Hospital worker dies from inhalation anthrax, raises bioterrorism concerns
Programs practice evaluation drills, update workplace emergency plans
First, it reached the media. Next, the politicians. Then, postal workers. Now anthrax has hit "home": the health care setting. "As this [anthrax threat] is expanding, we need to get a lot more serious about it," says Peggy Alteri, CEO of Harrison Center Outpatient Surgery Center in Syracuse and Camillus, NY.
When Kathy T. Nguyen, 61, an employee at Manhattan (NY) Eye, Ear, and Throat Hospital, tested positive for inhalation anthrax at the end of October, it led to the temporary shutdown of the outpatient hospital. Nguyen, who succumbed to the disease, worked in a basement supply room. Until recently, the space included a mailroom, and she occasionally handled mail. However, the source of the anthrax was not known at press time.
New York City Health Commissioner Neal Cohen, MD, said people who visited the hospital on or after Oct. 11, which was two weeks before the employee began to show symptoms, will be contacted. Up to 2,000 hospital workers, patients, and visitors who have been to the hospital since Oct. 11 are being offered antibiotics. A hazardous materials team took 40 environmental samples from the Manhattan hospital, but preliminary tests show no anthrax. Nasal swabs were taken from employees, and 25 people began a prophylactic regimen of antibiotics.
The New York City Health Department alerted other hospitals in New York City to watch out for suspicious illnesses. Symptoms of anthrax disease usually occur within seven days of exposure, according to the New York City Department of Health. Initial symptoms of inhalation anthrax may resemble the flu and may include low-grade fever, headache, chest discomfort, malaise, and general fatigue, the department says. After several days, symptoms may progress to severe breathing difficulty and shock, it says.
In light of recent anthrax incidents, some hospitals and surgery centers are being advised to practice evaluation drills and develop/update their workplace emergency plans. Also, authorities are investigating the possibility that private homes may be targets of anthrax-tainted mail. In Syracuse, NY, the Onondaga County Health Department sent an alert to health care providers suggesting that they should notify the department of unusual patterns of absenteeism or illness. The department also suggested they use reliable sources to confirm information on biological or chemical threats.
In terms of what to tell employees, the department offered the following suggestions:
- Stay alert and observe your surroundings for unusual events. (See "Epidemiologic clues of biologic warfare" in this issue.)
- Report any usual or sudden illness to your physician immediately.
- Remain calm, and follow the workplace emergency plan.
3 types of anthrax
The inhalation form of anthrax is particularly uncommon and particularly lethal. In its early presentation, inhalation anthrax could be confused with a viral or bacterial respiratory illness. The patient progresses over two to three days and then suddenly develops respiratory distress, shock, and death within 24-36 hours. Dyspnea, strident cough, and chills are common.
More than 95% of naturally occurring anthrax is cutaneous. The primary lesion is usually a painless itching pimple on the head, neck, or extremities. It appears about three to four days after exposure. Over the next day or so, this pimple undergoes central necrosis and dries into a black scab. The scab sloughs in two to three weeks. Localized disease becomes systemic and fatal in about 5%-25% of untreated cases. Gastrointestinal anthrax is very rare and results from the ingestion of contaminated meat. Death results from peritonitis or anthrax toxemia. (For more information on bioterrorism, see Bioterrorism Watch articles in this issue.)
How to handle the mail
Regarding the handling of mail, the department advised the following:
- Use common sense and care when inspecting and opening mail and packages.
- Use a letter opener.
- Suspect unusual-looking mail, e.g., no return address, no canceled postage, bulky, strange odor, discolored, or threatening message on the outside.
- If a letter is suspect, do not open it. Leave it, evacuate the room, and notify the police.
At Acadiana Surgery Center in New Iberia, LA, the secretary in charge of opening the mail is now wearing gloves for protection against any chemical or biological agents, says Lori Theriot, RN, director of nursing. "Anything out of the ordinary, she’s just throwing it away," says Theriot, who adds that any unsolicited mail also is being discarded.
4 steps to preparing for a disaster
The incident has raised concerns in the health care field about bioterrorism readiness. Although the Sept. 11 terrorist attacks did not involve bioterrorism, some of the suggestions coming out of those events are helpful in preparation for disasters of all types:
1. Plan for efficient discharge of patients. In a disaster, there are several good reasons to empty your ORs. For example, you can make those rooms, equipment, and staff available for emergency disaster cases, and you can conserve blood and other supplies that may be needed elsewhere.
At the time of the Sept. 11 terrorist attack on the Pentagon, Inova Surgery Center in Falls Church, VA, had six patients in the operating rooms (ORs) that should have been finishing their procedures within 30 minutes or so, says Sheree Lopez, RN, director of ambulatory surgery. Inova Fairfax Hospital, with which the surgery center has an affiliation, called an "external disaster."
"The protocol for that is to empty the ORs and do not start any elective surgeries," Lopez says. "For the patients who were in the OR, we finished them, took them to the recovery room, and closed the ORs." In addition, the hospital discharged about 200 patients from the hospital to prepare for potential admissions, which did not arrive, she says.
2. Plan for cancellation of nonemergency surgical procedures. The patients who were awaiting surgery were extremely accommodating, Lopez reports. "We told them there would be a 30-minute delay, based on what the disaster team found out," she says. "We had a TV in the waiting area, so it was evident what was happening." Thirty minutes later, the hospital’s disaster team said to cancel all elective surgery for the rest of the day.
"At the off-site facility, we had approximately 34 patients on the schedule," Lopez says. "I went into the lobby and spoke individually with each patient and family member waiting. I assured them I would work to get them on the schedule within the week." (The surgery center was able to fulfill that promise by running extra ORs and running some rooms later.) My advice is to be upfront and candid with them, and make every attempt to reschedule them within a two-week period."
The surgery center staff began calling patients who hadn’t arrived for their procedures. "At that point, we were standing ready for casualties if needed," Lopez says. "What would have been triaged to us normally would have been burns or fractures or things we could have fixed here." However, no patients arrived, she adds. (For information on how the surgery center turned the facility into a makeshift blood donor center, see Same-Day Surgery, November 2001, p. 121.)
3. Participate in disaster drills. Inova Surgery Center participates in biannual disaster drills and had participated in one the Saturday before the Sept. 11 disaster. "The ED and OR and nursing units were prepared," she says. "We update our disaster call lists every six months, and the safety and security staff keep a copy of that list."
Surgery centers that are not affiliated with a hospital may feel they are "locked out" of such disaster planning because they may be considered competitors to the hospital, but one facility has taken a proactive stance. "We contacted the fire department and said, We’re here if you have minor injuries,’" says Mark Mayo, and administrator at Valley Ambulatory Surgery Center and executive director of the Illinois Freestanding Surgery Center Association, both in St. Charles. "We wanted them to know that we have trained staff, equipment, and supplies, and that we want to help. It made sense to them."
AHA provides information
4. Prepare and educate your staff regarding bioterrorism. The AHA has distributed a significant amount of information to assist facilities in preparing for bioterrorism, including a recent Disaster Readiness Advisory. (For information on earlier Disaster Readiness Advisory, see November SDS, p. 124.) The AHA suggests that the information should be shared with the persons at your facility who are responsible for risk management, infection control, safety, public relations, and others involved in disaster response planning.
In addition, the AHA has updated its Chemical and Biological Agent Checklist that was printed in last month’s issue of SDS. A vaccine for the biological agent "Plague" is no longer available, and a seven-day course of antibiotics is the appropriate prophylaxis for plague, according to the AHA.
The hospital system that includes Inova Surgery Center is just beginning to educate staff on bioterrorism. The managers are being trained by the hospital’s infectious disease staff, and the managers will give the same training to their staffs. "The one message we want to impart is that our staff should not be afraid to take care of patients, if we indeed do get victims of bioterrorism," Lopez says.
The Chicago-based American Hospital Association (AHA) has developed a Disaster Readiness Advisory to assist health care providers in preparing for a bioterrorism incident. The advisory includes part of an April 1999 report prepared by the Association for Professionals in Infection Control and Epidemiology’s (APIC’s) Bioterrorism Task Force in Washington, DC, and the Centers for Disease Control and Prevention’s (CDC’s) Hospital Infections Program Bioterrorism Working Group in Atlanta.
To access the AHA advisory, go to www.aha.org, and click on "Disaster Readiness" and "AHA Communication to the Field." Scroll down to "Mem-ber Advisory: Bioterrorism Readiness Plan: A Template for Health Care Facilities, 10/17/01." The full text of the APIC/CDC report, including specific responses to agents such as anthrax, can be found at the AHA web site (www.aha.org) under "Disaster Readiness." Click on "Readiness Resources" and scroll down to the section titled "Reports." Click on Bioterrorism Readiness Plan: A Template for Health Care Facilities, 10/17/01.
For more information on preparing for a disaster, contact: Sheree Lopez, RN, Director of Ambulatory Surgery, Inova Fairfax Hospital Surgery Center, 3300 Gallows Road, Falls Church, VA 22042-3000. Telephone: (571) 226-5931. Fax: (571) 226-5919. E-mail: email@example.com.