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Minnesota Medicine
Published monthly by the Minnesota
Medical Association
August 2001/Volume 84
Health Care Planning for
Chemical and Biological Terrorism
Preparation is the health care
community's best defense against biologic and chemical attack.
By John
L. Hick, M.D., and Richard Danila, Ph.D., M.P.H.
The potential for health care system collapse in the face of a terrorist event was graphically illustrated by the use of the nerve agent sarin in the Tokyo subways in March 1995. Twelve people died and more than 5,000 sought medical care. Among those sickened were 135 emergency services personnel and 110 hospital employees, most of whom lacked appropriate personal protective equipment.1 Many nations and terrorist groups have developed chemical and biologic weapons because they are easy to acquire, are potentially highly destructive, and have profound psychological impact. Minnesota has experienced incidents involving ricin, a substance containing low levels of cyanide, and letter hoaxes involving anthrax; less-credible threats have involved agents such as phosgene. The potential magnitude of a chemical or biologic event, the challenge of caring for large numbers of chemically contaminated patients, and the risk of communicable disease transmission are factors that distinguish these events from natural disasters.
The Centers for Disease Control and Prevention (CDC) granted the Minnesota Department of Health (MDH) $1.2 million in 2000 to enhance the state’s capability to detect and respond to a bioterrorism event. The U.S. departments of Health and Human Services, Justice, and Defense have provided funds and training to enhance chemical and biologic event response capability. The Minnesota Department of Public Safety/Division of Emergency Management (DEM), and the MDH have jointly formed the Domestic Terrorism Consequence Management Advisory Committee to direct preparedness efforts throughout the state.
The following summarizes some of the main topic areas being examined by the MDH, DEM, and other planning groups and highlights areas of progress and areas of need, with an emphasis on hospital and physician-related issues. Although the success of the health care response will depend on support from other disciplines, the scope of this overview does not permit in-depth discussion of all involved areas.
Anticipated Chemical and Biologic Agents
Although any chemical or biological agent might be used as a weapon, agents vary widely in availability, ease of dissemination, and lethality. The CDC has developed lists of potential biologic pathogens. The “A” list comprises the most dangerous agents—smallpox, anthrax, plague, tularemia, botulinum toxin, and the hemorrhagic fever viruses in classes Filoviridae (eg, Ebola) and Arenaviridae—and is the focus of current planning activity. Of note, respiratory transmission occurs only with plague and smallpox, although CDC personnel have recently recommended aerosol precautions for hemorrhagic fever victims following documentation of respiratory transmission in monkeys.2
Physicians should understand that the only sign of a successful biologic release will likely be the presentation of patients who are likely to be ill with nonspecific signs and symptoms, to local health care providers. Any announced release will almost certainly be a hoax.
Chemical agents likely to be used by terrorists are the organ-ophosphate nerve agents (eg, sarin), cyanide, acid gases (eg, phosgene and chlorine), vesicants (eg, mustard and lewisite), and riot control agents (eg, tear gas). With chemical releases, immediate symptoms are likely. A mixed chemical and biologic event is also possible.
Hospitals should make information about these agents and their treatment readily available, and physicians should be familiar with the policies of their departments with respect to infection control precautions, supplies, protocols for decontamination, and treatment of contaminated patients.
Detection and Reporting
Minnesota is fortunate to have a robust infectious disease surveillance system, which requires clinicians to report to the MDH 60 specific bacterial, viral, and protozoal infections and several clinical syndromes.3 However, it may take days to weeks to confirm diagnosis of a reportable disease.
In a bioterrorism event, case information from clinicians in primary care, emergency medicine,
infectious disease, and critical care may be the earliest clue to an outbreak. Diseases in animal hosts may also provide early clues. In 1999 in New York City, for example, bird fatalities led to the implication of the West Nile virus in human encephalitis cases. Efforts are underway to improve information flow from clinical and veterinary sources to the
MDH.
The MDH requirement to report unexplained deaths and critical illnesses in previously healthy patients is an underused tool that could help detect a community outbreak, especially when patients are scattered among multiple hospitals. This reporting has typically occurred at the end of a long search for causes after many negative tests and cultures. Though clinicians cannot be expected to be familiar with all bioterrorism pathogens, their prompt reporting of unusual clinical syndromes or presentations to local or state health authorities may help in preventing or limiting a disease outbreak (see Table).
The majority of bioterrorism agents cause patients to present with influenzalike or enteric symptoms. Electronic databases at select metropolitan hospitals and clinics may be monitored to determine the frequency of diagnosis of disease entities including viral syndromes, enteric infections, and respiratory failure providing additional early clues to an epidemic. Hospital bed availability and the number of ambulance responses in the metropolitan area may indicate that the health care system is being abnormally taxed and may justify investigation. The utility of data from calls to health information lines and poison control centers is also being explored.
Laboratory
The MDH is developing special specimen-handling protocols for both clinical and environmental specimens. These protocols, as well as laboratory testing and safety information, will be shared with hospital lab personnel. Standard protocols will allow identification of almost all chemical and biologic agents at the state level, with the CDC and the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) serving as biologic reference and referral back-up labs. Each of the state’s laboratories will be designated as a Level A, B, or C lab. The MDH and the Mayo Clinic will maintain Biosafety Level 3 laboratories, which are capable of safely isolating all but the most dangerous pathogens (handled only at CDC or
USAMRIID).
Prehospital Decontamination
Local communities should agree upon guidelines for determining when decontamination of an individual is necessary. Victims exposed to an alleged biologic agent pose minimal risk to themselves or others, as contaminants on clothing will not become airborne. The CDC recommends that such victims contact public safety officials, shower with soap and water (preferably at home), and wash their clothes in hot water with added bleach.2,4 No medical evaluation needs to be performed unless the victim is exhibiting signs of underlying disease (eg, asthma), severe stress, or symptoms consistent with other victims, in which case the use of a chemical agent rather than a biologic agent is probable. The state duty officer for the DEM should be notified (see Table).
In general, the sicker the patient, the greater the risk to responding personnel. Off-gassing from clothing and direct chemical contact are the primary threat to health care workers, especially if the
patient has been exposed to organophosphate agents. Undressing the victim will remove approximately 90% of the chemical agent. Hospital and public safety personnel should plan for the processing of these patients.
Most patients will be minimally contaminated or affected. Decontamination, aside from clothing removal, will not be necessary for vapor exposure unless a nerve agent has been involved. In all mass exposure situations, soap and water decontamination is sufficient. Transporting patients to a predesignated nonclinical site, such as a local high school or health club, may be the easiest way to decontaminate large numbers of victims. Protocols to avoid contamination of these facilities should be prearranged.
Hospital Decontamination
Ideally, patients would be decontaminated at the incident site, but many patients self-present to hospitals. Previous experience with chemical terrorism and conventional disasters suggests that hospitals will not have time to call upon outside resources before beginning patient care. Therefore, hospitals must be prepared to immediately begin evaluating patients and providing decontamination services using staff on hand. In the Tokyo incident, St. Luke’s Hospital received 361 patients by private vehicle or on foot and 99 by ambulance or fire vehicle.5 The MDH Terrorism Clinical Care Workgroup and the Minnesota Regional Poison Center have developed guidelines to assist hospitals in determining who needs to be decontaminated (see figures 1 and 2). Facilities are encouraged to use local fire and other public safety resources to assist with decontamination but should recognize that those resources may be unavailable during an incident.
Although hospitals may be reluctant to accept contaminated patients, the Emergency Transportation and Labor Act (EMTALA) guarantees a screening examination and initial stabilization for all patients presenting for emergency care. EMTALA does not make exceptions for contaminated patients. Failure to comply with the
EMTALA rules subjects a hospital to investigation, fines, and possible loss of Medicare funds. Further, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that a facility be prepared to receive contaminated patients.6
Many hospitals have enclosed ambulance garages that are heated, well-ventilated, and supplied with water and drainage. The addition of multiple showerheads and a few backboard hose stations may greatly increase a hospital’s
decontamination capacity. In events involving large numbers of people, when patient care must take priority over wash water containment, the U.S. Environmental Protection Agency’s (EPA) Good Samaritan rules allow facilities to drain water from decontamination operations into sewers without liability, provided the EPA local field office is then notified of the event.7 The current recommendation for hospital-based decontamination of victims is a soap and water wash. Diluted household bleach (0.5%) solution may be used for inanimate articles such as prostheses and glasses.
Recently developed powered air-purifying respirators can provide protection from a wide variety of biologic and chemical agents. Although these devices are not approved for high-concentration environments, they are adequate for the levels of exposure expected by hospital decontamination personnel and are endorsed by the U.S.
Department of Health and Human Services. When combined with appropriate chemical-resistant suits, gloves, and booties, they provide excellent and relatively inexpensive personal protection. Of note, the Occupational Safety and Health Administration requires encapsulated suits with forced air supplies for personnel handling hazardous materials unless chemical levels in the environment can be monitored. It is unclear how these requirements would be applied to a hospital employee dealing with a contaminated patient in an emergency situation. However, equipping and training hospital personnel for higher protection levels for a low-probability event is unlikely to be either safe or beneficial for the employees.
The hospital should ensure that an immediately available pool of employees is designated as the decontamination team and that they are familiar with their equipment and procedures. General information for health care facilities preparing for chemical events is available from numerous sources.8-11
Facility Security
Hospitals and clinics should have a plan to secure the hospital within a few minutes of a biologic or chemical event to protect the facility and staff. Entry should be permitted only to staff and decontaminated patients. Tracking patients and visitors, and limiting entry into the hospital may help minimize exposures to and transmission of disease. If the facility’s security staff is small, environmental services or other personnel could be used to help lock doors and monitor exits. Community law enforcement resources are likely to be occupied during such an event and unable to assist health care facilities.
Pharmacy and Pharmaceuticals
Communities should do a threat analysis to determine adequate supplies of antidote and potential numbers of casualties. In the metropolitan area, hospital chemical antidote emphasis is on pralidoxime (2-PAM) and crystalline atropine for nerve agent toxicity. Crystalline preparations are inexpensive and have a long shelf life. They can be rapidly reconstituted, and unit doses can be withdrawn from multidose vials or bags. Protocols for reconstitution have been developed by members of a pharmacy planning group (see Table). Stocking significant quantities of other antidotes (eg, cyanide kits and British antilewisite) is not recommended, as these antidotes are unlikely to be effectively used in a large-scale civilian attack. Hospital pharmacies should work with hospital and community emergency preparedness personnel to determine their responsibilities in such an event.
Hospital pharmacies may wish to augment their supplies of oral antibiotics such as doxycycline and ciprofloxacin in order to have sufficient postexposure prophylaxis available for their patients and staff. Because doxycycline is effective against a broad range of potential bioterrorism agents and is inexpensive, it may be the preferred antibiotic. The potential advantage of ciprofloxacin—its efficacy against a few known genetically engineered strains of doxycycline-resistant anthrax—must be weighed against its expense. The hospital pharmacy should work with employee health services to determine a plan for prophylaxis or vaccination of staff and patients, including vaccine and supply handling, record-keeping, security, and distribution.
If community prophylaxis or vaccination is indicated, activation of pharmaceutical caches may be necessary. A supply of medications will be stored in the metropolitan area and be made available to greater Minnesota. Additional resources from national stockpiles
coordinated by the CDC would be available within 24 hours. The allocation and transport of these medications to the communities in need will be coordinated by the MDH and DEM. Communities will need to identify reception points, staff, and facilities for medication distribution.
Patient Care
Hospitals are ill-equipped to deal with large numbers of infectious aerosol precaution patients. The number of isolation rooms is limited, and ventilation systems may recirculate air within the hospital. It may be helpful for the hospital to first determine how a single patient with an airborne (eg, smallpox) or droplet-transmissible disease (eg, plague) would be handled depending on the resources of the facility.
One possible solution is to group and separate large numbers of these patients from uninfected patients. Air pressure in these cohort areas should be negative with no recirculation. Health care workers in these areas would be expected to wear appropriate protective
apparel.
The number of ventilators available to a given hospital is limited. In an epidemic—whether caused by a bioterrorist event,
pandemic influenza, or other source—the need for ventilators will eventually outstrip supply. When short-term ventilation is anticipated (eg, pending arrival of additional resources or cases of chemical intoxication), bag-valve-mask ventilation may be a reasonable option if enough staff, family members, or other personnel are available. The CDC is developing ventilator stockpiles that allow a large number of ventilators to be sent to a local area of need. Hospitals should determine how many additional ventilators they could support and may wish to inventory endotracheal tubes and bag-valve-masks. A clinical care planning group is working with physicians, attorneys, and ethicists on developing guidelines for ventilatory support in an epidemic situation when supplies are inadequate to meet demand. The 1999 Association for Professionals in Infection Control and Epidemiology (APIC) document “Bioterrorism: A Template for Health Care Facilities” provides a framework for hospitals planning for an epidemic and is available at the APIC Web site (see Table).
If a federal declaration of disaster were made, the National Disaster Medical System (NDMS) could be activated. The NDMS surveys hospital bed availability across the nation and coordinates the distribution of local patients to hospitals with available beds. Transport is accomplished by military airlift. The NDMS would assist hospitals during a biologic event by transferring uninfected patients out of the hospitals to make room for infected patients. The timeline for beginning these evacuations may be less than 24 hours after the initial request is made if the airlift resources are available. More information is available at NDMS Web site (see Table). Hospitals or community emergency operations centers may need to arrange transfers to other local or regional facilities.
Local health departments should identify facilities, including hotels, arenas, airplane hangars, college dormitories, and nursing homes, where basic medical care might be delivered should hospitals become overwhelmed by patients. Procedures for equipping and staffing such a facility should be agreed upon in advance. It is expected that the Good Samaritan law would cover practitioners working in such environments.
Family members will likely care for patients at home during an epidemic. Agent-specific instruction sheets will need to be developed. These instructions should include details about appropriate protection for the family as well as patient care.
Guidelines for clinical care of infected patients will be available from the MDH and will be posted on the MDH Web site. Chemical treatment guidelines are available from the Minnesota Poison Control Center (see Table).
Infection Control
Guidelines for care of patients with infections caused by bioterrorism pathogens will be available on the MDH Web site. This site will include basic information on transmission, personal protection, and waste handling. Facilities should have plans in place to track exposed staff and provide prophylactic antibiotics or vaccination if indicated.
Incident Command
Hospitals and health care facilities are encouraged to adopt an incident command system to foster communication among community health care providers. A command structure consistent with that used by the local community is required by the JCAHO.6 The Hospital Emergency Incident Command System (HEICS) allows hospitals to generate a flexible disaster response similar to command systems used by public safety agencies. The system is described at the California Emergency Medical Services Web site (see Table).
Staffing
Maintaining disaster-mode staffing levels for weeks during an epidemic will be nearly impossible. Flexible staffing plans must be developed to allow adequate coverage for the duration of the event without compromising patient care. Mental health professionals and critical incident stress debriefing teams should be made available to help meet employees’ emotional needs.
Hospitals must be careful that they are not depending on temporary staff (who may work at several hospitals) for services during a disaster. Additionally, facilities may wish to know how many of their nurses, physicians, and support staff have National Guard or
Reserve commitments that may remove them from the facility in times of disaster. Military resources outside Minnesota, Disaster Medical Assistance Teams (DMAT), and Disaster Mortuary Teams (DMORT) are excellent sources of supplementary personnel but may be unavailable in a multisite or national outbreak.
The MDH is identifying retired, part-time, and other physicians and nurses who might be available and willing to serve in a disaster. Emergency licensure of retired or out-of-state providers could be accomplished by a Governor’s Emergency Order, such as the one issued during the Red River flooding of 1997.
Mass Vaccination and Prophylaxis
With appropriate planning, the prophylaxis and vaccination of a community can be accomplished. During the 1995 meningitis outbreak in Mankato, for example, approximately 28,000 persons were vaccinated in a 72-hour period. Each community health department should work with local health care providers and the MDH to develop a plan to vaccinate or provide prophylactic medication to the residents of its city within 48 to 72 hours. Plans should also be made for smaller numbers of people. Civic auditoriums, sports arenas, schools, and armories may be appropriate sites for mass vaccination efforts. In a community-wide disaster multiple sites may need to be used. The MDH and DEM will be responsible for getting adequate stocks of antibiotic or vaccine to the community in need. The community will need to plan for the distribution, security, and administration of the medication.
Local communities should identify priority groups. Public safety, hospital, and health care employees, hospital inpatients, and certain critical city employees (eg, snowplow drivers) may be among those receiving the first supplies of vaccine or prophylaxis.
Provider Education
In general, health professionals have not been educated about terrorism. Threat awareness, personal protection, hazardous materials,
security, and decontamination are seldom-covered topics. Lack of education may cause health care workers to have unrealistic fears and either perform ineffectively or abandon their positions. Numerous educational opportunities will continue to be offered in the metro area.
A wide variety of reference materials are becoming available, both in print and on the Web. The MDH Web site will provide agent-specific summaries, detailed clinical information, infection control information, links to related Web sites, and information about upcoming opportunities (see Table). An excellent resource on chemical and biologic terrorism is the August 1997 JAMA terrorism special issue and the subsequent agent-specific articles on anthrax, smallpox, plague, botulinum toxin and tularemia.12-16
Communication
Rapid sharing of information needs to occur if an event is detected. Information must flow from the MDH to hospitals, clinics, and public health and safety personnel in the affected area, as well as between hospitals. The Health Alert Network (an electronic mail and Web-based system managed by the MDH) will enable accurate information to be provided to local community health departments. Hospitals and clinics may share information via broadcast fax or through an Internet-based site such as the EMSystem, a hospital status system introduced in the metropolitan area allowing messaging to all hospitals in case of a disaster, weather emergency, or other event.
Conclusion
No health care system can adequately prepare for the worst-case chemical and biologic scenarios. Fortunately, the vast majority of these events will be hoaxes, and real threats will often be aimed at well-defined targets rather than the population at large. The planning that is going into preparing for such events is resulting in a new level of general emergency preparedness in the state and is establishing communication and cooperation between agencies that have seldom worked together before.
Physicians need to understand how and when to report unusual diseases, and make sure that they have the supplies they need to protect themselves while caring for contagious or contaminated patients. Physicians also need to understand their role in their health care facility’s disaster plans. Appropriate planning and training means less risk of facility contamination and and provider exposure. Physicians should work with facility emergency preparedness personnel to
ensure that plans are as simple, realistic, and effective as possible. Hospitals and physicians are essential partners in community emergency preparedness planning, which can make the difference between a well-managed incident and a disaster. MM
John Hick is assistant professor of emergency medicine at the University of Minnesota, a faculty emergency physician at Hennepin County Medical Center, and chair of the Minnesota Department of Health Terrorism Clinical Care Workgroup. Richard Danila is assistant state epidemiologist and section manager of Acute Disease and Epidemiology at the Minnesota Department of Health.
Acknowledgment
The authors thank the members of the Minnesota Department of Health Terrorism Clinical Care Workgroup for their contributions to this paper.
References
1. Okumura T, Suzuki K, Fukada A, et al. The Tokyo subway sarin attack: disaster management, part 2: hospital response. Acad Emer Med. 1998;5:618-24.
2. Keim M. Principles for emergency response to bioterrorism. May 2, 2000 lecture at National Disaster Medical Service Conference, Las Vegas NV.
3. Minnesota Department of Health. Diseases Reportable to the Minnesota Department of Health. State Rule #4605-7040.
4. CDC - Bioterrorism Alleging Use of Anthrax and Interim Guidelines for Management—United States. Morbidity and Mortality Weekly Report. 1999:48(4);69-74.
5. Okumura T, Suzuki K, Fukada A, et al. The Tokyo subway sarin attack: disaster management, Part 1: Community Emergency Response. Acad Emer Med. 1998;5:613-17.
6. Joint Commission on Accreditation of Healthcare Organizations. CAMAC EC 1.6 revisions effective January 1, 2001.
7. Environmental Protection Agency. Comprehensive Environmental Response Compensation and Liability Act (CERCLA), Section 107 (d)(1-2).
8. Burgess JL, Kirk M, Borron SW, Cisek J. Emergency Department Hazardous Materials Protocol for Contaminated Patients. Ann Emer Med. 1999;34:205-12.
9. Cox RD. Decontamination and management of hazardous materials exposure victims in the emergency department. Ann Emerg Med. 1994;23:761-70.
10. Macintyre AG, Christopher GW, Eitzen E, et al. Weapons of mass destruction events with contaminated casualties: effective planning for healthcare facilities. JAMA 2000;283:242-9.
11. Bradley RN. Health care facility preparation for weapons of mass destruction. Prehosp Emerg Care. 2000;4:261-9.
12. Inglesby TV, Henderson DA, Bartlett JG, et al. Anthrax as a biological weapon. JAMA 1999;281:1735-45.
13. Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a biological weapon. JAMA. 1999;281:2127-37.
14. Inglesby TV, Dennis DT, Henderson DA. Plague as a biological weapon. JAMA. 2000;283:2281-90.
15. Aaron SS, Schechter R, Ingleby TV, et al. Botulism toxin as a biological weapon: medical and public health management. JAMA. 2001;285(8):1059-70.
16. Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia as a biological weapon: medical and public health management. JAMA. 2001;285(21): 2763-73.
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