08_08_28 -ha contingency plan for biological agent attack _28 8 08 at 1747

8/8/2019 08_08_28 -HA Contingency Plan for Biological Agent Attack _28 8 08 at 1747

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HA Contingency Plan

for Biological Agent Attack

(Revised 28 August 2008)


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Hospital AuthorityPrepared by: HA Central Committee on InfectiousDiseases & Emergency ResponsesIssue Date: Oct 2004Revision no. : 1 (Dec 04)Revision no. : 2 (28 Aug 08)

Title: HA Contingency Plan for BiologicalAgent Attack

1. TitleHA Contingency Plan for Biological Agent Attack

2. ScopeTo prepare health care professionals and Major Incident Control Centers (MICC) personnel with the

emergency response, management and control mechanism in times of biological agent attack. It

should be read together with the following documents:

i. HA Response Plan for Infectious Disease Outbreakii. HA Response Plan for Major Incidentsiii. HAHO Operations Circular No. 11/2008 Reporting Mechanism for Infectious Diseasesiv. HA Contingency Plan for CBRN Incidents (working draft July 2008)v. HA Operational Plan for HO MICCvi. Sample Hospital HAZMAT Decontamination Contingency Planvii.

HA Contingency Plan on Smallpoxviii. Relevant fact sheets on anthrax, smallpox, plague, botulism etc issued by HA CCIDER.

3. The Need for Concerna) The main concern with intentional use of biological agents is that they cannot be predicted as to

where, when and what agents would be used. Therefore, a timely response depends heavily on an

efficient global intelligence network and risk assessment.

b) Such attacks may be noticed, as for the case of anthrax powder in mail letters, and managementof exposure and decontamination are required. They may, however, be covert, only to be noticed

when cluster of cases occur after the incubation period.

c) HA preparedness is essential as persons exposed to these biological agents are most likely toseek medical care in hospital. In addition, persons who have been exposed elsewhere might beincubating the disease and might seek medical attention during their visit to Hong Kong.

4. Definition of a biological agent attackThe Government has defined a biological agent attack as the use, threatened use, or believed use

of biological agents for Terrorist or Criminal purposes.

5. Biological Agentsa) Biological agents/ weapons can be described as those whose intended target effects are due to the

infectivity of disease caused by microorganisms and other replicative entities, including viruses,

infectious nucleic acids and prions.

b) There are numerous biological agents that can potentially be abused. However, for preparationagainst such an incident, agents are targeted and categorized according to their public-health

impact to cause mass casualties, their ability to disseminate widely, their potential for person-to-

person spread, the availability of treatment options etc., into high risk agents.

c) The targeted agents, currently, are Bacillus anthracis, Yersinia pestis, smallpox and Clostridiumbotulinum and its toxin.

6. Infection Control AspectThe various fundamental elements required of a hospital to deal with such incidents are similar to

those required for prompt and efficient detection and management of any outbreak of infection whichinclude:

a) Clinical areas, especially AED and ICU:i. should alert to cases compatible with diseases associated with these biological agents and


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the necessary precautions. Early suspicion based on signs and symptoms, and looking for

any unusual and sudden increase of cases compatible with the use of biological agents,

especially those with a history of travel and possible exposure in other parts of the world.

ii. should review cases of sudden death in otherwise healthy subjects to see if any possibilitywith exposure to these biological agents.

iii. familiarize with the reporting and notification mechanism on effective notification ofsuch suspected cases, especially for those that are not notifiable diseases (Appendix II).

iv. should notify hospital laboratory/ Public Health Laboratory Centre (PHLC) of suspectedcases prior to sending any patient specimens for testing as there may be potential dangerto laboratory workers.

v. in transporting specimens, staff should follow the Guideline on Transport of ClinicalSpecimens and Infectious Substances (Revised in July 2006).

vi. familiarize with the arrangement with the PHLC of the Centre for Health Protection(CHP) in submitting patient specimens and suspicious isolates promptly for confirmation.

b) Microbiology Laboratoryi. though specimen would be sent by the police to PHLSB of CHP in the first instance if

police consider the object suspicious, microbiology laboratory should also make available,

as far as possible, tests for the detection of biological agents and standardize testing

protocols (for details, please refer to Appendix I Section 6).

ii. should enhance training on techniques required in the detection and identification of thesebiological agents.

iii. familiarize with the arrangement with the PHLC in submitting patient specimens andsuspicious isolates promptly for confirmation.

c) Hospital Infection Control Team (ICT):i. should be aware of proper isolation and environmental decontamination procedures in

handling patients with suspected exposure or infection due to these biological agents.

ii. should arrange educational seminars to update staff in the necessary precautions ininfections due to these biological agents.

d) Pharmacy:i. should make available the necessary drug items, including antibiotics, antitoxins and

vaccine, in case their uses are indicated.

7. Notification mechanism and Patient Managementa) Please refer to the attached checklist on management of patient suspected to be contaminated

with biological agents at AEDs (Appendix I).

b) The decontamination flow chart of Plan A & Plan B under the Medical Management ofHAZMAT Incident Victim is attached as Appendix III and VI for easy reference.

8. References- Centers for Disease Control and Prevention, the Hospital Infection Control Practices Advisory

Committee (HICPAC). Recommendations for isolation precautions in hospitals. Am J Infect

Control 1996; 24:24-52.

- Tucker JB. National health and medical services response to incidents of chemical and biologicalterrorism. JAMA 1997; 278:362-8.

- Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia as a biological agent. JAMA 2001;285: 2763-2773.

- Franz D, Jahrling PB, Friedlander AM, McClain DJ, Hoover DL, Bryne WR, et al. Clinicalrecognition and management of patients exposed to biological warfare agents. JAMA 1997;

278:399-411.

- Kortepeter MG, Parker GW Potential Biological Weapons Threat. EIDJ Vol 5 No 4 1999


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Checklist on management of patients suspected to be contaminated with U

biological agents that require immediate decontamination in AED U

Section Action

1. Scope 1.1 This document deals with patients suspected to be contaminatedwith biological agents attending AED that requires immediate

decontamination, which is likely to be due to overt release.

1.2 Possible agents for biological attack include:- Scheduled infectious diseases under Prevention and Control

of Disease Ordinance: Anthrax, Botulism, Cholera, Plague,

Smallpox, Typhoid Fever

- Other infectious diseases: Brucellosis, Staphylococcalenterotoxin B, Tularemia and any other rare and fatal

infectious diseases

2. Notification

mechanism

2.1 Notify HA Head Office Duty Officer (HODO), the Centre forHealth Protection (CHP) of Department of Health (DH), and

Police if biological agent attack is suspected

a) Use the attached form Notification of Suspected Cases ofBiological Agent Attacks and call HODO & CHP (CENO) /

MCO immediately before fax or email. (Appendix 2)

HODO 24 hr pager: 7116 3328 A/C 999

CHP (CENO)

Office hours* : CHP Central Notification Office (CENO)

Tel: 2477 2772

Outside office hours : CHP Medical Control Officer (MCO)

Pager 7116 3300 A/C 9179

* Office hours

(Monday: 9:00am 1:00pm / 2:00pm 6:00pm;

Tue Fri: 9:00am 1:00pm / 2:00pm 5:45pm;

Sat/ Sun/ Public Holiday: Closed)

b) Follow the standing notification procedures for infectious diseasesin HAHO Operations Circular 11/2008 dated 14 July 2008.

UAppendix I


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Section Action

2.2 Enter information in Accident & Emergency Information System(AEIS) Disaster Helpdesk Module.

2.3 Patients turn up at AEDs without going through clearance atthe incident site are managed as follows:

a) Clinically non-suspicious no further actionb) For clinically suspicious cases:

i. arrange appropriate PPE for staff protection;ii. arrange decontamination of victims with appropriate level of

PPE if required

iii. inform Fire Service Department if mass decontamination isrequired (see Section 8 & 9)

iv. notify HODO and CENO CHP and Police (see Section 2.1)v. enter information in AEIS Disaster Helpdesk Modulevi. for objects brought into AED by the victim, refer to Section

11

vii. inform hospital Infection Control Team2.4 For the management of clinical specimens (at site or hospital),

please see Section 14.

3. Despatch of medical

team(s)

3.1 AED may need to despatch medical teams to incident sites. Theteam should only stay at cold zone and handle clean patients.

3.2 The team may consider taking appropriate level of PPE just in casethere is change in wind direction or other unexpected accidents.

4. HODO to alert other

hospitals

4.1 For suspected biological agent attacks involving only a fewvictims, HODO will alert the concerned AED(s).

4.2 If the incident is confirmed and involve many victims who mayarrive at different AEDs, HODO will alert all relevant staff and

hospitals through Alert Channel to standby and prepare for

receiving these victims.

4.3 Head Office Major Incident Control Centre (HO MICC) will beactivated for overall coordination.


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Section Action

5. Clothes for victims 5.1 HA had agreed to supply emergency clothing to non-hospitalisedvictims if asked by Police or Fire Services Department.

5.2 One major hospital of each cluster to supply 200 sets of clothesand some plastic bags (QMH, PYNEH, QEH, PMH, TMH, PWH

& UCH).

6. Collection and testing

of Specimen

6.1 For biological attack, police will deliver the specimen to PHLSBof CHP if police consider the object suspicious.

6.2 If a specimen had been sent by the police to PHLC, CHP wouldtry to inform the concerned AED of the preliminary results. If no

phone call is received from CHP and it is known that a specimen

had been sent, MCO could be contacted at 7116 3300 A/C 9179

after waiting for 4 hours.

7. Transport of drugs

between hospitals

7.1 Hospital should keep stock of specific drugs and must have amechanism to allow AEDs to have access to emergency medicine

stocks.

7.2 Hospital should liaise with HAHO Duty Pharmacist of ChiefPharmacists Office at pager 7305 2171 if stock in own hospital

confirmed not enough.

7.3 HAHO Duty Pharmacist should source urgent drug supplies.7.4 Hospital supplying drugs should arrange messenger to transport

the drugs to the hospital in need.

7.5 Hospital should prepare a standard memo to be carried by themessenger explaining the purpose of the emergency delivery in

case problem is encountered during the journey.


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Section Action

8. Setting up of

decontamination

facilities by FSD near

hospitals

8.1 Hospital should provide a limited decontamination apparatus athospitals prior to the setting up of FSD decontamination facilities.

8.2 Hospitals can request FSD for assistance to set up adecontamination facility.

8.3 To prepare for possible incidents, individual hospitals should liaisewith FSD to identify the site for mass decontamination in hospital

compound.

8.4 Hospitals are requested to arrange female staff to assist FSD in thefemale decontamination units.

9. AEDs to assess

capacity for

decontamination

9.1 To identify location and assess time required for setting upfacilities (by hospitals itself and/or with assistance from FSD) and

the capacity available at the time.

9.2 To organize regular training and drills to ensure staff are familiarwith the procedures.

10. Decontamination of

patients

10.1Use water and soap. No need to use specific solution.10.2Hospital should arrange new and clean clothes to patients after

decontamination.

11. Patients properties 11.1Properties of patients should be collected by Police or hospitalsecurity staff with proper labelling.

11.2Pack clothes and other items in a pink plastic bag makingreference to the bio-hazard arrangement and with patient label.

11.3Seek Police advice on arrangement of patients belongings.

12. Patient privacy 12.1Individual hospitals should ensure patient privacy for victimdecontamination in hospitals. Set up appropriate cordon by

security guard and with police assistance if necessary.


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Section Action

13. Assess risk of

patients

13.1Clinicians to determine whether patients are high risk or low riskbase on clinical judgement and circumstantial information.

13.2AEDs to discuss with Cluster or Hospital Infection ControlOfficers (ICOs) in case of doubtful situation for suspected

biological agents. HODO will contact CHP for infection control

advice where deemed appropriate.

14. Clinical specimens at

AEDs/ hospitals

14.1 HA will only take specimen(s) from patients if clinicallyindicated.

14.2Keep any specimen provided by patients for investigation. Policewill first decide whether an attack is likely. If it is decided that the

incident is a hoax, there will be no further action. If an attack is

likely, police will send the specimen to the Public Health

Laboratory Service Branch (PHLSB) of CHP for laboratory

diagnosis.

14.3In transporting specimens, staff should follow the Guideline onTransport of Clinical Specimens and Infectious Substances

revised in July 2006.

15. Drug treatment 15.1 Refer to relevant fact sheets if available.15.2 HA and DH to provide mutual backup on drugs.

16. Discharge of Patient 16.1For Anthrax, HA to follow-up patients who have startedprophylaxis.

16.2Discharge advice to be given to all patients irrespective of follow-up (Please refer to CHP website for details:

http://www.chp.gov.hk)


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Section Action

17. Contact tracing 17.1The Communicable Disease Division, Surveillance &Epidemiology Branch, CHP will do contact tracing for cases of

biological agent attacks and refer patients to HA for isolation and

treatment. Cluster or Hospital ICO will collaborate with CHP in

tracing in-hospital contacts.

17.2For suspected case, CHP will follow-up patients who areasymptomatic, including those who need post-exposure

prophylaxis but had not attended HAs AED. CHP will refer

patients back to HA if patients have potential medical problems or

relevant symptoms.

18. Decontamination of

hospital environment&

equipment

18.10.5 % Sodium hypochlorite (need more contact time) or 5%Sodium hypochlorite can be used for hospital environment and

equipment disinfection respectively.

18.2After decontamination of the last victim, staff in Level C PPEPi toconduct a quick environmental decontamination. Then staff in

Level D PPEPii

P to complete the rest of the decontamination process.

18.3Hospitals to ensure staff safety and provide the following PPEs

i. Level C PPE

-full body CPF2 suit-full face mask

- a pair of multi-gas cartridges (with appropriate filter)

- a pair of nitrile gloves

- a pair of PVC safety knee boots

- adhesive tapes

ii. Level D PPE

-protective suit

- half face mask

-protective goggle

- a pair of multi-gas cartridges(with appropriate filter)

- a pair of latex gloves

- a pair of boots

19. Disposal of water

used for decontamination

19.1The used water needs to be diluted many times.19.2Use some neutralising agent such as 0.5% Na Hypochlorite to

detoxify the biological agents.

19.3Consult Cluster/Hospital ICOs if in doubt.


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Section Action

20. Prevailing

arrangement of

Admission to hospital

20.1Standard precautions and transmission-based precautions to bepractised.

20.2Inform Hospital Infection Control Team.20.3For the following diseases: plague, yellow fever, smallpox and

other agents of biological attack, patients should be sent to HA

Infectious Disease Centre (IDC) at Princess Margaret Hospital

(PMH).

20.4If HA IDC will receive the first 50 cases before other designatedhospitals to admit the patients. Please refer to the arrangement on

Decanting and mobilisation of patients in the HA Response

Plan for Infectious Disease Outbreaks.

20.5If inter-hospital transfers are required, please:

a) alert ambulance staff to take necessary precautions on infectioncontrol.

b) spell out the nature of patient and receiving ward/departmentof the patient when making request to FSD; and ensure proper

handover of patients to the ambulance crew on the patient

conditions.

c) For further details on inter-hospital ambulance transfers, pleasemake reference to HAHO Operations Circular no. 24/2005

dated 12 December 2005 on Classification of Ambulance

Calls for Emergency Inter-hospital Transfers by FSD

Ambulance.

21. Confirmation of the

biological agents

21.1Confirmation should be done by PHLC of CHP.

22. Handling of dead

patients

22.1Follow the latest DHs guideline on Precautions for Handling andDisposal of Dead Bodies at the Infection Control Corner of CHP

website.

-End-


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PatientsGum Label (Full label)

Notification of Suspected Cases of Biological Attacks

(Please phoneHODO and CENO/MCO immediately before fax or email this reporting form)

Note: Reporting of infectious diseases should follow the prevailing HAHO Operations Circular

From:

Hospital Name :

Department/Ward/Unit :

Fax No. :

Tel No. :

Suspected Agent

Please tick as appropriate :

Anthrax Others : (please specify) :

- Possible biological agents are Botulism, Cholera, Plague, Smallpox, Typhoid Fever, Brucellosis,Q fever, Staphylococcal enterotoxin B, Tularemia, Viral Hemorrhagic fevers and any other rare

and fatal infectious diseases

Suspected agent sample


Available Not Available

Prophylaxis started in A&E


Yes No

Contact History

Date and time of contacting the agent : / / (dd/mm/yy) at (time)

Place of contact : Mode of contact :

Symptoms :

Examination findings and investigation findings :

Reporting Doctor: ____________________________ _________________________ ______________________

(Name) (Signature) (Date)

Reply Slip from CHP

Test results by the Public Health Laboratory Centre of the Department of Health are as follows:

Specimen :

Microscopy :

Culture :

Remarks :

________________________________ ___________________________ ________________________

(Name of Microbiologist) (Signature) (Date and Time)

(Revised August 2008)

UAppendix II


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Hospital HAZMAT

Contingency Plan A

(Revised Aug 2008)

Hospital

Capacity depend on size

2R+8Y or 4R+16Y

AED AED AED

Sharing of antidotes

between AEDs

Activate Hospital HAZMAT

Decontamination Contingency

Plana. High index of suspiciousb. Protect staff (Level D PPE + mask)c. Assess victims : Primary surveyd. Decontamination if necessarye. Establish Diagnosis: Secondary survey

-Specimen swab if clinically indicated

f. Security control : Cordon off/Orderg. Prompt treatment

-refer to Fact Sheet

-Treatment if clinically indicated

-Prophylaxis depends on results from DH (for

anthrax)

h. Infection control : Standard precautions andtransmission-based precautions

i. Notify proper authorities :HODO, CHPand Hospital management

j. Epidemiology:AEIS Disaster Module

ICT

CHP

Admission into wardDeadTo Mortuary

Category3 Precaution

To IDC PMH if Plaque, Yellow fever,

Smallpox or other agents of biologicalattack

If

DAMA

Call CHPMCO

Home with FU

if require

prophylaxis

Home without FU

if not require

prophylaxis

Prophylaxis of victims/staff: Vaccination/Antimicrobial (Fact sheet)

Initial Stand-down and Final Stand-down

Explosion/Spillage

Victims SpecimenPHLC

HODO & CENO/MCO of CHPOn-site Decon.

by FSD

Hospital

Security

Staff

Clothing

Personal

belongings

Plastic bag

with label

Clear by

Police

Return to

victims

-Use HB2BO + soap

-Privacy

-Clothing, towel

& slippers

After decon,

-Use HB2BO to flush

equip. and floor

-Self-decon

-DOFF PPE

-Wait for result

from CHP/ Gov.

Lab.

-Floor clean by HB2BO

by staff with level D

PPE

Victims

Hospital

Management

Pharmacy

Laboratory

Radiology

Specialties

OT

ICU

Security

E&M

Supplies

ICT

Self-arrive

Incident Site

EOD/Police

Initial and

culture

results

G. LAB

Fax

Notification

Form

Contact Tracing

HA PA and

Hospital

MRO (media

relations

officer)

For Media

Handlin

FSCC/ HKPF

Alert

Decon. Zone

Backup by FSD

UAppendix III


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Hospital HAZMAT Incident

Contingency Plan B

(Revised Aug 2008)

Backup from AED Nurse Station(Patient registration)

a. Inform HODO and CENO/MCO of CHP

b. Inform Police

Prepare Decontamination

+ activation of Hospital HAZMAT

Decontamination Contingency Plana. Assess victims : Primary surveyb. Decontamination if necessaryc. Establish Diagnosis: Secondary survey

-Specimen swab if clinically indicated

d. Security control : Cordon off/Ordere. Prompt treatment

-refer to Fact Sheets

-Treatment if clinically indicated

-Prophylaxis depends on results from CHP (for

anthrax)

f. Infection control : Standard precautions andtransmission-based precautions

g. Notify proper authorities: HODO, CENOand Hospital managementh. Epidemiology:

-AEIS Disaster Module

-ICT

-CHP

Admission into wardDead

To mortuary

Category 3

Precaution

To IDC PMH if Plaque, Yellow

fever, Smallpox and other agents

of biological attack

If

DAMA,

call CHP

MCO

Home with FU

if require

prophylaxis

Home without FU

if not require

prophylaxis

Prophylaxis of victims/staff: Vaccination/Antimicrobial (Fact sheets)

Check by Triage Nurse

(OT Gown, Glove, Mask)

Victims Specimens CHP PHLC

Self Arrive Victims

EOD/Police

Initial and

culture results

Triage Nurse put on OT cap

and respiration filter

Triage nurse bring along

with plastic bag and bring

victims to First Aid Post

(keep a safe distance from

victim).

-Reassurance to victims

-Instruct patient to remove

his/her overcoat

-Get history and wait for

Decon team arrive.

Decon. Zone

Fax Notification Form

Instruct victims to

put suspicious object

or specimens into

plastic bag and seal

up (or cover it up).

Clothing

Personal

belongings

Plastic bag

with label

Clear by

Police

Return to

victims

-Use HB2BO +

soap

-Privacy

-Clothing, towel

& slippers

After decon,

-Use HB2BO to flush

equip. and floor

-Self-decon

-DOFF PPE

-Wait for result

fromPHLC/Govt. Lab

-Floor clean by

HB2BO by staff with

level D PPE

Contact Tracing

(Inform as

appropriate)

Hospital

Management

Pharmacy

Laboratory

Radiology

Specialties

OT

ICU

Security

E&M

Supplies

HA PA and Hospital

MRO(media relations

officer)

for media handling

UAppendix VI


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Legends:

AED Accident and Emergency Department

AEIS Accident & Emergency Information System

CENO Central Notification Office

CHP Centre for Health ProtectionDAMA Discharge Against Medical Advice

Decon. Zone Decontamination Zone

DH Department of Health

DHHQ Department of Health Headquarters

EOD Explosive Ordnance Disposal

FAP First Aid Post (outdoor area for initial holding of HAZMAT victims)

FSCC Fire Services Control Center

FSD Fire Services Department

G. LAB. Government Laboratory

GOPD General Outpatient Department

HA Hospital Authority

HAIDC Hospital Authority Infectious Disease Center

HA PA Hospital Authority Public Affairs

HAZMAT Hazardous material

HODO Head Office Duty Officer

HOMICC Head Office Major Incident Control Center

HKPF Hong Kong Police Force

ICB Infection Control branch

ICU Intensive Care Unit

ICT Infection Control Team

MCO Medical Control Officer (Centre for Health Protection)

MRP Media Relations Person

OT Operation Theatre

PHLC Public Health Laboratory Center

PHLSB Public Health Laboratory Service Branch

PMH Princess Margaret Hospital

PPE Personal Protective Equipments

PRO Public Relation Officer

SEB Surveillance and Epidemiology Branch

SOPD Specialist Outpatient Department

Hospital Authority

28 August 2008

08_08_28 -ha contingency plan for biological agent attack _28 8 08 at 1747

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