Precautions help hospitals brace for bioterrorism

Hospitals have the tools to protect HCWs

If more horrific scourges such as smallpox or plague emerge in another attack of bioterrorism, hospitals have the ultimate tools to prevent transmission — if health care workers use them. More vigilant use of infection control (IC) precautions will be a legacy of the anthrax attack, employee health experts predict. "The improvements in infection control for the last 20 to 30 years have prepared us well for smallpox," says Bill Jarvis, MD, associate director for program development at the Centers for Disease Control and Prevention’s (CDC) Division of Healthcare Quality Promotion.

As hospitals mobilized in the wake of the anthrax attack, they stressed the basics, such as hand washing and gloving, and reassessed their tuberculosis controls, which would be needed to cope with more contagious bioterrorism diseases.

"I don’t think things are ever going to go back to the way they were," says Robyn Gershon, MHS, DrPH, associate professor at the Mailman School of Public Health at Columbia University in New York City. She notes that clinicians now will consider a host of rare diseases when assessing patients. The shift in thinking could be as fundamental as the decade-old emphasis on preventing bloodborne pathogen exposures, she explains.

"Awareness just increases our concept of safety," says Gershon, who is assisting in the bioterrorism training of thousands of physicians in New York City. "When we knew about HIV and how it was transmitted, it was a great motivator. As we gain knowledge [about bioterrorism agents], it can only help to make us more aware, more careful, more alert," she says.

Hospital responds to anthrax traces

That awareness is not just hypothetical for Memorial Sloan Kettering Cancer Center in New York City. The hospital’s human resources staff and other administrative employees worked in an office building shared with Gov. George Pataki, where authorities announced possible traces of anthrax were found. (The finding never was confirmed.) The mysterious death of a hospital worker at Manhattan Eye, and Ear and Throat Hospital from inhalation anthrax heightened the employees’ fears.

Memorial Sloan Kettering opened an on-site clinic to evaluate any concerned employees who developed cold or flu symptoms. Meanwhile, infection control manager Janet Eagan, RN, MPH, CIC, and her staff began a program of education. Within days, they had spoken to 1,500 of the hospital’s 7,000 employees. Infectious disease physicians met individually with employees who handle mail and those who worked at the Pataki site.

"We’ve tried use a proactive approach in educating workers about good hand washing, good skin care, the value of short, clean nails. [I tell them], To get any infection, you have to have a break in the skin. Keep your hands soft and supple,’" she says. "These are very general infection control principals they can use to protect themselves."

Get aggressive with IC precautions

At Kishwaukee Community Hospital in Dekalb, IL, Christina Jones, RNC, CEN, MSHSA, director of emergency services, wanted to become knowledgeable about bioterrorism agents. Last year, she planned to attend a seminar on "Weapons of Mass Destruction" in December of 2000, only to find it canceled due to lack of interest. The seminar was rescheduled for September 12, 2001. Jones, director of emergency services, and Cindy Graves, the EMS system coordinator for KCH, attended the day-long course and became certified as Weapons of Mass Destruction trainers.

Their strongest message to ED staff: Be vigilant in use of standard precautions. "[The course instructors] stressed the use of our personal protective equipment [PPE] processes," she says. "We've got to be more aggressive about using PPE when it's appropriate and hand-washing technique." Studies have shown that physicians and health care workers follow appropriate hand-washing procedures in only 25% to 75% of all patient encounters.1

At Kishwaukee, a regular program of observation and feedback raised hand-washing rates to about 80%, says Shelly Johnson, RN, employee health nurse. Information shared by Jones in bioterrorism education sessions may raise that even higher. She gives this example from her Weapons of Mass Destruction course: An outbreak of Ebola in Zaire in 1995 sickened 296 people, with a death rate of 92%. Some 32% of the victims were health care workers.

After implementing standard precautions, the number of cases occurring among the staff dropped to zero, Jones relates from her course materials. "Many of the bioterrorism agents they're using now are things that are not easily identified," she says. "Many of the presenting symptoms look like flu. If you don't take [standard] precautions early on, you can be exposed to something that turns out to be very bad. You have to be aggressive about protecting yourself. You don't know which patient could be infected."

In New York City, the possibility of further bioterrorism attacks is an ever-present reality, as alerts periodically disrupt the daily routine. In a 10-day period, Gershon says she was evacuated from the subway system four times. One day, her normal 40-minute commute turned into a two-hour ordeal. No anthrax was found in those events. But as health care workers encounter the threat in their daily lives, they bring their heightened awareness into the workplace.

If the experience with HIV is a guide, health care workers will respond positively to as protections are developed, such as new vaccines or redesigned masks, Gershon says. "We rise to the occasion. I guess we have to rise to this one. This is definitely a new challenge," she says.


1. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999; 130:126-130.