered air or closed ventilation systems, compared with people who had been outdoors.
• Clusters of patients arriving from a single locale.
• Large numbers of rapidly fatal cases
• Any patient presenting with a disease that is relatively uncommon and has bioterrorism potential (e.g., pulmonary anthrax, tularemia, or plague).

B. Patient management and infection control practices

The management of patients following suspected or confirmed bioterrorism events must be well organized and rehearsed. Strong leadership and effective communication are paramount.

a) Isolation precautions

Agents of bioterrorism are generally not transmitted from person to person; re-aerosolization of these agents is unlikely. All patients in healthcare facilities, including symptomatic patients with suspected or confirmed bioterrorism-related illnesses, should be managed to utilize Standard Precautions. Standard Precautions are designed to reduce transmission from both recognized and unrecognized sources of infection in healthcare facilities and are recommended for all patients receiving care, regardless of their diagnosis or presumed infection status. For certain diseases or syndromes (e.g., smallpox and pneumonic plague), additional precautions may be needed to reduce the likelihood for transmission.

Standard Precautions prevent direct contact with all body fluids (including blood), secretions, excretions, non-intact skin (including rashes), and mucous membranes. Standard

Precautions routinely practised by healthcare providers include:

Hand-washing

Hands are washed after touching blood, body fluids, excretions, secretions, or items contaminated with such body fluids, whether or not gloves are worn. Hands are washed immediately after gloves are removed, between patient contacts, and as appropriate to avoid the transfer of microorganisms to other patients and the environment. Either plain or antimicrobial-containing soaps may be used.

Gloves

Clean, non-sterile gloves are worn when touching blood, body fluids, excretions, secretions, or items contaminated with such body fluids. Clean gloves are put on just before touching mucous membranes and non-intact skin. Gloves are changed between tasks and between procedures on the same patient if contact occurs with contaminated material. Hands are washed promptly after removing gloves and before leaving the patient care area.

Masks/Eye Protection or Face Shields

A mask and eye protection (or face shield) are worn to protect mucous membranes of the eyes, nose, and mouth while performing procedures and patient care activities that may cause splashes of blood, body fluids, excretions, or secretions.

Gowns

A gown is worn to protect skin and prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, excretions, or secretions. Selection of gowns and gown materials should be suitable for the activity and amount of body fluid likely to be encountered. Soiled gowns are removed promptly and hands are washed to avoid the transfer of microorganisms to other patients and environments.

b) Preparing for a Large Influx of Patients

When the number of patients exceeds the number of available beds and staffing, decisions will have to be made as to whether alternative, off-site facilities should be opened, who will staff these facilities, and how they will be supplied. Some of these decisions include:

Implementing the hospital emergency management plan and bioterrorism response plan;

• Cancelling non-emergency surgeries and other elective procedures;
• Discharging patients to other acute care facilities out of the affected geographical area, or to long-term care or home care and assuring that the level of care required by these patients can be met;
• Increasing stock supplies of personal protective equipment including N-95 respirators, if required;
• Increasing stock supplies of antibiotics (oral and parenteral);
• Determining the availability and sources of additional medical equipment such as ventilators and IV pumps and other equipment normally rented;
• Deciding when it is safe to discharge patients with communicable diseases and developing specific discharge instructions;
• Determining the maximum capacity of the morgue

c) Pharmacy Support

The pharmacy should maintain a reasonable, daily inventory of antibiotics currently recommended for the treatment of patients with suspected or diagnosed bacterial bioterrorist agents. These antibiotics include, but are not limited to, aminoglycosides, fluoroquinolones and doxycycline.

d) Discharge Planning

In all probability, patients in the hospital at the time that a bioterrorist event is evolving will have to be evaluated for discharge. Patients requiring continued acute care can prolong the stay. If found stable, discharge to home or long-term care facilities is the option.

Patients with bioterrorism-related infections should not be discharged until they are deemed non-infectious (plague, smallpox, and viral hemorrhagic fever). For each bioterrorist disease included in the Planning Guide, there are home care instructions.

e) Patient placement

In small-scale events, routine isolation technique i.e. placing the patients in designated isolation rooms and infection control practices should be followed. However, when the number of patients arriving is too large to allow routine triage and isolation strategies, cohorting patients who present with similar syndromes, i.e., grouping affected patients into a designated ward or floor of will be followed.

f) Patient transport

Most infections associated with bioterrorism agents cannot be transmitted from patient to- patient. In general, the transport and movement of patients with bioterrorism-related infections, as for patients with any epidemiologically important infections (e.g., pulmonary tuberculosis, chickenpox, measles), should be limited to the movement that is essential to provide patient care, thus reducing the opportunities for transmission of microorganisms within the hospital.

g) Cleaning, disinfection, and sterilization of equipment and environment

• Principles of Standard Precautions should be generally applied for the management of patient-care equipment and environmental control.
• Cleaning and disinfection of environmental surfaces, beds, bed rails, bedside equipment and other frequently touched surfaces and equipment should be done at least twice a day and also as and when visibly found soiled.
  Sodium hypochlorite solution to be made available and easily accessible to clean all the biohazard spills.
• Used patient-care equipment soiled or potentially contaminated with blood, body fluids, secretions, or excretions should be handled in a manner that prevents exposures to the skin and mucous membranes avoid contamination of clothing and minimize the likelihood of transfer of microbes to other patients, staff and environments.
• To the extent possible single-use patient items to be used and discarded appropriately. Reusable equipment is not used on other patients until it has been appropriately cleaned and sterilized.
  Sterilization is required for all instruments or equipment that enter normally sterile tissues or through which blood flows.
• Rooms and bedside equipment of patients with bioterrorism-related infections should be cleaned using the same procedures that are used for all patients as a component of Standard Precautions unless the infecting microorganism and the amount of environmental contamination indicate special cleaning. In addition to adequate cleaning, thorough disinfection of bedside equipment and environmental surfaces may be indicated for certain organisms that can survive in the inanimate environment for extended periods of time.
• Patient linen should be handled in accordance with Standard Precautions. Although linen may be contaminated, the risk of disease transmission is negligible if it is handled, transported, and laundered in a manner that avoids transfer of microorganisms to other patients, personnel and environments. Linen used on infected/ suspected to be infected with bioterrorism agent to be double-bagged in yellow trash cover. At the laundry, the linen to be soaked in the bleaching solution and to be treated as same as the other soiled linen are washed.
• Contaminated waste should be sorted and discarded in yellow-coloured bin/ covers, sharps in the sharps containers.
• Strict adherence to the policies for the prevention of occupational injury and exposure to bloodborne pathogens to be enforced and monitored.

h) Discharge management

• Ideally, patients with bioterrorism-related infections will not be discharged from the facility until they are deemed noninfectious. However, consideration should be given to developing home-care instructions in the event that large numbers of persons exposed may preclude the admission of all infected patients. Depending on the exposure and illness, home care instructions may include recommendations for the use of appropriate barrier precautions, handwashing, waste management, and cleaning and disinfection of the environment and patient care items.

i) Post-mortem care

• The hospital/ laboratories conducting post mortem examinations should be informed of a potentially infectious outbreak prior to submitting any specimens for examination or disposal. All personnel involved in post-mortem care to be instructed to use personal protective equipment, this would include the family members of the deceased.

C. Post Exposure Management

a) Decontamination of Patients and Environment

• The need for decontamination depends on the suspected exposure and in most cases will not be necessary. The goal of decontamination after a potential exposure to a bioterrorism agent is to reduce the extent of external contamination of the patient and contain the contamination to prevent further spread. Decontamination should only be considered in instances of gross contamination.
• Depending on the agent, the likelihood for re-aerosolization, or a risk associated with cutaneous exposure, clothing of exposed persons may need to be removed. After removal of contaminated clothing, patients should be instructed (or assisted if necessary) to immediately shower with soap and water. Potentially harmful practices, such as bathing patients with bleach solutions, are unnecessary and should be avoided. Clean water, saline solution, or commercial ophthalmic solutions are recommended for rinsing eyes. If indicated, after removal at the decontamination site, patient clothing should be handled only by personnel wearing appropriate personal protective equipment, and placed in an impervious bag to prevent further environmental contamination.

b) Prophylaxis and post-exposure immunization

Recommendations for prophylaxis are subject to change. Current recommendations for post-exposure prophylaxis and immunization are provided in Annexure II for relevant potential bioterrorism agents. However, up-to-date recommendations should be obtained through local health authorities. Health care workers exposed to infectious patients/ items to be identified post-exposure care to be delivered as deemed appropriate to the infective agent.
In addition to the usual demographics of the health care worker, the system should document:

• Place in the facility where exposure occurred (e.g., ED, CCU);
• Date of exposure;
• Family members sick with similar symptoms;
• Specific symptoms of the employee;
• Date of onset of symptoms;
• Type of personal protective equipment worn, if the exposure occurred in the hospital;
• Referral for medical assessment or treatment;

c) Psychological aspects of bioterrorism

Following a bioterrorism-related event, fear and panic can be expected from both patients and healthcare providers. Psychological responses following a bioterrorism event may include horror, anger, panic, unrealistic concerns about infection, fear of contagion, paranoia, social isolation, or demoralization. Service of mental health support personnel such as psychology counsellors, social workers, volunteers, religious priests could be sought to handle the psychological aspects. The following are the aspects to consider while addressing patient and general public fears:

1. Minimize panic by clearly explaining risks, offering careful but rapid medical evaluation/treatment, and avoiding unnecessary isolation or quarantine.
   Treat anxiety in unexposed persons who are experiencing somatic symptoms (e.g., with reassurance, or diazepam-like anxiolytics as indicated for acute relief of those who do not respond to reassurance).
2. Consider the following to address healthcare worker fears:

• Provide bioterrorism readiness education, including frank discussions of potential risks and plans for protecting healthcare providers.
• Invite active, voluntary involvement in the bioterrorism readiness planning process.
• Encourage participation in disaster drills.
• Fearful or anxious healthcare workers may benefit from their usual sources of social support, or by being asked to fulfil a useful role (e.g., as a volunteer at the triage site).

D. Laboratory Support and Confirmation

a) Obtaining diagnostic samples

• Sampling should be performed in accordance with Standard Precautions. In all cases of suspected bioterrorism, collect an acute-phase serum sample to be analyzed, aliquotted, and saved for comparison to a later convalescent serum sample. For confirming, susceptibility testing, advanced molecular testing, specimens will be referred to other laboratories as directed by the local health care authorities.

b) Precautions

• Use Standard Precautions when collecting clinical specimens. (Exception: See recommendations for isolation for smallpox and viral hemorrhagic fevers)
• Use biological safety cabinets to prevent the release of aerosols. Masks, gowns gloves and eye protectors should be used in addition to biological safety hoods when handling all suspected bioterrorism agents.

c) Packaging

• Place biohazard label on each specimen container (culture or blood specimen).
• Wrap specimen container with absorbent material and place in a leak-proof container with a tight cover.
• Place a biohazard label on the primary container.
• Place wrapped specimen container in the primary container.
• Place the primary container into a second leak-proof container and seal tightly.
• Place biohazard label on the second container.
• Place dry ice or ice pack (notice) in the second container if required. If the specimen is a paper or powder form, ice should be omitted.
• Place the second container in a third container.
• The third container should meet the state and federal regulations for shipping of hazardous materials and be properly labelled.
• Laboratory criteria for processing potential bioterrorism agents

d) Transport requirements

Specimen packaging and transport must be coordinated with the local health department. A document identifying the specimen with a biohazard symbol should accompany the specimen from the moment of collection.

4. Phase 4 – Recover

• Once all the suspected/ infected patients are discharged from the hospital, the ward/ room used for such patients must thoroughly cleaned.
• Surface cleaning is done using the disinfectant. Patient items, used equipments, linen, etc are disinfected/ sterilized.
• Environmental samples tested for growth of the organism/s.
• Regular hospital functioning re-started once all the possible infectious agents are removed from the system.