Disease quarantine rules reviewed State health panel discusses authority to curb outbreak from bioterror attack Related stories

Carla K. Johnson - Staff writer

In a worst-case scenario of bioterrorism, regional health officers would have emergency authority to detain and quarantine victims to prevent the spread of infectious disease.

But whether that authority is stated clearly enough in current state regulations has health officers worried.

"When it comes to smallpox, I'm not really sure the police chief will stand at my side and enforce my authority to impose quarantine," said Dr. Kim Thorburn, health officer for the Spokane Regional Health District, testifying Wednesday at a state Board of Health meeting in Spokane.

"I don't have staff with guns who can come in and hold people in quarantine," Thorburn said.

The health board voted Wednesday to review rules concerning quarantines and other emergency powers of health officers.

State law appears vague on certain questions: Can health officers commandeer buildings for use as quarantine centers? Can they require treatment and vaccination?

A Model State Emergency Powers Act has been drafted at the request of the Centers for Disease Control and Prevention and could be a guide, state Health Secretary Mary Selecky said.

Selecky is the former health officer of the Northeast Tri-County Health District, which serves Ferry, Pend Oreille and Stevens counties.

The board also passed a resolution calling for more money to help state and local health care systems increase their ability to respond to major disease outbreaks and terrorist attacks.

The state's health care system, squeezed by cost-containment efforts and work-force shortages, has little extra capacity for a catastrophic event or an epidemic, according to a report on preparedness approved Wednesday by the board.

If Congress appropriates additional money to fight bioterrorism, more of it should get down to state and local levels than it has in the past, the board's resolution stated.

Improving the state's health care capacity also would help in the event of a naturally occurring epidemic, such as influenza.

Washington state leads other states in its level of preparedness, but shares some of the weaknesses of the national public health system, according to the report.

An emergency preparedness assessment conducted last year found that fewer than 20 percent of hospital emergency departments in Washington, Oregon, Idaho and Alaska had plans for responding to major biological emergencies.

The board's report endorsed the idea of federalizing the manufacture of vaccines if drug companies are unable to ensure adequate supplies.

"There is a breakdown in vaccine production," board member Tom Locke said. "It's a system that doesn't work."

The free market is not working well for vaccines, Locke said, because producing them is expensive, legally risky and not as profitable as making drugs such as the anti-impotence pill Viagra.

The health leaders' conversation circled back to smallpox several times during the meeting. Smallpox is a highly infectious, sometimes fatal disease that hasn't occurred in the United States since 1949.

In a huge victory for worldwide public health, smallpox was declared eradicated in 1980. Research stocks of the virus were supposed to be contained at two locations: the Centers for Disease Control and Prevention's Atlanta laboratory and a similar lab in Russia.

But the Soviets secretly produced smallpox for their bioweapons program in the 1980s. Bioterrorism experts fear some may have spread to terrorist-sponsoring countries.

-- Anonymous, November 15, 2001

Answers

I thought the idea was 24-hour notice. Certainly all I need, because my plan is to sit tight at home if need be. But 24 hours is a long time if steps really need to be taken.

I've had this scenario where smallpox needn't be an issue, because you aren't contagious prior to showing symptoms (unless I'm sadly mistaken about that). My biggest concern (well, other than death, extreme disfigurement and blindness) is the impact on the economy if folks lock down. Normally I take public transportation to work, but there is an inconvenient alternative to that. My company could somehow require that noone, absolutely noone (did I say noone?) is allowed to come to work if they were exhibiting any signs vaguely like smallpox, and perhaps not allowed to come back if they do develop smallpox. I'm in a highrise, multitenant building, so something would have to be done about the elevators as well. I have plenty of supplies at home, don't need to go to any stores for quite a while. It's doable, but of course not quite enough folks would cooperate to make that possible.

Trivia, read recently that "quarantine" is from something meaning "forty".

-- Anonymous, November 15, 2001

Brooks,

I'm not sure this is going to answer your question about how long... however, this is something that I pulled from one of the medical databases here at work. It has come out in the last week. (This is also a test to see if I can yank stuff from there and post here... if so, I'll try to do more digging.)

On September 11, 2001, following the terrorist incidents in New York City and Washington, D.C., CDC recommended heightened surveillance for any unusual disease occurrence or increased numbers of illnesses that might be associated with the terrorist attacks. Subsequently, cases of anthrax in Florida and New York City have demonstrated the risks associated with intentional release of biologic agents. 1 This report provides guidance for health-care providers and public health personnel about recognizing illnesses or patterns of illness that might be associated with intentional release of biologic agents.

Health-Care Providers Health-care providers should be alert to illness patterns and diagnostic clues that might indicate an unusual infectious disease outbreak associated with intentional release of a biologic agent and should report any clusters or findings to their local or state health department. The covert release of a biologic agent may not have an immediate impact because of the delay between exposure and illness onset, and outbreaks associated with intentional releases might closely resemble naturally occurring outbreaks. Indications of intentional release of a biologic agent include (1) an unusual temporal or geographic clustering of illness (e.g., persons who attended the same public event or gathering) or patients presenting with clinical signs and symptoms that suggest an infectious disease outbreak (e.g., >=2 patients presenting with an unexplained febrile illness associated with sepsis, pneumonia, respiratory failure, or rash or a botulism-like syndrome with flaccid muscle paralysis, especially if occurring in otherwise healthy persons); (2) an unusual age distribution for common diseases (e.g., an increase in what appears to be a chickenpox-like illness among adult patients, but which might be smallpox); and (3) a large number of cases of acute flaccid paralysis with prominent bulbar palsies, suggestive of a release of botulinum toxin.

CDC defines three categories of biologic agents with potential to be used as weapons, based on ease of dissemination or transmission, potential for major public health impact (e.g., high mortality), potential for public panic and social disruption, and requirements for public health preparedness. 2 Agents of highest concern are Bacillus anthracis (anthrax), Yersinia pestis (plague), variola major (smallpox), Clostridium botulinum toxin (botulism), Francisella tularensis (tularemia), filoviruses (Ebola hemorrhagic fever, Marburg hemorrhagic fever); and arenaviruses (Lassa [Lassa fever], Junin [Argentine hemorrhagic fever], and related viruses). The following summarizes the clinical features of these agents. 3-6

Anthrax A nonspecific prodrome (i.e., fever, dyspnea, cough, and chest discomfort) follows inhalation of infectious spores. Approximately 2- 4 days after initial symptoms, sometimes after a brief period of improvement, respiratory failure and hemodynamic collapse ensue. Inhalational anthrax also might include thoracic edema and a widened mediastinum on chest radiograph. Gram-positive bacilli can grow on blood culture, usually 2-3 days after onset of illness. Cutaneous anthrax follows deposition of the organism onto the skin, occurring particularly on exposed areas of the hands, arms, or face. An area of local edema becomes a pruritic macule or papule, which enlarges and ulcerates after 1-2 days. Small, 1-3 mm vesicles may surround the ulcer. A painless, depressed, black eschar usually with surrounding local edema subsequently develops. The syndrome also may include lymphangitis and painful lymphadenopathy.

Plague Clinical features of pneumonic plague include fever, cough with muco- purulent sputum (gram-negative rods may be seen on gram stain), hemoptysis, and chest pain. A chest radiograph will show evidence of bronchopneumonia.

Botulism Clinical features include symmetric cranial neuropathies (i.e., drooping eyelids, weakened jaw clench, and difficulty swallowing or speaking), blurred vision or diplopia, symmetric descending weakness in a proximal to distal pattern, and respiratory dysfunction from respiratory muscle paralysis or upper airway obstruction without sensory deficits. Inhalational botulism would have a similar clinical presentation as foodborne botulism; however, the gastrointestinal symptoms that accompany foodborne botulism may be absent.

Smallpox (variola) The acute clinical symptoms of smallpox resemble other acute viral illnesses, such as influenza, beginning with a 2-4 day nonspecific prodrome of fever and myalgias before rash onset. Several clinical features can help clinicians differentiate varicella (chickenpox) from smallpox. The rash of varicella is most prominent on the trunk and develops in successive groups of lesions over several days, resulting in lesions in various stages of development and resolution. In comparison, the vesicular/pustular rash of smallpox is typically most prominent on the face and extremities, and lesions develop at the same time.

Inhalational tularemia Inhalation of F. tularensis causes an abrupt onset of an acute, nonspecific febrile illness beginning 3-5 days after exposure, with pleuropneumonitis developing in a substantial proportion of cases during subsequent days. 7

Hemorrhagic fever (such as would be caused by Ebola or Marburg viruses) After an incubation period of usually 5-10 days (range: 2-19 days), illness is characterized by abrupt onset of fever, myalgia, and headache. Other signs and symptoms include nausea and vomiting, abdominal pain, diarrhea, chest pain, cough, and pharyngitis. A maculopapular rash, prominent on the trunk, develops in most patients approximately 5 days after onset of illness. Bleeding manifestations, such as petechiae, ecchymoses, and hemorrhages, occur as the disease progresses. 8

Clinical Laboratory Personnel Although unidentified gram-positive bacilli growing on agar may be considered as contaminants and discarded, CDC recommends that these bacilli be treated as a "finding" when they occur in a suspicious clinical setting (e.g., febrile illness in a previously healthy person). The laboratory should attempt to characterize the organism, such as motility testing, inhibition by penicillin, absence of hemolysis on sheep blood agar, and further biochemical testing or species determination.

An unusually high number of samples, particularly from the same biologic medium (e.g., blood and stool cultures), may alert laboratory personnel to an outbreak. In addition, central laboratories that receive clinical specimens from several sources should be alert to increases in demand or unusual requests for culturing (e.g., uncommon biologic specimens such as cerebrospinal fluid or pulmonary aspirates).

When collecting or handling clinical specimens, laboratory personnel should (1) use Biological Safety Level II (BSL-2) or Level III (BSL- 3) facilities and practices when working with clinical samples considered potentially infectious; (2) handle all specimens in a BSL- 2 laminar flow hood with protective eyewear (e.g., safety glasses or eye shields), use closed-front laboratory coats with cuffed sleeves, and stretch the gloves over the cuffed sleeves; (3) avoid any activity that places persons at risk for infectious exposure, especially activities that might create aerosols or droplet dispersal; (4) decontaminate laboratory benches after each use and dispose of supplies and equipment in proper receptacles; (5) avoid touching mucosal surfaces with their hands (gloved or ungloved), and never eat or drink in the laboratory; and (6) remove and reverse their gloves before leaving the laboratory and dispose of them in a biohazard container, and wash their hands and remove their laboratory coat.

When a laboratory is unable to identify an organism in a clinical specimen, it should be sent to a laboratory where the agent can be characterized, such as the state public health laboratory or, in some large metropolitan areas, the local health department laboratory. Any clinical specimens suspected to contain variola (smallpox) should be reported to local and state health authorities and then transported to CDC. All variola diagnostics should be conducted at CDC laboratories. Clinical laboratories should report any clusters or findings that could indicate intentional release of a biologic agent to their state and local health departments.

Infection-Control Professionals Heightened awareness by infection-control professionals (ICPs) facilitates recognition of the release of a biologic agent. ICPs are involved with many aspects of hospital operations and several departments and with counterparts in other hospitals. As a result, ICPs may recognize changing patterns or clusters in a hospital or in a community that might otherwise go unrecognized.

ICPs should ensure that hospitals have current telephone numbers for notification of both internal (ICPs, epidemiologists, infectious diseases specialists, administrators, and public affairs officials) and external (state and local health departments, Federal Bureau of Investigation field office, and CDC Emergency Response office) contacts and that they are distributed to the appropriate personnel. 9 ICPs should work with clinical microbiology laboratories, on- or off-site, that receive specimens for testing from their facility to ensure that cultures from suspicious cases are evaluated appropriately.

State Health Departments State health departments should implement plans for educating and reminding health-care providers about how to recognize unusual illnesses that might indicate intentional release of a biologic agent. Strategies for responding to potential bioterrorism include (1) providing information or reminders to health-care providers and clinical laboratories about how to report events to the appropriate public health authorities; (2) implementing a 24-hour-a-day, 7-day-a- week capacity to receive and act on any positive report of events that suggest intentional release of a biologic agent; (3) investigating immediately any report of a cluster of illnesses or other event that suggests an intentional release of a biologic agent and requesting CDC's assistance when necessary; (4) implementing a plan, including accessing the Laboratory Response Network for Bioterrorism, to collect and transport specimens and to store them appropriately before laboratory analysis; and (5) reporting immediately to CDC if the results of an investigation suggest release of a biologic agent.

Reported by: National Center for Infectious Diseases; Epidemiology Program Office; Public Health Practice Program Office; Office of the Director, CDC.

CDC Editorial Note: Health-care providers, clinical laboratory personnel, infection control professionals, and health departments play critical and complementary roles in recognizing and responding to illnesses caused by intentional release of biologic agents. The syndrome descriptions, epidemiologic clues, and laboratory recommendations in this report provide basic guidance that can be implemented immediately to improve recognition of these events.

After the terrorist attacks of September 11, state and local health departments initiated various activities to improve surveillance and response, ranging from enhancing communications (between state and local health departments and between public health agencies and health-care providers) to conducting special surveillance projects. These special projects have included active surveillance for changes in the number of hospital admissions, emergency department visits, and occurrence of specific syndromes. Activities in bioterrorism preparedness and emerging infections over the past few years have better positioned public health agencies to detect and respond to the intentional release of a biologic agent. Immediate review of these activities to identify the most useful and practical approaches will help refine syndrome surveillance efforts in various clinical situations.

Information about clinical diagnosis and management can be found elsewhere. 1-9 Additional information about responding to bioterrorism is available from CDC at http://www.bt.cdc.gov ; the U.S. Army Medical Research Institute of Infectious Diseases at http://www.usamriid.army.mil/education/bluebook.html ; the Association for Infection Control Practitioners at http://www.apic.org ; and the Johns Hopkins Center for Civilian Biodefense at http://www.hopkins-biodefense.org .

-- Anonymous, November 15, 2001