Bioterrorism: Infection Control Help.

On April 24, 1997, Washington D.C. hosted an unwanted event that awoke the nation. Employees at the B'nai B'rith Building, which houses an international Jewish organization, found a package with a broken petri dish leaking an unknown reddish substance. The words "Anthrax" and "Yersinia, a.k.a. Bubonic Plague," stared back at them from small labels on the plastic containers. Their desperate phone call for help sparked an invasion. Firemen arrived in Level A and Level B suits. An army of public safety officers and vehicles encircled the building. Even worse, emergency personnel stripped 16 workers down to their underwear and decontaminated them while CNN broadcasted the scene live to millions of watchers around the world. Inside the building, 100 workers unfortunate enough to be in the building that day were forced to shelter in place or stay in their offices for hours as the petri dish was rushed to Bethesda Naval Research Facility for examination.

Fortunately, nine hours later, analysis of the petri dish contents turned out negative for anthrax and bubonic plague. The quarantined employees were allowed to go home. With the White House only blocks away from the incident, however, questions started flowing, and phone calls were made.

If such an incident were to happen today, three years later, the same flood of questions might be directed to the military hospitals in the area. So the Infection Control Service (ICS) at Walter Reed Army Medical Center (WRAMC) located in Washington, D.C., wanted to be ready with the appropriate information. ICS's mission is to "identify and reduce the risk of acquiring and transmitting infections among patients, staff, visitors, and others that have contact with patients."

The ICS staff, including Lieutenant Colonel Suzanne E. Johnson and Infection Control Nurses Bernice Friedman and Carol Vamvakias, soon realized that they needed a good, quick, easy-to-use source of information from which to answer questions and that such a source was not readily available. The Association for Professionals in Infection Control (APIC) recently had published a document that covered four of the more common bioterrorism agents. Also, the U.S. Army Medical Research Institute of Infectious Diseases (U.S. AMRIID) at Fort Detrick in Maryland had issued several manuals and books on chemical and bioterrorism issues. One book in particular, Medical Management of Biological Casualties, proved very helpful, with pages of information on different biological agents and protocols for treating and preventing casualties.

After reviewing these documents and a few others, the ICS staff at WRAMC decided to create a tool for bioterrorism infection control and to make it "as simple as possible" (Figure 1). They began by collating information already produced in various public and government publications onto a one-page protocol sheet titled "Bioterrorism: Infection Control Practices for Patient Management." The sheet categorized a number of feared agents, including those threatened at the B'nai B'rith Building, into three groups: bacterial agents, viruses, and biological toxins. For each agent, they delineated six "infection control groups": isolation precautions, patient placement, patient transport, cleaning and disinfection of equipment, discharge management, and postmortem care.

Using this protocol sheet, a doctor, nurse, emergency responder, public health professional, or safety officer can quickly know what to do with people exposed to different agents. Thus, for anthrax, a user of the protocol sheet would immediately know what isolation precautions to take: "standard precautions for all aspects of patient care." Moving the eye down the tool, the user would see simple X's on the chart showing that there are "no restrictions" for patient placement and patient transport. For cleaning and disinfection of equipment, the chart calls for "routine terminal cleaning of room with hospital-approved disinfection upon discharge" and "linen management as with all other patients." With respect to discharge management, the protocol advises that "no special discharge instruction" is needed and that "home care providers need to be taught principles of standard precautions." For postmortem care, the tool tells users to "follow principles of standard precautions" and to "disinfect surfaces with blea ch/water solution of 1:9 (10 percent solution)."

Other possible bioterrorist agents and diseases covered by the protocol include brucellosis, cholera, glanders, plague, tularemia, Q-fever, smallpox, Venezuelan equine encephalitis, viral encephalitis, viral hemorraghic fever, botulism, ricin, T-2 mycotoxins, and Staphylococcus enterotoxin B.

Once WRAMC staff had finished compiling the tool, they invited the Surgeon General's infection control consultant to review their product. After the infection control consultant approved the tool and the information it provides, the staff made the tool available for public use.

Dr. Steve Cantrill in the Emergency Management Department of the Denver Public Health Department recently reviewed the publication and described it as a "very good tool." In his words, it's a "good survey of all the bioterrorist agents, it puts all the information we need on one page, it's one resource we can go to regarding bioterrorism. Basically, it's very practical."

Dr. Sandro Cinti from the Department of Infectious Diseases at the University of Michigan, also analyzed the work of the WRAMC staff and concluded that the bioterrorism infection control sheet is "a very good tool" and "a very quick reference."

It is to be hoped that there will be no more incidents like the one at the B'nai B'rith Building--real or hoaxes. With the tool produced by the Walter Reed Infection Control Services, however, more emergency and hospital personnel will be better prepared to deal with either possibility.

Readers who want more information on "Bioterrorism: Infection Control Practices for Patient Management," can find it by visiting the WRAMC Web site at [less than]http://www.wramc.amedd.army.mil/departments/idcontrol/[greater than], by calling [phone], or by sending e-mail to Lieutenant Colonel Suzanne E. Johnson at [less than][e-mail][greater than].

Author's note: The opinions and assertions attributed in this article to WRAMC ICS staff constitute the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.