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What to Do. Part 10 of 13 Comments and contributions are encouraged: please e-mail DRcomments@hpa.org.uk. HPA Centre for Infections. Reviewed April 2009. If faced with suspect cases……. Seek expert advice as soon as possible!. Overt Release.

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What to Do

Part 10 of 13

Comments and contributions are encouraged:

please e-mail DRcomments@hpa.org.uk

HPA Centre for Infections

Reviewed April 2009

If faced with suspect cases……

  • Seek expert advice as soon as possible!

Overt Release

  • Guidance re-issued August 2002 (first issued March 2000)

    • Police lead

    • Chief Constable advised by Joint Health Advisory Cell

    • Cabinet Office will coordinate centrally

    • Agent-specific information

  • Report threats/ suspicion

  • Available on DH website

  • Suspect Packages and MaterialsBiological / Chemical threats by post

    • General handling of mail and identification of suspect material

      • Open all mail with a letter opener or other method that is least likely to disturb contents, and with minimum of movement

      • Do not blow into envelopes

      • Do not shake or pour out contents

      • Keep hands away from nose and mouth while opening mail

      • Wash hands after handling mail

    Suspect Packages and MaterialsTypes of letters and packages

    • Those with suspicious/ threatening messages

    • Letters with oily stains

    • Envelopes that are lopsided, rigid, bulky, discoloured, have an obvious strange odour or feel like they contain powder

    • No postage stamp, no franking, no cancelling of the postage stamp

    • Improper spelling of common names, places or titles

    • Hand written envelopes/packages from an unknown source particularly if addressed to an individual and marked personal or addressee only

    Suspect Packages and MaterialsWhat to do

    • Do not open

    • If already opened, do not touch or clean up

    • Keep exposed persons separate from other staff

    • CALL POLICE - they are responsible for the risk assessment

    • If credible:

      • define potentially exposed persons

      • decontamination by emergency services

      • chemoprophylaxis may be required, depending on nature of suspect material

    Suspect Packages and MaterialsFurther information

    • The updated guidance document is available from:

    • http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947391200

    • Health and Safety Executive guidance 2001 is available from:

    • http://www.ukresilience.info/package.htm

    Protection of healthcare workersProphylaxis

    • Bacterial infection:

      • Anthrax

      • Plague (pneumonic)

      • Tularemia

      • Brucellosis

      • Glanders/melioidosis

      • Q fever

      • Enteric organisms

    • Antibiotic:

    • Antibiotics and Particulate Facemasks

    • Cipro - for 7 days after last known “exposure”

    • None required

    • None required

    • None required

    • None required

    • None required

    Viral infection:





    Protection of healthcare workersProphylaxis if dealing with infected cases

    • “Prophylaxis”:

    • Vaccinate within 2 (- 4) days all hospital employees

    • None

    • None required

    Protection of healthcare workersPatient isolation/ precautions

    Pneumonic Plague

    • Side room required if few patients, or cohort nurse

      • possibly whole ward(s)

      • isolate for first 72 hr treatment

    • Standard precautions

      • gloves, gowns, hand-washing

    • Respiratory precautions

      • particulate face masks (highest efficiency available), eye protection

    Protection of healthcare workersPatient Isolation/ precautions

    • Anthrax

      • Side room NOT required

      • Standard precautions

        • gloves

        • plastic aprons

        • hand-washing (especially for skin lesions)

    Protection of healthcare workersPatient Isolation/ precautions

    • Tularemia, Glanders, Q Fever, Melioidosis, Brucellosis

    • Generally side room NOT required (except for Tularemia)

    • Standard precautions

      • gloves

      • gowns

      • hand-washing (especially for skin lesions)

      • wearing of face masks in case of Tularemia

    Protection of healthcare workersPatient Isolation / precautions

    • Botulism

      • Isolation NOT required

      • Hand-washing

    Protection of healthcare workersPatient Isolation/ precautions

    • Smallpox and VHF

      • Strict isolation in Designated Centre

      • Otherwise

        • Side room ESSENTIAL(negative pressure ventilation)

        • Standard precautions(gloves, fluid repellent gowns, eye protection and hand-washing)

        • Respiratory precautions(high-efficiency FFP3 face masks)

    Protection of healthcare workersInvestigations

    • Keep to minimum necessary

      • especially after initial patients diagnosed

    • Individual packaging

      • High risk labels

    • Do not use vacuum-tube system

      • Transport by hand, in sealable container

    • Keep lab staff informed

    Concern about deliberate release – hysteria [1]

    • Definition

      • Symptoms occurring among a group of persons with shared beliefs regarding those symptoms

      • Suggestive of organic illness but no identifiable environmental cause and little clinical or laboratory evidence of illness

      • Essentially a diagnosis of exclusion but prompt identification of the outbreak is important to limit cases

    Concern about deliberate release – hysteria [2]

    • Symptoms

      The range of symptoms is wide and inconsistent:

      • Commonly includes nausea, vomiting and/or dizziness

      • Relapses can occur in the same person over multiple days of theoutbreak

      • Occurs in adolescents or children, groups under stress and females disproportionately more than males

    How real is the threat?

    • Who knows?

    • No current ‘credible threat’ to UK

    • Public/ media response in US compared to number of cases

    • Large scale release technically very difficult

    What to do with possible cases [1]

    • Contact CCDC, microbiologist, infectious diseases consultant, HPA CfI for advice

    • Investigations

      • Culture blood, sputum, skin lesions, nose swabs etc

      • Acute serum

      • Label as ‘Infection risk’

      • ‘Chain of evidence’

      • Do not use vacuum tube system

    What to do with possible cases[2]

    • Consider empirical addition of fluoroquinolone to standard regimens

    • Nurse in standard isolation

    • Minimise contacts and maintain list

    Are you (we) ready?

    • Awareness

    • Surveillance

    • Planning

      • Stockpiles e.g. antibiotics

      • Training

      • Protective equipment

      • Vaccination

    • “Don’t panic?”

    • Coping with victims

    Preparedness [1]

    • Be aware (risks low)

    • Review CMO letters and HPA CfI website regularly

    • Discuss planning with local colleagues

    • Keep list of key numbers to call if concerned including people to inform if event – ensure is up to date

    • Think laterally

    Preparedness [2]

    • Avoid overuse of antibiotics, vaccines, gas masks, survival gear

    • Involve public health early, develop and use standard protocols

    • Be aware of local incidents plans, relevant emergency planning documents etc

    • Best to get to know key players in your area before any possible event

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