Transcript Critical Care Transport Run Review October 2004

Biologic Weapons
in War
The use of germs to kill, immobilize or
demoralize the Enemy.
It WILL happen.
Again.
Vicken Y. Totten MD, MS
FACEP
1
2
Warfare agents
Projectiles and explosives – physical injuries
incompatible with life
Chemical and nuclear – poisoning incompatible
with life
Eco devastation – the environment will no
longer sustain human life
Carthage
Genetic imperialism
Rape and forced impregnation change a genome
“Germ Warfare”
3
Purpose of bioterrorism
To instill fear, change lifestyles
Immobilize populations
Waste resources
Occupy trained personnel
Weaken the Enemy
4
Germ Warfare (BioWar)
Different agents have different infectious dose,
germ survival in the environment, effectiveness,
availability & LD-50, but: all should be feared.
Psychological impact almost as lethal as their
physical effects.
Hot zones where contracting these germs means
sure but slow! and contagious! death.
1 to 2 weeks turn your body into liquefied, virus
- infected tissue culture. You
Hemorrhage virus infected blood: potential to
wipe out 20-99% of population
5
The Salt Lake Tribune (5/12, May)
“ if "a killer flu strikes, with several thousand
sick or injured and no room to spare in
understaffed hospitals, care will be denied to
the sickest adults and children."
Individuals "who are severely burned, have
incurable and spreading cancer, fatal genetic
diseases, end-stage multiple sclerosis or
severe dementia will be turned away.
They can be sent elsewhere for comfort care,
such as painkillers, but they will not be treated
for the flu, according to the guidelines.
6
BioWeapons = Germ Warfare
Not new: used for thousands of years
What’s new is “Weaponizing”
increases virulence
Assists in spread by technology
Biologic capability is relatively
inexpensive and widespread.
Risk of a serious bioterrorism incident.
7
Serendipitous and deliberate
Zoonoses in the “New World”
Deliberate small pox in the New World
Actual infection is not even required: post
attack, US anthrax hoaxes had many of
the effects hoped-for from actual
infections: Disrupting business, life styles
and demoralizing the Enemy.
8
Ashdod of the Philistines
1320-1000 BC
I Samuel: The Philistines stole the Israelites’
Ark of the Covenant.
Rats (mice) appeared, then “the Lord’s hand on
the people of Ashdod and its vicinity, throwing
[the city] into a great panic. He afflicted the
people of the city, both young and old, with an
outbreak of tumors (emerods) in the groin.”
As a result, the Philistines returned the Ark of
the Covenant with “five golden emerods and
five golden mice.”
9
Plague of Athens (430-426 BCE)
Thucydides’ “The Peloponnesian War”
attributed the success of the war to the
plague.
The plague arrived in the first days of
summer, during the second year of the
war, at the same time as Archidamus, son
of the king of Lacedaemon.
10
Plague of Athens
Spartans besieging the city were not
affected by the disease.
Many Athenians died, and eventually
capitulated.
Plague probably came by boat with the
alleys up from Egypt, with immune
soldiers.
11
14th and 15th century Europe.
 Armies would fling diseased and decaying cadavers
(especially of slaughtered enemy soldiers) over
protective town walls to demoralize and sicken the
besieged cities.
1346 -1347. Tartars defeated Genoese army by
catapulting plague-dead soldiers over the walls into
Kaffa (Caffa), by the Black Sea
 1422. Lithuanians flung dead soldiers and 2000 cart
loads of excrement into Carolstein.
 These battles contributed to the 25 million victims of the
European Black Plague
12
THE BLACK DEATH
PANDEMIC
Worst from 1346 and 1352 with
outbreaks till 1800s
Killed 25 million people(1/3 of the
world’s population at that time)
30-60% of the populations of large cities
died from the disease
final “foray” occurred in Marseilles in
1720.
Still around
13
World War II British
tested anthrax in Gruinard Island off the
coasts of Scotland.
Anthrax can live decades in soil.
Cleaning the Island years later was very
costly.
14
United States, Post WWII
1950, Germany accuses US of releasing
Colorado beetles over German crops.
China, North Korea, and the Soviet
Union accused the US of using biological
weapons during the Korean War.
15
Second Sino-Japanese War
The Imperial Japanese Army bombed
Ningbo with fleas carrying bubonic
plague.
1941. More plague-contaminated fleas
airdropped by 40 planes onto Changde.
These operations caused epidemic plague
outbreaks.
16
United States 1980s
September 1984, The Dalles, OR, dozens got
food poisoning: Salmonella enterica
typhimurium.
1st: Shakey’s Pizza. Later, 10 more restaurants.
More than 700 ill; the only hospital ran out of
beds.
CDC involved. Deliberate contamination was
proved; the Rajneesh cult was suspected but
never convicted.
17
Weaponized Super-Germs
vs common organisms
Small inoculums will infect large populations
(highly infectious)
Easily transmitted from person to person:
airborne better than contact.
Either lethal or prolonged illness with lasting
morbidity (ties up Enemy resources and diverts
them from War Effort; demoralizes)
Treatment: none
18
Properties for
“Maximum Credible Threat”
highly lethal & toxic
easily produced in large quantities.
environmental & aerosol stability
Dispersal capability to (1 mm to 5 mm
particle size)
person to person communication
no treatment or vaccine.
19
Potential human biological
pathogens.
NATO handbook lists 39 agents including
bacteria, viruses, rickettsiae, and toxins.
Biologic agents spread on their own;
therefore, the “dose” needed is less.
Highly toxic poision, Ricin: 8 metric tons
vs 1 kg anthrax for same number
casualties
20
Comparison
Agent
Type
Untreated
Mortality %
Relative
Infectivity
Dose
Incubatio
n Period
Treatment
Anthrax
Bacteria
80
1000+
Spores
1-4 Days
Pre Exposure
Antibiotics*
Botulism
Virus
40-90
Moderate
2-7 Days
Some Antibiotics
Plague
Bacteria
90
10
Organisms
2-3 Days
Antibiotics
Smallpox
Virus
75
High
7-14 Days
Vaccine
Tularemia
Bacteria
30
25
Organisms
2-4 Days
Antibiotics
V.H.F.
Virus
50-90
High
2-7 Days
Antibiotics
* Not effective after symptoms develop
21
Anthrax, Plague and Smallpox:
best candidates
Highly lethal:
Anthrax, untreated anthrax > 80% die; Variola Major:
30% of unvaccinated patients die; Septicemic
Plague 100%
All can be produced in quantity
Plague available world wide; no need to raid
containment facilities
Anthrax & Smallpox stable for aerosol
transmission;
Anthrax spores survive for decades;
smallpox can be freeze-dried.
22
All Weaponized.
Iraq produced anthrax for use in Scud missiles;
former Soviet Union produced smallpox virus by
the ton;
Japanese weaponized plague
All uncommon diseases with non-specific initial
presentation
Delayed recognition will allow for secondary
spread
Vaccines poor or limited in availability.
23
Treaties: honored in the breach
1972 Biological Weapons Convention
Soviet Union in 1979 accidentally
released anthrax
Iraq in 1995 had anthrax, botulinum
toxin, and aflatoxin
24
United States 1969 stockpile:
Bacillus anthracis,
botulinum toxin,
Francisella tularensis,
Brucella suis,
Venezuelan equine encephalitis virus,
staphylococcal enterotoxin B
Coxiella burnetti (9).
25
Soviet Union stockpile:
smallpox,
plague,
anthrax,
botulinum toxin,
equine
encephalitis
viruses,
tularemia,
Q fever
Marburg
melioidosis
Typhus
26
More details about:
Plague (Yersinia pestis),
Smallpox (Variola major and minor)
Anthrax (Bacillus anthracis),
Tularemia (Francisella tularensis)
Influenza is seldom mentioned but would
be an excellent BioWeapon
Many diseases have been accused of
being BioWeapons, including SARS,
Swine Flu and HIV
27
Plague
28
Plague (Yersinia pestis),
gram-negative, anaerobic coccobacillus.
transmitted to humans through fleas,
rodents, or droplet infection.
Human-to-human transmission quick
Called “Black death” because the septic
shock causes cyanosis, & peripheral
gangrene
“Blackening”
29
30
Rodents and fleas
Endemic in rodents; fleas transmit but
don’t sicken.
The next mammal is the next victim.
10,000 years of human garbage attracting
flea-ridden rats. Less a disease of
nomads.
31
Plague –
mode of transmission
Natural: Fleas from
infected rodents
BioWar: aerosolized
Large aerosol
droplets contain 100500 organisms
 Person-to-person
transmission
32
Plague
Worldwide: one of most feared diseases
throughout history
As many as 200 million deaths in last
1000 years.
Not gone! India had outbreak in 1994.
Endemic in US Southwest in rodents
33
Plague:
Clinical Manifestations
Cervical bubo
Ecchymosis, septicemia
Gangrene, septicemia
Inglesby T, et al. JAMA 2000;383:2281
34
Plague
3 forms: bubonic, pneumonic and septicemic;
Bubonic is classic.
infected individuals die within 2 -3 days
Bubonic has a mortality of 30 - 75 %;
pneumonic & septicemic forms have mortality
of 90 - 100 % respectively
Septicemic plague usually occurs secondary to
bubonic or pneumonic plague.
35
Plague:
Black lesions
& bubos
(fingers &
toes, penis &
nose)
36
Symptoms: Bubonic Plague
AMS:
Lymphadenopathy: swollen,
Hallucinations,
tender lymph nodes (buboes)
headache, fever,
in armpits, groin; even
chills.
supra-clavicular and
cervical buboes rupture &
semiconscious to
suppurate
lethargic.
Black blisters and
" Madness”
hematemesis
(agitated delirium)
Recovered victims disabled:
 Hematemesis,
muscular tremors,
bloody diarrhea
“withered thighs and
tongues“
37
Plague bubo
38
Plague Septicemia
Non-specific gram-negative septicemic
symptoms:
Flu-like illness rapidly progresses to
pneumonia, hemoptysis.
Blood cultures +, but no lymphadenopathy;
respiratory contagion at 2 to 5 feet.
Pneumonic plague is 100% fatal unless
treatment is given with 24 hours of the onset of
symptoms.
39
Pneumonic Plague
Most contagious and deadly: pneumonic
plague
Airborne person-to-person airborne
spread.
Y. pestis is not spore forming, and is
viable for only 60 minutes as an aerosol.
Doesn’t live long on surfaces.
40
Pneumonic Plague: CXR
41
Plague Diagnosis and Treatment
CXR nonspecific
Suspicion, setting, environment
Standard treatment of bubonic, septicemic, or
pneumonic plague is streptomycin, 30mg/kg IM
q 12 h x 10 days.
 alternatives: chloramphenicol, gentamicin, or
doxycycline.
Chemoprophylaxis includes treatment with
tetracycline or doxycycline.
42
Plague Vaccine
Not a generally viable option
The Greer vaccine is an inactivated form
of the disease, and requires a course of
injections over 6 months.
A recombinant sub-unit vaccine is being
investigated.
Outbreak would spur vaccine
development – too late
43
Smallpox
44
Smallpox Communicability
Contact: fomites, person to person
Aerosol: communicability by aerosol
requires negative-pressure isolation.
One single case -> 10 to 20 others.
No more than 20% of the population has
any immunity from prior vaccination
No acceptable treatment
45
Smallpox: Mode of transmission
Patient-to-patient transmission likely
Droplets, Large & Small
More infectious
if coughing
or bleeding
46
Smallpox – the Virus
2 Wild types
Variola major
Variola minor
Variola called "smallpox" to distinguish
it from Syphilis, the "great pox"
Smallpox is believed to have emerged in
human populations about 10,000 BC.
47
Pustules up close. Note: thick covering of skin. not like typical blisters.
48
Small Pox Symptoms:
Maculopapular rash, then
Raised fluid-filled blisters
characteristic scars, commonly on the face,
which occur in 65–85% of survivors.
Blindness resulting from corneal ulceration and
scarring; Limb deformities due to arthritis and
osteomyelitis are less common complications,
2–5% of cases.
49
Variola Diseases
V. major produces a more serious disease
than V. minor
V. major mortality 30–35%
V. minor causes a milder form of disease
(also known as alastrim, cottonpox,
milkpox, whitepox, and Cuban itch; kills
about 1% of its victims.
?Protective immunity?
50
Smallpox
versus
chicken pox
51
Smallpox
Lesions
progress
simultaneously; in
Chicken
pox they
come in
crops
52
Biological Warfare Using Smallpox
Ravaged Europe; surviving population
relatively immune
Frequently used against American
Indians:
The British: June 24 1763, William Trent,
a local trader, wrote, “…we gave them
two Blankets and an Handkerchief out of
the Small Pox Hospital. I hope it will
have the desired effect.“
53
54
Diagnosis
Clinical setting: classic syndrome & rash
is enough to make the diagnosis
Electron Microscopy of vesicle; see
Orthopox virus; does not prove variola
Culture definitive but SLOW. Chick
membrane or cell culture
PCR (ref lab) is faster
55
Treatment
Isolation!!
Supportive care
Fluid balance
Electrolytes
Hemodynamic support
Respiratory support if needed
No proven effective antivirals
Antibiotics for secondary infections
56
Smallpox Infection Control
Strict Universal Precautions
Prevent inhalation of particles 5µ or
smaller
Transfer to appropriate isolation room
In large epidemic, may cohort patients
Limit transportation
(but use mask on patient if necessary)
57
Post-Exposure Prophylaxis
Vaccine
Partially effective up to 3 days s/p exposure
Reduces incidence 2-3 fold
Decreases mortality by ~50%
Plus Vaccinia immune globulin (VIG)
3 fold decrease in incidence and mortality
Passive immunity for 2 weeks
(?) Cidofovir – antiviral agent is effective in
animals against other poxviruses
58
Smallpox
prevention
No more wild smallpox
Vaccine available
Last case 20 years ago
Immunization may NOT
confer lifelong
immunity.
CDC has 10-15M doses
of vaccine, can produce
more fairly quickly
59
Reactions to
Smallpox
Vaccine
60
More
reactions
61
Anthrax and tularemia (rabbit
fever)
Most infectious in aerosol
cause the highest number of dead and
incapacitated
greatest downwind spread
62
Anthrax &
Tularemia (rabbit fever)
These are the most infectious aerosols
Aerosols cause the highest number of
dead and incapacitated
Spread downwind & person to person
Available in the wild
Weaponized versions are Abx resistant
63
Anthrax
64
Anthrax history
Biblical Egyptian plague.
Bacillus anthracis, a gram-positive, spore
forming bacillus.
Transmission by inhalation, ingestion, or
skin breaks from infected animals or their
products, or from terror attack.
Often associated with sheep and wool
65
Cutaneous lesions are black
66
Anthrax as BioWeapon
Anthrax as a Biological Weapon, 2002:
Updated recommendations for management
JAMA. 2002;287(17):2236-2252
(doi:10.1001/jama.287.17.2236)
Thomas V. Inglesby; Tara O'Toole; Donald A.
Henderson; et al.
http://jama.amaassn.org/cgi/content/full/287/17/2236
67
Lesion of Cutaneous Anthrax Associated With
Microangiopathic Hemolytic Anemia and Coagulopathy in
a 7-Month-Old Infant
68
Infant w Cutaneous Anthrax
Previous slide photo was from hospital
day 12, when 2-cm black eschar was
present in the center of the cutaneous
lesion.
Reprinted from Freedman et al.
69
70
BioWar Anthrax not new
Aerosol technologies for large-scale
dissemination are developed and tested
Brits weaponized Anthrax pre-WWII
1995, Iraq acknowledged producing
weaponized Anthrax
Soviet Union & at least 13 other
countries: Clear evidence of offensive
biological weapons programs.
71
72
US: 2001 Anthrax Attacks
Powder containing Anthrax spores in at
least 5 letters to Florida, New York City,
and Washington, DC.
22 confirmed or suspected Anthrax cases
B anthracis spores in all the letters were
“Ames strain” a research strain
Aerosol release of B anthracis would be
odorless and invisible and would have the
potential to travel many kilometers before
dissipating.
73
74
Types of Anthrax
cutaneous, (Woolsorter's disease),
gastrointestinal
inhalational
CNS (meningitis)
Anthrax invades the lymphatic system
and causes hemorrhages, sepsis,
produces necrotizing toxins & death
75
Cutaneous anthrax stemming from wearing
contaminated wool scarf
76
Cutaneous anthrax
inoculation of spores through open skin lesions.
Painless, pruritic papules appear w/i 5 d.
Papules develop into vesicles
By 7 days, central necrosis develops
Necrosis progresses to black eschar that
eventually sloughs off.
Cutaneous: Not usually fatal
Half the victims of mailed powdered anthrax
2001 got cutaneous anthrax.
77
hrax
Cutaneous Anthrax Eschar
Raised, vesiculated edge, inflamed, and with a black base to the ulcer
78
Cutaneous anthrax ulcer
Antibiotics
reduce
systemic
symptoms
Antibiotics
don’t alter
lesion course
79
GastroentericAnthrax
anthrax
Gastrointestinal
• poor,
Seen only
in poor, developing
Seen in
developing
countries
countries
with food shortages
or
with food
shortages
or
inadequate
veterinary
inspectionSub–
inadequate
food
inspection.
recent cases in SubSahelian Africa,
Saharan
Africa,
Central
Asia,
Central Asia, Russia, India &
Russia,
India, and Thailand
Thailand.
Usually have concurrent cutaneous
cases
from butchering
• Usually
have concurrentthe
cutaneous
casesanimal
from butchering
the affected
affected
or handling
the
animal
or handling the infected meat.
infected
meat
Probable frequency: one outbreak
frequency:
one outbreak
per•64Probable
infected
animals
eaten.
per 64 infected animals eaten.
80
Gastrointestinal anthrax
From eating contaminated meat:
Starts with pharyngeal ulcers and edema.
Hemorrhagic mesenteric adenitis, ascites,
hematemesis, and melena may occur.
Morbidity from loss of blood, fluids,
electrolytes. Subsequent shock.
Death from intestinal perforation or anthrax
toxemia.
Symptoms subside in 10 to 14 days in survivors
81
Inhalational Anthrax
Sudden, severe, acute febrile illness in
persons at risk following a specific attack
Fulminant course and death or acute
febrile illness
Example: from 2001 attacks: postal
workers, members of the news media, and
politicians and their staff
Half got inhalational anthrax
82
Inhalation anthrax
 Usually fatal. Infective dose is 8,000-15,000
spores.
 Flu-like symptoms for 4 days.
 Primary pulmonary infection rare.
 Endospores are engulfed by alveolar macrophages,
get transported to the mediastinal and hilar lymph
nodes, germinate and multiply in lymph nodes.
 Hemorrhagic mediastinitis, peribronchial
hemorrhagic lymphadenitis, Lymphatic drainage
blocked.
 Pulmonary edema.
 Toxin released into circulation.
 Death from septicemia, toxemia, or pulmonary
bleeding/edema.
83
Anthrax CXR
CXR: widened mediastinum (classic
but not so common), infiltrates,
pleural effusion
Chest CT: hyperdense hilar and
mediastinal nodes, mediastinal
edema, infiltrates, pleural effusion
Hemorrhagic mediastinitis,
hemorrhagic thoracic lymphadenitis,
hemorrhagic meningitis;
84
85
Diagnostic tests
Toxin: ELISA
Peripheral blood smear & culture: grampositive bacilli
CXR: classically, “widened mediastinum”
pleural effusion, mediastinal edema (boards
question)
Chest CT scan: hyper-dense mediastinal and
hilar lymph nodes
Thoracocentesis: hemorrhagic pleural effusions
86
Diagnosis
DFA stain of infected tissues
Thoracentesis: hemorrhagic pleural
effusions
Peripheral blood smear: grampositive bacilli on blood smear
Blood culture: large gram-positive
bacilli with preliminary
identification of “Bacillus species”
87
Treatment:
Natural strains sensitive to penicillin
Doxycycline (preferred) of tetracyclines
Fluroquinolones should have equivalent
efficacy; Penicillin, doxycycline, &
ciprofloxacin are FDA approved for
inhalational anthrax.
Other drugs: clindamycin, rifampin,
imipenem, aminoglycosides,
chloramphenicol, vancomycin, cefazolin,
tetracycline, linezolid, and the
macrolides.
88
Anthrax Prophylaxis
Natural anthrax is PCN & TCN sensitive;
weaponized Anthrax is resistant.
CDC recommends:
Oral ciprofloxacin 500 mg q 12 hours.
Prophylaxis for 60 days (unless exposure
has been excluded) because disease can
present 50 days or more after exposure.
89
Anthrax Vaccine
Poor, many side effects & limited availability.
1997: all U.S. military personnel are required
to receive it.
Anthrax vaccine adsorbed (AVA): inactivated
cell-free product, produced by Bioport Corp,
Lansing, Mich.
6-dose SC series: 0, 2, & 4 weeks; then 6, 12, &
18 months; annual boosters.
Peacetime / civilian safety has been questioned.
90
Weaponizing Anthrax
B anthracis engineered to resist
tetracycline and penicillin. 1999 study
induced in vitro Ofloxacin resistance
Assume PCN & TCN resistance if
terrorist attack
Fluroquinolones 1st choice. Maybe.
Once susceptibility known, use most
widely available, efficacious, and least
toxic antibiotic
91
Francisella tularensis
aerobic, gram-negative, intracellular
coccobacillus
found in the water, soil, and vegetation.
Natural reservoir: small mammals such
as rabbits, squirrels, and mice
In many ways, similar to Plague
92
Tularemia Disease
3 types: Ulcero-glandular, Oro-glandular,
Pneumonic.
Usual humans infections from insect bites,
contact with (skinning) infected rabbits or other
small mammals, inhalation, & contact with
contaminated environments
The last 2 modes of transmission are what
makes F. tularensis an ideal agent for BioWar.
93
Ulceroglandular Tularemia
Most common. It occurs after a bite from an
infected arthropod or from handling an infected
mammal.
Symptoms begin as flu-like and an ulcer
appears at the site of infection.
Regional lymph nodes enlarge and may
resemble buboes.
The patient may become bacteremic.
Low mortality rate, but may take quite a long
time for recovery.
94
Oro-glandular Tularemia
Usually after ingestion of contaminated raw
meat, contaminated water; occasionally from
inhalation.
Symptoms: stomatitis, exudative Pharyngitis or
tonsillitis.
Cervical or retropharyngeal lymphadenopathy
will occur and also may resemble buboes.
Bacteremic possible; low mortality rate, but
long recovery.
Immunity ?
95
Pneumonic Tularemia
 Most severe form
 Inhalation of aerosolized bacteria. Or secondary to
hematogenous spread from cutaneous or oral lesions.
 Symptoms: fever, non-productive cough, pleuritic chest
pain, chills, headache, and malaise. It may resemble
community-acquired pneumonia.
 No person to person spread; no isolation needed.
 Mortality rate of 30-60%.
96
Tularemia Chest x-ray
May show infiltrates, hilar adenopathy, or
pleural effusion.
Can have TB-like miliary infiltrates.
Sometimes caseating granulomas found on lung
biopsy.
Culture of F. tularensis will grow in about 2448 hours, and can make the definitive diagnosis
PCR or ELISA may also be used to aid in the
diagnosis.
97
Treatment of Tularemia
Streptomycin 30mg/kg IM q 12 h x 10-14 days.
Alternative gentamicin 5mg/kg IM or IV q day
x 10-14 days.
Vaccination is not recommended as a postexposure prophylaxis.
No live attenuated vaccine against tularemia
yet.
Weaponised Tularemia: oral doxycycline or
ciprofloxacin are recommended as postexposure prophylaxis.
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Viral Hemorrhagic Fevers
RNA viruses: highly lethal, high infectivity
by aerosol route. 90- 100% mortality
Sx: febrile illness, liver failure, DIC,
hypotension, death. Highly contagious.
Dx: Setting, environment, H&P
Confirm: viral serologies or culture
(difficult)
Available in the wild; hard to handle.
Weaponizable when techniques for tissue
culture mature.
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The Viral Hemorrhagic Fevers
Ebola Hemorrhagic Fever and Marburg
Disease from the Filoviridae family.
Lassa Fever from the Arenaviridae family
Rift Valley Fever & Crimean Congo
Hemorrhagic Fever, from the
Bunyaviridae family
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Clinical
Hallmarks
of Ebola
Bleeding
everywhere:
DIC,
capillary leaks,
“bleeding eyes”
Nose, GI tract…
Highly
Infective
101
VHR Patient Isolator
102
Treating in Isolator Difficult
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VHF - Treatment
Mostly supportive and ineffective
In a mass casualty situation, Triage (in
the harshest sense of the word)
For lesser numbers, consider antivirals
Ribavirin for Lassa, CCHF, Rift Valley
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Personal Protective Equipment
(PPE)
No universal standard of PPE for health care
providers in BioWar.
Health Care workers will be among the first
infected secondarily
Fear of contamination or infection may prevent
some physicians from going to work
At a minimum: mask, gown, gloves. Complete
change of clothes and shower BEFORE
LEAVING FACILITY.
HCW may be isolated into workplace
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Decontamination in hospital
Decontamination PRIOR TO patient arrival,
and AWAY from hospital ventilation ducts.
Do you know where the UH decon room is?
BioAgent: undress, & mask the patient. For
most agents, this would be enough.
Anthrax: washing the patient with soap and
water reduces the likelihood of secondary
aerosolization of the spores.
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Mass Casualty
 Wet decontamination (undress completely, shower &
with soap/detergent, contain effluent.)
 Isolate & decontaminate all clothing & patient goods
 Dilute bleach solution: hypochlorite can render a
biological agent harmless, is safe for equipment and
most fabrics
 (hypochlorite is contraindicated for open wounds)
 Heat and radiation for durable equipment:
 Autoclaving and dry heat at 100 C x 2 hours
 Solar UV radiation and desiccation to inactivate
biological agents.
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108