All public health and medical responses to events of bioterrorism begin at the local level. Pediatricians are front-line health care providers in every community and may become front-line responders in a bioterrorist attack. It is impossible to predict where a child or parent may first seek care for an illness caused by a bioterrorist agent, so primary-care pediatricians, as well as those working at secondary- and tertiary-care facilities, must be prepared to promptly diagnose and isolate a patient who has an illness potentially related to bioterrorism and to notify the proper authorities.
Good infection control practices require that anyone, child or adult, who presents with a fever and rash be immediately placed in a private room with the door closed. This is standard practice because a number of highly contagious childhood infectious diseases present this same way (varicella, measles, rubeola, meningococcus), regardless of whether the illness is ultimately determined to be due to an agent of bioterrorism. Infection control precautions may also include the use of masks, gowns, gloves, and equipment for eye protection, depending on each situation.
Once the initial history and physical examination have been completed, if a disease related to bioterrorism is suspected, the pediatrician must notify the proper authorities, including the infection-control practitioner (if one is available at the facility) and local public health authorities. Each local public health system is organized slightly differently, so pediatricians should become familiar with their own local public health agency and phone number for local reporting.
Rapid reporting to authorities is essential. Each agency level has developed and continues to refine response plans to handle a bioterrorist event. Rapid activation of these plans provides the best opportunity to limit disease spread during an outbreak. Local authorities may initiate an immediate investigation or seek assistance from the State health department.
For a list of State health department Web sites, go to: http://www.cdc.gov/other.htm#states.
For a list of State epidemiologists, go to: http://www.cste.org/members/state_and_territorial_epi.asp.
States report their investigations to and request epidemiologic assistance from the Centers for Disease Control and Prevention (CDC). The CDC can provide public health consultation, epidemiologic support, and other technical assistance to State health departments. The CDC usually becomes involved in a State's investigation at the request of the lead State epidemiologist or health officer.
The CDC can be reached during all hours through the CDC Director's Emergency Operation Center at 770-488-7100.
Each State has a public health system, although the structure and reporting network varies from State to State. In some States, the State health department has authority over county and local health departments. In other States, county and local health departments function autonomously. State health departments facilitate consultations with specially designated laboratories that are capable of responding to public health emergencies (go to Laboratory Response Network). State bioterrorism response plans will reflect these differences. All pediatricians and health care facilities should learn the structure of their local public health system and the point of contact for reporting illnesses suspected of being related to bioterrorism.
Most hospitals have started to develop bioterrorist response plans that may be part of a larger hospital disaster plan. Hospitals play a very large role in the care of bioterrorist victims and anxious or worried parents and others. Optimally, hospitals should have been included in the response planning of local public health agencies. Office and hospital-based pediatricians can become better prepared to respond to a bioterrorist attack by becoming familiar with local hospital bioterrorist and disaster plans. In addition, pediatricians are uniquely qualified to ensure that the special needs of children (e.g., medical supplies and therapeutics specific for children) are addressed in local medical response plans. (Chapter 9, Integrating Terrorism and Disaster Preparedness into Your Pediatric Practice).
All suspected cases of bioterrorism are subject to criminal investigation. Public health authorities are responsible for notifying local and Federal law enforcement. In many jurisdictions, these relationships are already established and detailed in State and local public health bioterrorist response plans.
Collecting the appropriate clinical laboratory specimens in a case of actual or suspected bioterrorist-related illness is critical for the medical care of the patient, as well as for public health and legal investigations. Specimen collection varies by the agent suspected and should be done in consultation with public health authorities. Local and State public health authorities can advise on specific specimen collection and shipping in each case and consult with the CDC as needed. For detailed information regarding specimen collection, packaging, and shipping, go to: http://www.bt.cdc.gov/labissues/index.asp.
The Laboratory Response Network (LRN) is a national network of local, State, and Federal public health, hospital-based, veterinary, agriculture, food, and environmental testing laboratories that provide laboratory diagnostic capability to respond to biological and chemical terrorism and to other public health emergencies. The CDC, along with the Association of Public Health Laboratories and the Federal Bureau of Investigation (FBI), created the LRN, which has been operational since 1999. There are more than 100 LRN laboratories across the United States, and the network continues to expand. Consultation with LRN facilities is facilitated through State health departments. For more information, go to: http://www.bt.cdc.gov/lrn/.
Rapidly detecting and isolating patients with an infectious illness related to bioterrorism is essential to prevent transmission in health care settings. If an infection related to bioterrorism is suspected, the patient should be placed on contact precautions and airborne infection isolation, in addition to standard precautions, until preliminary test results are available and the transmissibility of disease can be reevaluated.
Agents of bioterrorism are generally not transmitted from person to person. The release of an agent is most likely from a point source. However, smallpox, Viral hemorrhagic fevers (VHFs), and pneumonic plague may be highly transmissible from person to person via respiratory droplet and, in some cases, by aerosol spread.
All patients in a health care facility and all patients suspected of infection with a Category A bioterrorist agent (anthrax, botulinum toxin, plague, smallpox, tularemia, and VHFs) should be cared for using standard precautions. Formerly known as universal precautions, standard precautions are the minimal accepted level of precaution. Standard precautions prevent direct contact with blood, other body fluids, secretions, excretions, nonintact skin/rashes, and mucous membranes and should be observed during all aspects of patient care.
Standard precautions include the following:
Effective infection control sometimes requires additional precautions beyond standard precautions. These are called transmission precautions and consist of the following:
Transmission precautions are instituted based on the type of organism suspected (Table 4.2).
Contact precautions are used in addition to standard precautions when patients are suspected or known to be infected with agents transmitted by direct contact with the patient's skin or by indirect contact with surfaces or patient-care items in the patient's environment.
Droplet precautions are used in addition to standard precautions when patients are suspected or known to be infected with microorganisms transmitted by droplets >5µm in size that are generated when a patient coughs, sneezes, or talks. These particles, when expelled, may travel 3 feet before landing on a surface.
Formerly known as airborne precautions, airborne infection isolation is the highest level of precaution. It is used in addition to standard precautions when caring for patients suspected or known to be infected with microorganisms transmitted by nuclei of airborne droplets <5µm in size. When dispersed, these nuclei remain suspended in the air and can be dispersed over long distances and potentially throughout a health care facility.
For additional information about infection control measures, go to: "Guideline for Isolation Precautions in Hospitals" at http://www.cdc.gov/ncidod/dhqp/gl_isolation.html and "Guideline for Environmental Infection Control in Health-Care Facilities, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee" at http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html.
The equipment and supplies necessary to diagnose and treat a patient suspected of being infected with a bioterrorist agent vary by the level of care that will be provided at a particular facility. An office-based primary care pediatrician may need to be concerned only with short-term isolation and preliminary stabilization of a patient, which will require a relatively short list of supplies that usually are available in the well-stocked pediatric medical office. Hospital-based pediatricians may be providing longer term and more complex care to patients and should consult their hospital administration regarding the hospital's bioterrorist response plan and the response plans of State and local health authorities.
Response planning requires a detailed and integrated approach between public health and medical facility administrators. For guidance and helpful checklists, go to: "The Public Health Response to Biological and Chemical Terrorism: Interim Planning Guidance for State Public Health Officials, July 2001," at http://www.bt.cdc.gov/Documents/Planning/PlanningGuidance.PDF, and "Bioterrorism Readiness Plan: A Template for Healthcare Facilities, April 1999," at http://www.cdc.gov/ncidod/dhqp/pdf/bt/13apr99APIC-CDCBioterrorism.PDF. (PDF Help).
During a bioterrorist event, local pediatricians and their staffs should maximize their ability to keep the office running smoothly and to provide care. The first step is for every staff member to have a personal family emergency plan. Once staff members are assured that they and their family members are safe, they are better able to focus on their professional duties.
Second, every office needs an emergency plan. This plan should include details for handling an emergency both in-office and in the community. Items that should be included in an in-office emergency plan include the following:
Items that should be included in a plan for an emergency in the community include the following:
Depending on the situation, dedicated staff may be needed just to handle anxious or worried parents. (For further information on office emergency plans, go to Chapter 9, Integrating Terrorism and Disaster Preparedness into Your Pediatric Practice)
The community-based pediatrician should have the following items readily available to evaluate children suspected of having an illness related to bioterrorism:
Other laboratory supplies that might be required in the early evaluation of a patient should be available through public health authorities. Public health authorities will advise on the collection of specimens and on patient transport to locally designated emergency response facilities.
Health care professionals can register to receive E-mail updates about bioterrorism and response planning at http://www.bt.cdc.gov/clinregistry/index.asp.
Treatment consists of supportive care (e.g., fever management, fluid management, nutritional supplementation, ventilatory support, and emotional care) and medical treatment (antibiotics and antitoxins) specific to the bioterrorist organism implicated.
The Department of Health and Human Services has stockpiled vaccine for potential use in an outbreak of smallpox and anthrax. Although these vaccines are not available to the public before a bioterrorist event, they could be made rapidly available to high-risk populations in the event of an attack.
Smallpox vaccine contains live vaccinia virus, an orthopox virus that is related to smallpox virus but that does not cause smallpox. Currently, the United States has stockpiled two types of vaccine:
The smallpox vaccine is administered using a bifurcated needle that results in multiple punctures to the superficial layers of the skin. For a video about smallpox vaccination administration, go to: http://www.bt.cdc.gov/agent/smallpox/vaccination/administration-video/index.asp.
The vaccination site heals over the course of 3 weeks and leaves a small scar. In the 1960s through 1972 when smallpox vaccination was part of the routine childhood immunization schedule, children—especially girls—were often vaccinated in locations on the body where the scar was not visible. Because smallpox vaccine will be released only in response to a bioterrorist attack, it is recommended that the vaccine be administered only in the deltoid region of the arm, so that the vaccination site and scar can be seen easily and evaluated for both medical and public health purposes (Figure 4.7, 113 KB).
If given before exposure, the smallpox vaccine is highly effective against smallpox (95-97%), and if given up to 4 days after exposure, it also can prevent or minimize the severity of disease. The lower age limit for vaccine administration for a child who has not been exposed is 1 year. There is no lower age limit for a child who has been exposed to smallpox.
The vaccine has a number of common side effects, as well as the risk of more serious adverse reactions. Although many children experience side effects commonly seen after other childhood vaccinations (e.g., fever, lymphadenopathy, fatigue, malaise, and fussiness), far fewer children experience vaccinia-specific adverse reactions such as generalized vaccinia, eczema vaccinatum, vaccinia necrosum, postvaccinal encephalitis, and fetal vaccinia. Fortunately, by screening for contraindications, these complications may be largely avoidable.
For extensive information about smallpox vaccination, administration, screening for contraindications, adverse events, and treatment of adverse events, go to:http://www.bt.cdc.gov/agent/smallpox/vaccination/index.asp.
Anthrax vaccine protects against invasive disease and is currently recommended only for high-risk populations:
The licensed AVA anthrax vaccine, manufactured by BioPort Corporation, Lansing, Michigan, is prepared from cell-free filtrate of Bacillus anthracis culture that contains no live or dead bacteria. The vaccine is administered in a series of six subcutaneous injections, given at 0, 2 weeks, 4 weeks, 6 months, 12 months, and 18 months, followed by annual boosters. Mild local reactions are common in adults, occurring in approximately 30% of vaccinates. Systemic reactions are uncommon, occurring in <0.2% of vaccinates.
The anthrax vaccine has not been tested in children and currently is not recommended for children younger than age 18. However, the CDC is evaluating the safety and effectiveness of using anthrax vaccine after exposure in children. Prophylaxis for anthrax in children is currently based on antimicrobial treatment (e.g., ciprofloxacin, doxycycline, and amoxicillin).
The Strategic National Stockpile (SNS) was established in 2003 and is jointly managed by the Department of Homeland Security (DHS) and the Department of Health and Human Services (HHS). The SNS is a national repository of antibiotics, chemical antidotes, antitoxins, vaccines, life-support medications, and other medical and surgical items. SNS maintains a stock of supplies that are specific for the medical needs of children and has received guidance from the American Academy of Pediatrics (AAP), as well as from academic and public health experts in general pediatrics, pediatric infectious diseases, pediatric pharmacology, and pediatric critical care medicine.
The SNS is designed to supplement and re-supply State and local public health agencies in the event of a national emergency anywhere and at any time in the United States or its territories. The SNS is prepared for immediate response by having push packs strategically positioned across the United States. Push packs provide medical supplies for an initial response to a broad range of emergencies and arrive on site within 12 hours of deployment. If additional supplies are required, they can be shipped within 24 to 36 hours through vendor-managed inventory. (Chapter 2, Systems Issues, Centers for Disease Control and Prevention and Federal Response Plan.)
To receive SNS assets, the governor of the affected State should directly request deployment from the CDC or HHS. Most likely there will already have been public health consultation between the State department of health and the CDC. Requests for consultation with the CDC or SNS deployment can be made through the CDC Director's Emergency Operation Center at 770-488-7100. For further details on the SNS, go to: http://www.bt.cdc.gov/stockpile/.
Each State's emergency response plan, which is coordinated with public health authorities, should involve some local stockpiling of critical antibiotics and emergency medical supplies. If needed, additional supplies are available through the SNS. Each State plan details the logistics for transporting shipments within the State to where they are needed. In addition, many local and State health departments have partnered with local health facilities to hold practice runs of large-scale drug dispensing and vaccination clinics.
Isolation needs will vary greatly depending on the type of attack. For those diseases that are not transmitted person to person (anthrax, tularemia, and botulism), isolation is not needed. The people exposed will be those at the geographic location where the organism or toxin was released.
For diseases that are transmissible, such as smallpox, plague, and VHF, infection control measures include isolation. Depending on the number of cases, victims may be isolated within a hospital. If demand exceeds the capabilities of a traditional health care facility, supplemental isolation and medical care facilities may be needed (e.g., schools, college campuses, motels, churches, or unused hospitals). If patients do not require advanced medical care, home isolation may be sufficient. Home isolation was used successfully during the SARS and monkeypox outbreaks of 2003.
As part of their bioterrorism response planning activities, public health agencies are identifying facilities that can be used to isolate patients during an outbreak. Related planning includes having an inventory of the isolation and negative-pressure rooms in a particular area, establishing back-up isolation facilities, establishing and training public health and medical response teams, and reviewing and updating State quarantine laws. For public health bioterrorism planning guidance documents, go to: http://www.bt.cdc.gov/bioterrorism/.
Large-scale vaccination may be recommended in some outbreaks related to bioterrorism, namely smallpox. Vaccination may be offered to an affected community, county, State, or the entire Nation. Large-scale smallpox vaccination clinics are intended to supplement the concurrent "surveillance and containment" strategy, (also called "search and containment" and "ring vaccination"). Surveillance and containment requires that individuals who are ill with smallpox are quickly identified and isolated, followed by rapid identification and vaccination of their contacts within 4 days of exposure.
For additional information about vaccination strategies to be used during a smallpox outbreak, go to: http://www.bt.cdc.gov/agent/smallpox/response-plan/index.asp.
Large-scale vaccination clinics may offer vaccination to anyone who does not have medical contraindications to receiving the vaccine under emergency circumstances. The Advisory Committee on Immunization Practices (ACIP) is reviewing and refining the contraindications to smallpox vaccination after an event for people who have not been exposed.
During a bioterrorist attack, one of the most important and challenging roles for the local pediatrician is providing information to families with children. During the anthrax attacks of 2001, public health and medical facilities were inundated with requests for information and medical evaluation. As a result, these same agencies have prepared communication messages and information sheets that can be shared with families before and during a crisis. Parents will want information that is age-appropriate for their children, as well as suggestions for ways to answer their children's questions. Pediatricians may want to consider accessing some of these materials and having them available before an emergency occurs.
A number of organizations have developed materials to help educate children and their families about emergencies and bioterrorism. More information can be obtained from the following organizations and their Web sites: