Bioterrorism & Emerging Infectious Diseases

Planning & Preparedness


 

Agent-specific Recommendations:

 

Smallpox

 

DESCRIPTION OF AGENT / SYNDROME

Etiology
Smallpox is an acute viral illness caused by the variola virus. Smallpox is a bioterrorism threat due to its potential to cause severe morbidity in a nonimmune population and because it can be transmitted via the airborne route. A single case is considered a public health emergency. (8)

Clinical features
Onset of disease is manifested by high fever, malaise, prostration and headache and backache. Skin lesions appear, quickly progressing from macules to papules to vesicles. Ulcerative lesions appear in the mouth and pharynx.

  • Crust begins to form on the skin lesions about 8-9 days after onset.
  • The rash is synchronous in onset and involves face and extremities (including palms and soles) more than the trunk.

Mode of transmission
Smallpox is transmitted via both large and small respiratory droplets. Patient-to-patient transmission is likely from airborne and droplet exposure, and by contact with skin lesions or secretions. Patients are considered more infectious if coughing or if they have a hemorrhagic form of smallpox.

Incubation period
The incubation period for smallpox is 7-17 days; the average is 12-14 days.

Period of communicability
Unlike varicella, which is contagious before the rash is apparent, patients with smallpox become infectious at the onset of the rash and remain infectious until their scabs separate (approximately 3 weeks).

Emergency Medical Services

Emergency Medical Personnel will be trained to recognize signs and symptoms of smallpox. If a patient is suspected of having smallpox, dispatch will send the patient to the East End entrance of the Rebecca Sealy Hospital. An Emergency Department will be established in this area.

When Rebecca Sealy Hospital is activated as a smallpox hospital, Psychiatry inpatients in that hospital will be promptly moved to a pre-designated area in the John Sealy Towers.

Emergency Room in Rebecca Sealy

The East End Clinic in Rebecca Sealy will become the location for patients who are suspected or diagnosed with smallpox. All triage will be done in this area. Patients will be admitted to an ICU area if necessary or sent to an area designated for patients suspected of having smallpox or an area for patients confirmed to have smallpox.

  • In the event that a patient is taken to the main UTMB ER and inadvertent exposures occur, the healthcare workers and exposed patients will be vaccinated. All will be informed about the signs and symptoms of smallpox and allowed to return to daily life.
  • Employees will be asked to cover their smallpox vaccination area with a dressing and wear clothing that covers the site during work hours.
Pharmacy
The pharmacy will invoke the Pharmacy Action Plan. When smallpox vaccine arrives from CDC, it will be stocked, reconstituted and dispensed by the Pharmacy. All other supportive medicines for smallpox patients are readily available.

Hospital Employees
Hospital employees, Medical, Nursing, and Respiratory Therapy, students, and all other employees in various healthcare disciplines will be formed into patient care teams. All team members will be vaccinated against smallpox. Healthcare workers will be assigned to shifts with smallpox patients and not enter the main hospital during the shift. Team members will be asked to wear scrubs, issued upon arrival to work, and asked to remove the scrubs and shower before leaving for the day. After they shower, they may enter the main hospital facility. All “team” members will be asked to record their temperature once a day while working with the smallpox patients and for three weeks after the last contact with smallpox patients or their environment.

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INFECTION CONTROL PRACTICES FOR PATIENT MANAGEMENT

Isolation Precautions
For patients with suspected or confirmed smallpox, both Airborne and Modified Contact Precautions should be used in addition to Universal Precautions.

  • Airborne Precautions are used for patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small particle residue, 5µ or smaller in size) of evaporated droplets containing microorganisms that can remain suspended in air and can be widely dispersed by air currents.
  • Airborne Precautions require healthcare providers and others to wear a powered air-purifying respirator (PAPR) when entering the patient room.
  • Modified Contact Precautions will be used in addition to Airborne Precautions. Gloves, gowns and goggles will be used to enter the room even if direct contact with the patient is not anticipated.

Patient linens, medication, and supplies
Access to the Rebecca Sealy Hospital will be restricted to the designated medical teams. Linens, medication, and nourishment will be delivered to the west end of the building by UTMB employees and left in the lobby. A “team member” will deliver the supplies to the necessary location. Phone and computer access will be available.

Patient transport
Patient transport will be severely restricted. A portable ICU will be created if necessary and the Rebecca Sealy OR will be available if needed. Patients will wear an N-100 mask while being transported within the building.

Cleaning, disinfection, and sterilization of equipment and environment
A component of Modified Contact Precautions is careful management of potentially contaminated equipment and environmental surfaces.

Items will be autoclaved or disposed of, if possible. Laundry/linens/gowns must be autoclaved before being taken to the laundry. Heavily contaminated laundry should be rinsed before autoclaving.

  • All food will be delivered on disposable trays. Used items will be red bagged.
  • All waste from Rebecca Sealy Hospital will be placed in Red Bags and incinerated.
  • Waste and linens will be removed from the facility via the Rebecca Sealy loading dock. UTMB employees removing the items will wear gloves, N-100 masks and waterproof gowns.
  • When possible, noncritical patient care equipment should be dedicated to a single patient (or cohort of patients with smallpox).
  • If use of common items is unavoidable, all contaminated, reusable equipment should not be used for the care of another patient until it has been appropriately cleaned and reprocessed.

Discharge management
In general, patients with smallpox will not be discharged until it is determined that they are no longer infectious. Patients are no longer infectious after all of their crusts have fallen off.

Post-mortem care
Airborne and Modified Contact Precautions should be used for post-mortem care. Bodies will be stored in the Rebecca Sealy Mortuary. The Galveston County Health District will provide directions for cremation. Family visitation will not be allowed.

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LABORATORY SUPPORT AND CONFIRMATION

Laboratory selection
Clinical virology specimens may be sent to the UTMB Clinical Lab who in-turn will send the specimen to the CDC, and USAMRIID. Testing can be performed only in BSL - 4 laboratories. The FBI will coordinate collection of evidence and delivery of forensic specimens to FBI or Department of Defense laboratories.

Transport requirements
Specimen packaging and transport must be coordinated with local and state health departments, and the FBI. A chain of custody document should accompany the specimen from the moment of collection. For specific instructions, contact the Bioterrorism Emergency Number at the CDC Emergency Response Office, 770/488-7100. Advance planning may include identification of appropriate packaging materials and transport media in collaboration with the clinical laboratory at individual facilities.

Patient, Visitor, and Public Information
Fact sheets for distribution will be available, including a clear description of symptoms and where to report for evaluation and care if such symptoms are recognized. Details about the type and duration of isolation will be included. Vaccination information that details who should receive the vaccine and possible side effects will also be provided.

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POST-EXPOSURE MANAGEMENT

Decontamination of patients / environment

  • Patient decontamination after exposure to smallpox is not indicated.
  • Items potentially contaminated by infectious lesions should be handled using Modified Contact Precautions.
  • The hospital grade disinfectants already in use in UTMB Hospitals will be effective for disinfection of surfaces contaminated with the smallpox virus.

Prophylaxis and post-exposure immunization
Recommendations for prophylaxis are subject to change. Up-to-date recommendations should be obtained in consultation with local and state health departments and CDC. Post-exposure immunization with smallpox vaccine (vaccinia virus) is available and effective. Vaccination alone is recommended if given within 3 days of exposure. Passive immunization is also available in the form of vaccinia immune-globulin (VIG) (0.6ml/kg IM). If greater than 3 days has elapsed since exposure, both vaccination and VIG are recommended.

VIG is maintained at USAMRIID, 301/619-2833. Vaccination is generally contraindicated in pregnant women, and persons with immunosuppression, HIV–infection, and eczema, who are at risk for disseminated vaccinia disease. However, the risk of smallpox vaccination should be weighed against the likelihood for developing smallpox following a known exposure. VIG should be given concomitantly with vaccination in these patients. Following prophylactic care, exposed individuals should be instructed to monitor themselves for development of flu-like symptoms or rash during the incubation period (i.e., for 7 to 17 days after exposure) and immediately report to designated care sites selected to minimize the risk of exposure to others.

Facilities should ensure that policies are in place to identify and manage health care workers exposed to infectious patients. In general, maintenance of accurate occupational health records will facilitate identification, contact, assessment, and delivery of post-exposure care to potentially exposed healthcare workers.

Triage and management of large scale exposures / potential exposures
Regardless of the number of patients who present to UTMB with smallpox, all patients will be cared for in the Rebecca Sealy Hospital. If the number of patients exceeds the patient care area on 3A-D, clinic space may be used. An ER/Triage area will be setup in the clinic space at the east end entrance. The OR/PACU space may be used for ICU care.

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REFERENCES

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