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In 1999, the Centers for Disease Control and Prevention (CDC) in Atlanta felt there was a credible-enough chance of germ warfare that it earmarked $121 million for bioterrorism activities. Of that, $51 million has gone into stockpiling vaccines and other drugs to combat such diseases as anthrax and smallpox. Other funds were poured into laboratory support, enhanced communications systems with state and local health departments, and improved surveillance and epidemiology activities.
As part of this, the CDC also designed a four-tier system of labs designed to detect and identify bioterrorist agents. While the average home health care agency is unlikely to face an epidemic of anthrax among its patients, it is important that it develop at least a basic emergency plan to deal with the potential threat.
Rose Williamson, RN, QI coordinator with Wilson (NC) County Home Health, has been putting together an inservice for her agency’s staff on biological and chemical agents, symptoms of exposure, appropriate responses, and reporting procedures. (See "Anthrax: A Fact Sheet," below.) Yet she has stopped and asked herself a question that is on a lot of peoples’ minds: Am I overreacting?
"I want my folks to feel knowledgeable and as prepared for disaster as is possible to be without making things worse," Williamson explains.
As a health care provider, it is of paramount importance that all health-related incidences be taken into account when planning for disaster-related situations. But when the actual chance of exposure
is still relatively low, you have to wonder if preparing for the worst is a waste of time.
Not necessarily, say many in the field. Even though the odds are low that any one of us will be infected with anthrax or another bioterrorism agent, it is considerably more likely than it was a year ago. Further, were such a disaster to occur, having a plan in place would save considerable time that could mean the difference between life and death.
Bioterrorism "should be an integral part of any organization’s disaster plan. The Sept. 11 event [should] serve as a reminder to us all to update and attend to our disaster response plans," says Loretta Schlachta-Fairchild, RN, PhD, president and CEO of iTelehealth Inc. in Frederick, MD. "The bioterrorism part is but one element that should be addressed."
Schlachta-Fairchild says to focus solely on bioterrorism would be an overreaction, but that creating a disaster plan response is something to be strongly considered by every home care agency.
Diane Henry, RN, program compliance advisor for Oklahoma City-based Professional Providers Solutions and author of Health and Safety Compliance For Home Health Care, shares that opinion.
"I feel very strongly that the health care infrastructure should be providing mass training on these [bioterrorism] measures and any others that we have identified since Sept. 11th," she says.
Henry’s advice is being taken to heart by home care agencies across the country.
Susan Ezell, RN, RN-QI, AAA, SEA, quality improvement coordinator with the Area Agency on Aging of Southeast Arkansas in Pine Bluff, has also been hard at work putting together information for her agency’s family disaster plan. In it, she is including information on a supplies kit and an emergency preparedness checklist.
But she admits to having her doubts about
the project, not from a practical standpoint but because, "I don’t want to cause undue panic. We’ve had enough of that for awhile."
Alice Fritz-Warren, RN, BSN, MS, regional performance improvement director, Sun Plus Home Health in San Leandro, CA, says that developing an inservice on bioterrorism is a great project.
"As a matter of fact, we were asked if we had a bioterrorism response protocol when we were surveyed by the Joint Commission," she says. "We weren’t dinged for not having a protocol specifically for bioterrorism, but I guess pretty soon we will all be expected to have one. I actually started a reference notebook at the time and got some good information from the CDC."
Although the tendency has been, at least within the home care field, to focus on natural disasters such as hurricanes or earthquakes, Denise (Dee) McCarraher, RN, audit nurse/
case manager with IVNA of Richmond, VA, says it’s time to enlarge the focus.
"I think it’s time for all of us to review and update our policies and ourselves," she says. "Bio incidents are not what we have generally looked at in the past nor are terrorists acts. And while I agree we should not take this education to our elderly patients and frighten them, we must prepare ourselves to provide the care they need under these circumstances."
The first step in developing an emergency plan for bioterrorism or any type of emergency is to clearly define what measures must be taken and rank them in order of importance. (See "Enhancing bioterrorism preparedness and response," in this issue.)
Which patients, for example, must be seen or taken to the hospital in the event home care aides or nurses cannot get to their homes?
From there, it’s solid advice to assign specific tasks to your staff with the understanding that they will be responsible for implementing them once the go-ahead has been given.
These procedures should be reviewed and updated regularly so that all staff remain clear on their given tasks and any changes that might have been made to the plan since the last review. For example, staff turnover may necessitate changing staff responsibilities — something you don’t want to decide in the throes of a crisis.
A good idea is to set up a phone tree to make certain that everyone involved is notified as quickly as possible, and have the last person on the phone tree contact the first as a means of double-checking its effectiveness.
Don’t overlook background material, says Henry. "In developing or reviewing their emergency management plans, home health agencies should include emergency management and bioterrorist information."
Consider creating fact sheets for your patients and their families to inform them of what they should do in case of emergency and a basic outline of how your agency plans to deal with the crisis — will staff visits be reduced? (See "Broad Generalizations of Safety Measures to Follow.") Will only certain patients receive home care visits? Such a fact sheet should include a list of supplies that should be kept on hand and a list of emergency phone numbers including the local hospital’s emergency department.
If you are looking to develop a plan specifically to deal with bioterrorism, consider talking with your local Federal Emergency Management Agency representative.
If you are near a military base, "try contacting the medical folks [there]. It is the medics and corpsmen who teach biohazard-related things," says Dean Smith, BSHS, RN, C, PHN, clinical application specialist for San Diego-based UCSD Home Care. Maybe they will share, as most of the stuff is unclassified. Besides, many servicemen and women have spouses in the medical fields as well. You should be able to find someone to chat with easily."
While having an emergency plan in place is certainly a good thing from a patient perspective, it is also required by law, Henry says. "All businesses are required by [Occupational Safety and Health Administration] regulation to provide a safe work environment for employees. This includes training in specific areas like exposure control, bloodborne pathogens, and emergency management. You should have an emergency management plan in place along with exposure control plan, respiratory protection program, hazard communication plan, just to name a few.
"I personally think it would be a good time for your safety committee, human resources department or administrator to review your emergency management plan to ensure the plan provides procedures to follow in all emergency situations," she adds. "If we have these required programs and plans in place, and staff are instructed and trained on the procedures provided, then that would be sufficient. It may be a good time to provide an inservice and review the emergency management plan and procedures with the staff. It may help relieve some of the fears employees are experiencing and give a sense of security in knowing the agency is concerned with the safety and welfare of their employees."
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Source: Bureau of Diplomatic Security, Washington, DC.
What is anthrax?
Anthrax is an acute infectious disease caused by the spore-forming bacterium bacillus anthracis. Anthrax most commonly occurs in wild and domestic lower vertebrates (cattle, sheep, goats, camels, antelopes, and other herbivores), but it can also occur in humans when they are exposed to infected animals or tissue from infected animals.
Why is it an issue?
Because anthrax is considered to be a potential agent for use in biological warfare, the Department of Defense has begun mandatory vaccination of all active duty military personnel who might be involved in conflict.
How common is it and who can get it?
Anthrax is most common in agricultural regions where it occurs in animals. These include South and Central America, Southern and Eastern Europe, Asia, Africa, the Caribbean, and the Middle East. When anthrax affects humans, it is usually due to an occupational exposure to infected animals or their products. Workers who are exposed to dead animals and animal products from other countries where anthrax is more common may become infected with B. anthracis (industrial anthrax). Anthrax in wild livestock has occurred in the United States.
How is it transmitted?
Anthrax infection can occur in three forms: cutaneous (skin), inhalation, and gastrointestinal. B. anthracis spores can live in the soil for many years, and humans can become infected with anthrax by handling products from infected animals or by inhaling anthrax spores from contaminated animal products. Anthrax can also be spread by eating undercooked meat from infected animals. It is rare to find infected animals in the United States.
What are the symptoms?
Symptoms of disease vary depending on how the disease was contracted, but symptoms usually occur within seven days.
• Cutaneous: Most (about 95%) anthrax infections occur when the bacterium enters a cut or abrasion on the skin, such as when handling contaminated wool, hides, leather, or hair products (especially goat hair) of infected animals. Skin infection begins as a raised itchy bump that resembles an insect bite but within 1-2 days develops into a vesicle and then a painless ulcer, usually 1-3 cm in diameter, with a characteristic black necrotic (dying) area in the center. Lymph glands in the adjacent area may swell. About 20% of untreated cases of cutaneous anthrax will result in death. Deaths are rare with appropriate antimicrobial therapy.
• Inhalation: Initial symptoms may resemble a common cold. After several days, the symptoms may progress to severe breathing problems and shock. Inhalation anthrax is usually fatal.
• Intestinal: The intestinal disease form of anthrax may follow the consumption of contaminated meat and is characterized by an acute inflammation of
the intestinal tract. Initial signs of nausea, loss of appetite, vomiting, fever are followed by abdominal pain, vomiting of blood, and severe diarrhea. Intestinal anthrax results in death in 25% to 60% of cases.
Where is it usually found?
Anthrax can be found globally. It is more common in developing countries or countries without veterinary public health programs. Certain regions of the world (South and Central America, Southern and Eastern Europe, Asia, Africa, the Caribbean, and the Middle East) report more anthrax in animals than others.
Can it be spread from person to person?
Direct person-to-person spread of anthrax is extremely unlikely to occur. Communicability is not a concern in managing or visiting with patients with inhalational anthrax.
Is there a way to prevent infection?
In countries where anthrax is common and vaccination levels of animal herds are low, humans should avoid contact with livestock and animal products and avoid eating meat that has not been properly slaughtered and cooked. Also, an anthrax vaccine has been licensed for use in humans. The vaccine is reported to be 93% effective in protecting against anthrax.
What is the anthrax vaccine?
The anthrax vaccine is manufactured and distributed by BioPort Corp. of Lansing, MI. The vaccine is a cell-free filtrate vaccine, meaning it contains no dead or live bacteria in the preparation. The final product contains no more than 2.4 mg of aluminum hydroxide as adjuvant. Anthrax vaccines intended for animals should not be used in humans.
Who should get vaccinated?
The Advisory Committee on Immunization Practices recommends anthrax vaccination for:
• People who work directly with the organism in the laboratory.
• People who work with imported animal hides or furs in areas where standards are insufficient to prevent exposure to anthrax spores.
• People who handle potentially infected animal products in high-incidence areas. (Incidence is low in the United States, but veterinarians who travel to work in other countries where incidence is higher should consider being vaccinated.)
• Military personnel deployed to areas with high risk for exposure to the organism (as when it is used as a biological warfare weapon).
Contact the anthrax Vaccine Immunization Program in the Army Surgeon General’s Office at (877) 438-8222. Web site: www.anthrax.osd.mil. Pregnant women should be vaccinated only if absolutely necessary.
What is the protocol for anthrax vaccination?
The immunization consists of three subcutaneous injections given two weeks apart followed by three additional subcutaneous injections given at six, 12, and 18 months. Annual booster injections of the vaccine are recommended thereafter.
Are there adverse reactions to the vaccine?
Mild local reactions occur in 30% of recipients and consist of slight tenderness and redness at the injection site. Severe local reactions are infrequent and consist of extensive swelling of the forearm in addition to the local reaction. Systemic reactions occur in fewer than 0.2% of recipients.
How is it diagnosed?
Anthrax is diagnosed by isolating B. anthracis from the blood, skin lesions, or respiratory secretions or by measuring specific antibodies in the blood of persons with suspected cases.
What’s the treatment?
Doctors can prescribe effective antibiotics. To be effective, treatment should be initiated early. If left untreated, the disease can be fatal. Three types of antibiotics are approved for anthrax: ciprofloxacin, tetracyclines (including doxycycline), and penicillins. For people who have been exposed to anthrax but do not have symptoms, 60 days of one of these antibiotics is given to reduce the risk or progression of disease due to inhaled anthrax.
Where can I get information about the recent Department of Defense decision to require men and women in the Armed Services to be vaccinated against anthrax?
The Department of Defense recommends that servicemen and women contact their chain of command on questions about the vaccine and its distribution. The anthrax Vaccine Immunization Program in the U.S. Army Surgeon General’s Office can be reached at (877) 438-8222. Web site: www.anthrax.osd.mil
Source: National Center for Infectious Diseases, Atlanta, GA.