1. Pre-Event Planning Evaluating your facility

2. Plan of Action • Emergency management plan • Mitigation • Preparedness • Response • Recovery

3. Identifying a Problem • Most common features of an outbreak caused by a bioterrorism agent • Influenza-like illness • Viral exanthem: rash/fever • Gastrointestinal complaints

4. Surveillance Methods • Databases • Mainframe systems • Admissions • Emergency department • Microbiology

5. Surveillance Methods • Mainframe systems • Laboratory • Pathology • Radiology • Pharmacy

6. Surveillance Methods • Access to system • Report distribution • Computer access • Patient electronic medical record • HIPAA concerns ?

7. Confirming the Diagnosis • Coordination of surveillance plan • Review of symptoms • Gathering data • Communication with internal and external resources

8. Facilities/Environmental • Isolation Rooms • Negative Pressure • Alternatives • Transportation Routes • Lockdown • Disinfectants • PPE

9. 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

10. Laboratory Support • BSL levels • 1: General office • 2: Biosafety cabinets • 3: Negative airflow • 4: “Moon suits”

11. Specimen Collection • Collection • Preparation • Media • Preservation • Shipping • Notification

12. Febrile, Vesicular Rash Illness Algorithm for Evaluating Patients for Smallpox

13. 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

14. 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

15. Negative Stain Electron Microscopy Vaccinia

16. Specimen Collection • Vaccinia and variola specimen collection essentially the same • Check CDC website for: • Recent updates in orthopox specimen collection specifics • Appropriate infection control practices • Shipping criteria • Laboratories • www.bt.cdc.gov/agent/smallpox/ response-plan/files/guide-d.pdf

17. Specimens for Vaccinia-Related Disease: Vesicular Rash • Lesion ‘roofs’ and crusts • Vesicular fluids: • Touch prep • EM grid • Biopsy • Serum • Others (e.g., CSF)

18. 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

19. Vaccinia lesion on foot

20. Lifting a crust or ‘roof’ from the skin

21. Applying microscope slide to lesion

22. 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

23. 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

24. 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

25. Laboratory Confirmation • By State Health Dept., CDC and Military labs- • Antigen detection • PCR • IgM enzyme immunoassay • Immuno-staining

26. Level A Lab ProceduresYersinia pestis • Gram stain • Wayson stain • Growth characteristics on agar • Growth characteristics in broth Centers for Disease Control and Prevention

27. Yersinia pestisGram stain • Small, gram-negative bipolar-stained coccobacilli Must confirm by DFA and mouse inoculation Centers for Disease Control and Prevention

28. Most likely Acinetobacter Actinobacillus H. aphrophilus Bordetella spp. Pasturella spp. Least likely DF-3 Brucella spp. Francisella spp. Gram Negative Coccobacilli

29. 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

30. TransportationCommunicationsSecurity

31. Transportation is More than…

32. Communications is More than…

33. Security is More than…

34. Transportation

35. 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

36. Anticipate Transportation Needs: • Transfer agreements with lower levels of care: • Which patients? • What facilities? • How…what means of transportation?

37. 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

38. 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

39. 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

40. Transportation • Utilize personnel from labor pool as patient transporters • Assemble stretchers and wheelchairs in proximity to ambulance off loading and triage area • Identify transportation needs of `walking’ decontaminated or non-injured individuals

41. Communications

42. Communications Mission • Organize and coordinate internal and external communications • Act as custodian of all logged/documented communications

43. Anticipate Communication Needs: • Provisions for normal system overloaded or inoperable: • Telephone • Page • Cellular • Fax • Alternative arrangements: • Telephone trees • Pay phones • Walkie-talkies

44. 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

45. Internal Communication • Systems and equipment • Train staff to repair equipment • Availability of replacement parts • Telephone lines buried, marked and protected

46. Internal Communication • Keep written records • Radio transmitter/receivers equipped to operate on multiple frequencies • Potentially use closed circuit TV or broadcast one-way messages

47. Internal Communications:Patient Records • Updating and keeping track of patient records essential • Triage tags • Medical records • Registration • History • Treatment

48. 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

49. 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

50. External Communications: • Law enforcement or military • EMS dispatch/services • Public utilities • Radio operations • Public safety communication services • Health Department