Bioterrorism Newsletter by mercy2beans109

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									                                                    Maryland Department of Health and Mental Hygiene
                                                                          Laboratories Administration

  Bioterrorism                                                                              Parris N. Glendening, Governor
                                                                                Kathleen Kennedy Townsend, Lt. Governor


  Newsletter                                                                         Georges C. Benjamin, M.D., Secretary,
                                                                                  Department of Health and Mental Hygiene
                                                                                        J. Mehsen Joseph, Ph. D., Director,
                                                                                                 Laboratories Administration




Volume 1, Number 1                                                                                            January 2001


The Role of the Clinical Laboratory in                                               On April 21, 2000, the CDC
                                                                                     published a Strategic Planning
Preparedness and Response to Bioterrorism                                            Workgroup report on “Prepared-
                                                                                     ness and Response to Biological
In recent years there has been a rise in the number of bioterrorism
                                                                                     and Chemical Terrorism: A
incidents in the United States, and almost all of them have proved to be
                                                                                     Strategic Plan.” The strategic
hoaxes. Most of these have involved threats of an anthrax release. In
                                                                                     plan is based on five focus areas:
1997, Congress addressed the threat of terrorism by enacting legislation
                                                                                     Preparedness and Prevention,
and providing funds to build the public health infrastructure to develop
                                                                                     Detection and Surveillance,
the capacity to respond to threats and actual terrorist events. The U.S.
                                                                                     Diagnosis and Characterization of
Department of Health and Human Services (HHS) was given the
                                                                                     Biological and Chemical Agents,
responsibility for bioterrorism attacks on the civilian population.
                                                                                     Response, and Communication.
The Department of Health and Human Services has designated the
                                                                                     The plan calls for state and local
Centers for Disease Control and Prevention (CDC) to coordinate and
                                                                                     health care agencies to investigate
lead the overall planning to upgrade national public health capabilities
                                                                                     unusual events and unexplained
of responding to biological and chemical agent terrorism.
                                                                                     illnesses, and for diagnostic
                                                                                     laboratories to be equipped to
What is bioterrorism? Bioterrorism is the intentional use of microbial
                                                                                     identify biological and chemical
agents, their toxins, or chemical products to harm individuals or
                                                                                     agents. The plan also calls for the
populations. A bioterrorism attack may be politically motivated or
                                                                                     creation of a multilevel laboratory
motivated by personal reasons. Public health response to bioterrorism
                                                                                     response network linking clinical
includes detection of the event (Health Surveillance), rapid laboratory
                                                                                     laboratories to public health
diagnosis of the agent, epidemiologic investigation, and implementation
                                                                                     agencies in all states and local
of control measures. Agents most likely to be used by a terrorist are
                                                                                     areas and to facilities that can
those that are not endemic or typically present in the community.
                                                                                     analyze biological agents.
Practitioners need to familiarize themselves with the clinical present–
                                                                                     Implementing the plan by 2004
ations of these agents. Level A clinical laboratories will need to have
                                                                                     will ensure that the national
procedures in place to rule out these agents and refer suspected isolates
                                                                                     laboratory response network for
to the state public health laboratory. Once a suspect agent is identified,
                                                                                     bioterrorism include facilities in
it should be referred immediately to the public health laboratory to
                                                                                     all 50 states.
confirm the initial identification.
                                                                                     A bioterrorism event may be
Biological threat agents under current consideration are Bacillus
                                                                                     either overt or covert. An overt
anthracis, Yersinia pestis, Francisella tularensis, Brucella spp, Clostridium
                                                                                     event is usually announced by
botulinum, Variola major (smallpox virus), and viral hemorrhagic fevers.
                                                                                     the perpetrator to create fear and
These agents are referred to as select biological agents. Routes of
                                                                                     disrupt normal operations.
exposure most likely to be used for these agents are inhalation by
                                                                                     Therefore, these events are
aerosols and ingestion of contaminated food or water.

                                                                                                       Continued on next page
The Role of the                       Level A consisits primarily of           Level D are federal laboratories
Clinical Laboratory                   hospital laboratories that would         located at CDC and USAMRIID
in Preparedness and                   be first responders to cover a           which have biosafety level IV
                                      bioterrorist event. These laborato-      facilities to study highly infectious
Response to Bioterrorism              ries are expected to rule out or         viral agents, such as those casuing
                       (Continued)    refer to the public health labora-       smallpox and hemorrhagic fevers.
                                      tory the select biological agents.       These facilities are responsible
recognized very early and the         If a select biological agent is          for developing new tests and
response is immediate. The            detected and identified, it should       technologies, and maintaining
police department and fire            still be referred to both the public     stock agents referred by state
department are first responders,      health laboratory for genetic            public health laboratories.
followed by the FBI, to gather        characterization and to the              Federal laboratories provide
evidence and attempt to find the      national collection center for these     training, procedures, and reagents
perpetrators. A covert event is       agents.                                  to the state public health laborato-
unannounced and the first evi-                                                 ries and assist them in conducting
dence may be cases of infection       Level B is primarily made up of          training for level A laboratories
appearing in hospital outpatient      public health laboratories, which        and other agencies responsible
departments, hospital admissions      will rule-in the select agents and       for responding to bioterrorism.
and physicians’ offices. The          refer to level C laboratories.
disease outbreak will first           These laboratories have biosafety
appear as a natural outbreak, and     level II and biosafety level III         Referral of Microorganisms
will require epidemiologic            facilities.
and laboratory investigation to                                                Level A laboratories are requested
determine if the outbreak is          Level C contains advanced, large         to refer all specimens and
the result of a terrorist attack.     public health laboratories with          microorganisms that may
Recognition of the outbreak will      biosafety level III facilities and the   represent one of the select bio-
emerge slowly and the response        genetic technology and typing            terrorism agents to the DHMH
will be delayed. Appropriate          tests to rule-in biological agents.      Laboratories Administration for
treatment may also be delayed         These agents are retained in stock       further characterization. All such
until the infectious agent is         cultures for future reference and        agents will be retained in a culture
isolated and identified. Charac-      for development of more rapid            collection for later reference in
terization of the infectious agent    methods of identification, as well       developing improved and rapid
by gene sequencing may help to        as for referral of these biological      detection technologies. These
distinguish the naturally occur-      agents to the national collection        agents will also be sent to the
ring agent from a laboratory-         center at CDC.                           CDC for the national culture
derived strain or a genetically                                                collection, to be used for a similar
derived strain. The first respond-                                                 purpose.
ers are health care workers, and
early recognition of the agent will                                               Other examples of laboratory
assist these workers to use appro-                                                findings that should be
priate protective measures.                                                       referred to the DHMH Lab–
                                                                                  oratories Administration are
A national laboratory response                                                    the following:
network was established by CDC
and the Association of Public                                                     1. If gram-positive bacilli are
Health Laboratories to develop                                                       isolated from sputum and/
the infrastructure needed to                                                         or blood culture from
respond to bioterrorist threats.                                                     patients with pulmonary
Laboratories are classified at four                                                  disease, the isolate should
levels, based on their capacity to                                                   not be discarded as a
identify the common biological                                                       contaminant but referred
threat agents.                                                                       to the Laboratories Admin-
                                                                                     istration for further
                                                                                     characterization to
   eliminate Bacillus anthracis. If   What do Laboratory Directors             laboratory.
   the Level A laboratory identi-     Need to Do Now?                        • How to rule-out possible
   fies the bacillus as a non-                                                 bioterrorism agents as quickly
   pathogenic strain, the isolate     Review safety procedures to              as possible.
   need not be referred.              determine if the laboratory could      • How to appropriately send
                                      safely handle an initial culture         potential bioterrorism agents to
2. If gram-negative coccobacilli      and identification of threat agents,     the State Public Health Labora-
   are isolated from sputum           review testing procedures to             tory immediately to rule-out or
   and/or blood culture from          determine if they are consistent         rule-in an agent.
   patients with pneumonic            with recommended identification        • The safety devices needed
   disease, the isolates should       schemes, assure that appropriate         to protect your staff when
   not be discarded but referred      packaging is available for the           working with these agents.
   to the Laboratories Adminis-       transport of culture/specimens,
   tration, unless the Level A        and contact the State Public
   laboratory is certain the          Health Laboratory to become            Laboratories Administration
   identify of the isolate is other   integrated into the Stat’s response
   than a select biological agent.    planning (call 410-767-6100).          The DHMH Laboratories
                                                                             Administration has expanded
3. If gram-negative coccobacilli      Collaborations formed during           its capacity to rapidly identify
   or bacilli are observed in a       development of the national            the select bioterrorism agents.
   gram-stained smear but fail        bioterrorism response network          Collaboration with Maryland
   to grow in culture, a portion      will be equally valuable in            hospitals and independent
   of the specimen should be          strengthening the State’s surveil-     laboratories, to develop a network
   referred to the Laboratories       lance and control of endemic and       providing access to this testing
   Administration. This condi-        emerging infectious diseases.          methodology, is just beginning.
   tion may occur where the lab       Preparation and planning are           Along with various State agencies,
   is not using special media         necessary so that if an attack does    the Maryland Department of
   required for the isolation of      occur, microbiologists will be able    Health and Mental Hygiene is
   fastidious microbes such as        to rapidly identify the probable,      actively engaged in providing
   Francisella tularensis.            priority biological agents.            laboratories with background
                                                                             information about bioterrorism
                                      Clinical laboratories are the          preparedness and response.
Storage of Select Agents              sentinels for bioterrorism and         Each issue of this quarterly
                                      may be the first to see an             Bioterrorism Newsletter will
Proper storage of select agents is    organism in a covert attack, such      describe the role of the laboratory
absolutely essential to restrict      as Bacillus anthracis in a blood       network and give pertinent
access to these agents. It is         culture or Yersinia pestis in sputum   information about biological
recommended that they be kept         culture. The diagnostic micro-         agents, detection methods, and
in locked storage with only a few     biology laboratory staff should        safety precautions. Plans are
key laboratory staff having access.   have uniform procedures and            under way to develop a hands-on
A record of stored agents should      training and be able to recognize      workshop for the important
be kept and an inventory taken        bioterrorism agents. They must         biological agents, so that all
periodically to enable the Labora-    know what to send for further          participants are able to recognize
tory Director to determine if any     testing and who to send it to,         unusual microorganisms and
stock cultures are missing. When      and must know if there are any         take appropriate action. Other
cultures are missing and the          special safety considerations for      workshops are planned to inform
circumstances cannot be resolved,     this testing. The Laboratories         the laboratory community about
the Laboratories Administration       Administration can provide             the State planning that is taking
should be notified promptly to        guidance on these issues.              place, the participating agencies,
be alerted about the missing                                                 and the roles of each member of
stock culture.                        Level A laboratories need to know      the bioterrorism network.
                                      the following information:

                                      • Their role as a Level A

								
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