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CDC: Infection control on front lines in bioterror war

Help us maintain a high degree of vigilance’

Rallying readiness for bioterrorism attacks, top officials at the Centers for Disease Control and Prevention (CDC) are calling upon infection control professionals to play critical roles in the nation’s preparedness.

"The nation is currently confronting an unprecedented biological attack," said James Hughes, MD, director of the CDC national center for infectious diseases (NCID). "There has been a very important role in this [anthrax] outbreak played by health care epidemiologists and infection control professionals, both in surveillance and in response."

Hughes comments were made at a recent CDC satellite videoconference to review the situation and appeal for help from ICPs and health epidemiologists. Hughes conceded, however, that the CDC needs to try to "strengthen the link between health care providers, infection control professionals, and public health at the local and state level. As we maintain vigilance for diseases possibly caused by bioterrorism threat agents, prompt reporting of such infections to local and state health authorities remains absolutely essential."

"This is not over until the [bioterrorists] are caught," said Julie Gerberding, MD, MPH, director of the CDC division of healthcare quality promotion (DHQP), and acting deputy director of the NCID. "We rely on the front lines of care, including the infection control professionals and hospital epidemiologists, to help us maintain that high degree of vigilance in our capacity to detect and respond to any new threat that does emerge."

Key roles for ICPs include identifying initial cases and sounding the alarm that a bioterrorism event may be unfolding, said Lisa Rotz, MD, medical epidemiologist in the CDC bioterrorism preparedness and response plan. Unusual signs and syndromes should raise a red flag for suspicious ICPs, she noted. (See checklist, below.)

Expecting the Unexpected: Tip Sheet for Bioterrorism
Lisa Rotz, MD, a medical epidemiologist in the Atlanta-based Centers for Disease Control and Prevention bioterrorism preparedness and response program, recently listed the following watch areas and possible signs that something is amiss:
Surveillance: Clinical indicators to monitor
	Utilization of medical services
	Emergency department visits
	Intensive care unit admissions
	Hospital admissions
	Increases in certain illness syndromes
Other signs:
	Unusual temporal/geographic clustering of illness (e.g., patients attended same event/gathering)
	Unusual age distribution for common diseases (e.g., chickenpox-like illness in adults)
	Several people presenting with similar symptoms
Syndromes potentially associated with bioterror agents
	Rash with fever
	Upper or lower respiratory illness with fever
	Sepsis or nontraumatic shock
	Unexplained death with history of fever
	Localized cutaneous lesion
	Diarrhea/gastroenteritis
	Meningitis/encephalitis/or unexplained acute encephalopathy/ delirium
	Botulism-like syndrome
	Lymphadenitis with fever

"Keeping track of increases of [emergency department] visits, ICU [intensive care unit] and hospital admissions could [provide] an early indicator that something is occurring in the community at large," she said. "Monitoring increases in certain syndromes of illness that might be seen in clusters in a hospital should also prompt further investigation."

Things ICPs should be alert for include a clustering of illness in groups of people that attended the same event or gathering, she added. Ensure all phone numbers for key contacts are up to date in case of an incident. "Don’t be afraid to call if you are suspicious," Rotz said. "It’s very important to notify people internally — so you can get assistance in determining what is going on — as well as externally, because public health professionals can help you. CDC has a 24-hour telephone number [(770) 488-7100] that has someone available 24 hours a day to consult with."

If surveillance leads to case finding — for example, of an anthrax case — certain measures must go into effect. Patients admitted with anthrax are not considered contagious, but caution is necessary because they may have spores on their clothing. If patients have been exposed to anthrax spores, they should be managed initially by health care workers wearing gowns, gloves, and N95 respirators, according to Lynn Steele, MS, CIC, an epidemiologist in the DHQP.

"The person who has been exposed should be instructed to wash [his] hands and . . . other exposed skin immediately," Steele emphasized. "[He] should gently remove clothing and shower with soap and water. [That person] should be instructed to rinse [his] eyes with clean water or saline solution. Clothing should be handled minimally by health care workers wearing protective equipment, and then placed in a [sealed] bag."

Attempts to decontaminate patients with bleach or other caustic solutions are generally unnecessary and should be avoided, she added. "For disease to occur, individuals must first be exposed to anthrax spores," she said. "These spores must enter the skin through some broken barrier, be swallowed, or inhaled." Inhalational anthrax is not transmitted from person to person.

"Cutaneous anthrax disease transmission, if it occurs at all, is extremely rare," she said. "There are two reports of transmission to care attendees in the Eurasian literature. But it should be noted that there have been more than 220 cases of naturally occurring cutaneous disease in the United States. [These patients] have been cared for in hospitals since 1955, with no transmission to health care providers or others. And remember, lots of this care was done in a climate where gloves were not routinely worn for patient care."