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Currents To Medical Center employees: At the Oct. 2 communications meeting, we received an update on our planning for bioterrorism threats. The highlights of the presentation are outlined below. A committee was formed more than a year ago to develop a plan to address bioterrorism threats and incidents. The committee members represent the broad range of expertise needed to prepare our plan. As an organization, MUSC has had experience in preparing for and responding to emergencies (such as hurricanes). Our past experience combined with the high level of in-house expertise serve us well in addressing bioterrorism. As we move forward, we will continue to communicate our plans and educate employees regarding bioterrorism preparedness. Thank you very much. W. Stuart Smith Vice President for Clinical Operations and Executive Director, MUSC Medical Center MUSC addresses threat of bioterrorism With heightened concern over the threat of bioterrorism and the manner and means communities have to deal with such threats, the Medical University of South Carolina has been called upon by other medical centers in the southeast region to share its plan for bioterrorism preparedness and response. Members of the MUSC/Medical University Hospital Authority task force for bioterrorism guided the management team in a clearer understanding of the nature of the threat, as well as some of the mechanisms already in place at MUSC to handle such a crisis. “We need to have enough information to calm ourselves and enough information to share with others in our community,” said Joan Herbert, administrator, Institute of Psychiatry, who addressed the management team at the Oct. 2 communications meeting. “The message is that while the matter is automatically anxiety producing, there are some reassuring messages as well.” The plan has been in process since 1999, according to Al Nesmith, disaster control officer, who heads the Bioterrorism Preparedness and Response Team. “What we have today is a product of over a year of effort,” Nesmith said. Details of the MUSC plan will be presented within the next month pending incorporating plans generated at the state and national levels, he said.  The Medical Center is already well equipped to handle disasters, including the relevant protective equipment, said team member Jodell Johnson, R.N., Infectious Diseases. Bob Cantey, M.D., director of MUSC Infectious Diseases, described in detail the four most likely agents terrorists might use—specifically smallpox, anthrax, plague and botulinum toxin. He also discussed the degree of risk associated with each, quelling some concerns over the likelihood of widespread release. Cantey gave an overview of each agent and supplemented it with a fact sheet, which references the Journal of the American Medical Association. Smallpox Of the bioterrorist threats, smallpox is “potentially the most manageable, especially if the vaccine is available,” according to Cantey. “Of those infected, mortality is an average of 30 percent, but is concentrated in the very young and elderly.” Smallpox was eradicated from human populations as of 1977 and is not known to exist outside of laboratories at the Center for Disease Control and in Russia, Cantey said. Vaccination is highly effective, but has not been used since 1972, though more than 7 million doses remain in storage. An effective immune globulin is also available. Persons given the single dose vaccination lose antibodies within 5-10 years. Persons receiving a booster dose have antibodies for a period exceeding 30 years. Primary immunization given within four days of exposure may prevent or ameliorate illness. Patients previously immunized would be expected to have an earlier and more reliable immunity. Smallpox could be used as a bioweapon by aerosol dissemination, or by sending infected individuals into a susceptible population. A single case may result in 10-20 secondary cases. The virus is spread person-to-person by respiratory droplets, skin lesions, secretions and contaminated clothes or bed linens. Transmission occurs with the onset of the rash. The time from exposure to symptoms ranges from 7-17 days. The first symptoms are flu-like, followed in 2-4 days by a rash, which lasts 1-2 weeks. Infected patients should stay at home, Cantey said, in order to reduce exposure to others. Household contacts should be immunized immediately. The virus may survive 24 hours in the environment if ultraviolet light is not present. Soiled cloth, however, can be infectious for a longer period. The virus is readily killed by household bleach diluted 1:10. Anthrax Anthrax, caused by the bacterium Bacillus anthracis, is widely available and the spores are relatively easy to prepare, though broad dispersal of the spores in a fatal form has not occurred. Cantey cited the radical Japanese group responsible for the sarin gas attack aerosolized anthrax several times in Tokyo without success. The spores are not spread through person-to-person contact. According to Cantey, the spores can be aerosolized in particles that are deposited in the lungs, where they can survive up to 60 days. Incubation period is unknown, but is thought to be a few days, resulting in fever, chills, gastrointestinal symptoms, chest pain followed in a few hours to days with dyspnea, diaphoresis and shock. Death occurs in nearly all untreated patients within three days. If caught at an early stage of exposure, the patient would be treated and sent home, Cantey said. A highly effective vaccine, approved by the US Food and Drug Administration, requires six doses over 18 months and is available to Armed Services only. It is protective after the first three doses given over four weeks. A large number of antibiotics are effective, but must be taken for 60 days, or until three doses of vaccine have been given. An effective antitoxin is also available. Persons exposed to an anthrax aerosol should change clothes and wash with soap and water. Plague According to Cantey, technical difficulties with the production, storage and dispersal of a plague (yersinia pestis) aerosol make it an unlikely candidate for use by terrorists. “Terrorists would need a pretty sophisticated setup,” he said. The plague is typically flea-borne and produces an infection of the lymph nodes that in some cases causes a fatal pneumonia not easily differentiated from the usual causes of pneumonia. When dispersed by aerosol it produces pneumonia, but does not involve the lymph nodes. Though initial diagnosis would be difficult, once recognized, the pneumonia responds to a variety of antibiotics. Secondary spread due to aerosol droplets can be prevented by the use of a simple surgical mask. Studies indicate that an aerosol of 50 kg of the bacterium over a city of 5 million would produce 150,000 cases of pneumonia, of which 36,000 would be fatal. The bacilli would remain viable for approximately one hour up to 10 kilometers from the drop site. A vaccine was available for the prevention of non-pneumonic forms of plague, but is no longer, according to Cantey. The treatment for those exposed to the bacilli is seven days of antibiotics and is effective. Botulinum toxin Botulinum toxin is the single most poisonous substance known, Cantey said. Little is known about the feasibility of aerosolizing the toxin for use as a bioweapon, though Iran, Iraq, North Korea and Syria are known to have attempted it. The potential effectiveness of the aerosols, which are absorbed through the mucosa of the mouth and respiratory tract, is unknown. It has been estimated that a point-source aerosol release of toxin could incapacitate or kill 10 percent of persons within .5 kilometers downwind. The toxin is quickly detoxified by the chlorine used in drinking water and could not be used to contaminate the water supply, Cantey said. The toxin blocks the transmission of nerve impulses at the neuromuscular junction, causing paralysis. The onset of symptoms after exposure is estimated to occur within 12-80 hours of a large dose. Death is caused by paralysis of the respiratory muscles. A vaccine, though not widely available, exists, as does an equine anti-serum. In addition to Nesmith, Cantey and Johnson, members of the Bioterrorism Preparedness and Response Team are: Michael Schmidt, University Biosafety; George Bryan, Emergency Medicine; Lisa Steed, Pathology Laboratory Medicine; Carole Small, Pharmacy; Paul Moss, Medical Center Security; Joe Avant, Occupational Safety and Health; Caroline Davila, Public Relations; Jeff Hample, Public Safety; Chip Tinley, Emergency Services; Dean Kilpatrick, Crime Victim Research and Treatment Center; Natalie Ward, Clinical Services, MICU; Mary Allen,  Environment of Care coordinator; Robert Winn, MEDUCARE; Phyllis Malpas, Clincal Services, Endoscopy; and John Malmrose, Physical Plant; Janice Rhodes, RN, Clinical Services educator.   Improvements sought in matters of patient confidentiality The Medical Center's Quality Counsel, during a recent meeting, noted an increase in the number of incidents of staff discussing patient information within earshot of other patients, according to Joan Herbert, administrator, Institute of Psychiatry. MUSC typically reports fewer than the norm recorded by the National Resource Corporation (NRC). NRC lists 4.9 percent as normative nationally. During the period January—March, MUSC recorded 4.1 percent, or .8 percent below the normative rate. During the period April—June, however, the number rose to 6.1 percent. The information is gathered through patient surveys. Herbert urged managers to review the data carefully that applies to their area, urging offending areas to look at the operational process in order to prevent future incidents.   Flu vaccine available The MUSC Medical Center Employees’ 2001 flu vaccine program begins on Oct. 24, announced Jodell Johnson, R.N., Infectious Diseases. The vaccine will be available on Wednesdays through Dec. 12 (or until the supply is depleted) from 7:30 a.m. to 4 p.m. in room 286 of the Main Hospital. Vaccinations will also be available on Saturday, Nov. 10 and Sunday, Nov. 18, from 5 – 9 p.m. Infection Control Practitioners are also available to travel to units to administer the vaccine to employees. “Supply should not be an issue this year,” Johnson said.   STAR system undergoing improvement The system for employee time and attendance (STAR) is undergoing improvements, according to Sid McMahon, authority project manager for Kronos (STAR). The current version of the STAR system will no longer be supported after this year. McMahon touted the benefits of the new system, indicating that it will: Function more like other familiar Windows programs, such as Word and Excel Be easier to identify and correct missed punches, exceptions and comments Allow MUSC to modify and develop its own reports because of the open database format Parallel testing and training will begin in October, McMahon said. The targeted “go live” date is Nov. 18. Clock cutover procedures remain to be determined. McMahon said the mandatory training sessions will be two hours in length, with six—10 persons per class. For more information, contact McMahon at 953-8745 or e-mail him at mcmahons@musc.edu.