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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

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Pre-Event Planning

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Pre-Event Planning

Evaluating your facility

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Plan of Action

  • Emergency management plan

    • Mitigation

    • Preparedness

    • Response

    • Recovery

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Identifying a Problem

  • Most common features of an outbreak caused by a bioterrorism agent

    • Influenza-like illness

    • Viral exanthem: rash/fever

    • Gastrointestinal complaints

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Surveillance Methods

  • Databases

    • Mainframe systems

      • Admissions

      • Emergency department

      • Microbiology

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Surveillance Methods

  • Mainframe systems

    • Laboratory

    • Pathology

    • Radiology

    • Pharmacy

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Surveillance Methods

  • Access to system

  • Report distribution

  • Computer access

  • Patient electronic medical record

    • HIPAA concerns ?

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Confirming the Diagnosis

  • Coordination of surveillance plan

  • Review of symptoms

  • Gathering data

  • Communication with internal and external resources

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  • Isolation Rooms

  • Negative Pressure

    • Alternatives

  • Transportation Routes

  • Lockdown

  • Disinfectants

  • PPE

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Laboratory Support

  • Level of involvement

    • Level A: Initial work- r/o BT agents

    • Level B: County/state- agent confirmation

    • Level C: Large state lab/ advanced labs

    • Level D: CDC/DOD labs

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Laboratory Support

  • BSL levels

    • 1: General office

    • 2: Biosafety cabinets

    • 3: Negative airflow

    • 4: “Moon suits”

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Specimen Collection

  • Collection

  • Preparation

  • Media

  • Preservation

  • Shipping

  • Notification

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Febrile, Vesicular Rash Illness Algorithm for Evaluating Patients for Smallpox

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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

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Lab Methods for Confirmation of Orthopoxvirus Diagnosis

  • PCR related methods for DNA identification, (e.g., real-time PCR)

  • Electron microscopy

  • Histopathology

  • Culture

  • Serology

    • Antigen detection (IFA, EIA ag capture)

    • IgM capture

    • Neutralization antibodies

    • IgG ELISA

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Negative Stain Electron Microscopy


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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

    • response-plan/files/guide-d.pdf

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Specimens for Vaccinia-Related Disease: Vesicular Rash

  • Lesion ‘roofs’ and crusts

  • Vesicular fluids:

    • Touch prep

    • EM grid

  • Biopsy

  • Serum

  • Others (e.g., CSF)

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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

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Vaccinia lesion on foot

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Lifting a crust or ‘roof’ from the skin

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Applying microscope slide to lesion

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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

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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

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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

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Laboratory Confirmation

  • By State Health Dept., CDC and Military labs-

    • Antigen detection

    • PCR

    • IgM enzyme immunoassay

    • Immuno-staining

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Level A Lab ProceduresYersinia pestis

  • Gram stain

  • Wayson stain

  • Growth characteristics on agar

  • Growth characteristics in broth

Centers for Disease Control and Prevention

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Yersinia pestisGram stain

  • Small, gram-negative bipolar-stained coccobacilli

Must confirm by DFA and mouse inoculation

Centers for Disease Control and Prevention

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Most likely



H. aphrophilus

Bordetella spp.

Pasturella spp.

Least likely


Brucella spp.

Francisella spp.

Gram Negative Coccobacilli

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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

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Transportation is More than…

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Communications is More than…

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Security is More than…

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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

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Anticipate Transportation Needs:

  • Transfer agreements with lower levels of care:

    • Which patients?

    • What facilities?

    • How…what means of transportation?

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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

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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

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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

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  • 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 non-injured individuals

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Communications Mission

  • Organize and coordinate internal and external communications

  • Act as custodian of all logged/documented communications

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Anticipate Communication Needs:

  • Provisions for normal system overloaded or inoperable:

    • Telephone

    • Page

    • Cellular

    • Fax

  • Alternative arrangements:

    • Telephone trees

    • Pay phones

    • Walkie-talkies

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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

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Internal Communication

  • Systems and equipment

    • Train staff to repair equipment

    • Availability of replacement parts

    • Telephone lines buried, marked and protected

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Internal Communication

  • Keep written records

  • Radio transmitter/receivers equipped to operate on multiple frequencies

  • Potentially use closed circuit TV or broadcast one-way messages

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Internal Communications:Patient Records

  • Updating and keeping track of patient records essential

    • Triage tags

    • Medical records

      • Registration

      • History

      • Treatment

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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

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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

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External Communications:

  • Law enforcement or military

  • EMS dispatch/services

  • Public utilities

  • Radio operations

  • Public safety communication services

  • Health Department

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Security Mission

  • Ensure any activity is done with maximum security

  • Provide personal security to staff, patients, visitors and property

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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

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  • 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

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  • Entry route for staff, supplies etc

  • Personnel identification policy

  • Establish ambulance entry and exit routes

  • Secure triage, ER, morgue and other sensitive areas

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  • Maintain effective crowd control

  • Maintain chain of evidence for any criminal or other investigation

  • Provide vehicular and pedestrian traffic control

    • Parking and decontamination issues

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  • Secure food, water, medical and blood reserves

  • Credentialing/screening process of volunteers

  • Initiate contact with fire, police agencies through communication liaison when necessary

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Anticipate, Plan and Practice

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Isolation Guidelines

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  • 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

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  • 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

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  • For pneumonic plague, Droplet Precautions until 72 hours of anti-microbial 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

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  • 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

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  • 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

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  • 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

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  • 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

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  • 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

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  • 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

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  • Cleaning, disinfection, sterilization continued

    • Cleaning bucket and mop handle to remain in patient’s room.

  • Contact and Airborne Precautions for post-mortem care

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  • 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

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  • 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

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