Update to Disaster Readiness Advisory #2

October 3, 2001

Disaster Readiness Advisory #2 included a Chemical and Biological Agent Checklist, noting the agents most likely to be used in a terrorist attack.

More recent information indicates that a vaccine for the biological agent "Plague" is no longer available, and a seven day course of antibiotics is the appropriate prophylaxis.

Disaster Readiness

Advisory #3

September 21, 2001


  Bioterrorism Readiness Plan:
A Template for Health Care Facilities


Document prepared by

APIC Bioterrorism Task Force
Judith F. English, Mae Y. Cundiff, John D. Malone, & Jeanne A. Pfeiffer

CDC Hospital Infections Program Bioterrorism Working Group
Michael Bell, Lynn Steele, & J. Michael Miller

(The views expressed in this article by authors Judith F. English and John D. Malone, employed by the Department of the Navy, do not reflect the official policy or position of the Department of the Navy, or the Department of Defense, or the U.S. Government.)


The Association for Professionals in Infection Control and Epidemiology (APIC) recognizes the importance of awareness and preparation for bioterrorism on the part of healthcare facilities. In cooperation with the Centers for Disease Control and Prevention (CDC), APIC offers this Bioterrorism Readiness Plan to serve as a reference document and initial template to facilitate preparation of bioterrorism readiness plans for individual institutions.

This document is not intended to provide an exhaustive reference on the topic of bioterrorism. Rather it is intended to serve as a tool for infection control (IC) professionals and healthcare epidemiologists to guide the development of practical and realistic response plans for their institutions in preparation for a real or suspected bioterrorism attack. Institution-specific response-plans should be prepared in partnership with local and state health departments. Many of the facility bioterrorism planning components may be incorporated into existing disaster preparedness and other emergency management plans. These components may also be useful for identifying and responding to other infectious disease outbreaks in the community. Individual facilities should determine the extent of their bioterrorism readiness needs, which may range from notification of local emergency networks (i.e. calling 911) and transfer of affected patients to appropriate acute care facilities, to activation of large, comprehensive communication and management networks.

Hospitals and clinics may have the first opportunity to recognize and initiate a response to a bioterrorism-related outbreak. Healthcare facilities should have IC policies in place authorizing the healthcare epidemiologist, IC committee chairman, or designee to rapidly implement prevention and control measures in response to a suspected outbreak. Should a bioterrorism event be suspected, a network of communication must be activated to involve IC personnel, healthcare administration, local and state health departments, the Federal Bureau of Investigation (FBI) field office, and CDC (see Reporting Requirements and Contact Information below). Existing local emergency plans should be reviewed, and a multidisciplinary approach outlined that includes local emergency medical services (EMS), police and fire departments, and media relations in addition to healthcare providers and IC professionals. Annual disaster preparedness drills held at many facilities can improve response capacity by incorporating a bioterrorism scenario to test and refine Bioterrorism Readiness Plans at each individual facility.

Section I:   General Categorical Recommendations for Any Suspected
Bioterrorism Event

A.  Reporting Requirements and Contact Information

Healthcare facilities may be the initial site of recognition and response to bioterrorism events. If a bioterrorism event is suspected, local emergency response systems should be activated. Notification should immediately include local infection control personnel and the healthcare facility administration, and prompt communication with the local and state health departments, FBI field office, local police, CDC, and medical emergency services. Each health care facility should include a list containing the following telephone notification numbers in its readiness plan:




FBI FIELD OFFICE 1-___/___-____ *
BIOTERRORISM EMERGENCY NUMBER, CDC Emergency Response Office 770/488-7100

* Telephone numbers for FBI field offices and State health departments are listed in Appendix 1 and 2.

B.  Potential Agents

Four diseases with recognized bioterrorism potential (anthrax, botulism, plague, and smallpox) and the agents responsible for them are described in Section II of this document. The CDC does not prioritize these agents in any order of importance or likelihood of use. Subsequent installments of this document will address additional agents with bioterrorism potential, including those that cause tularemia, brucellosis, Q fever, viral hemorrhagic fevers, and viral encephalitis, and disease associated with staphylococcal enterotoxin B.

C.  Detection of Outbreaks Caused by Agents of Bioterrorism

Bioterrorism may occur as covert events, in which persons are unknowingly exposed and an outbreak is suspected only upon recognition of unusual disease clusters or symptoms. Bioterrorism may also occur as announced events, in which persons are warned that an exposure has occurred. A number of announced bioterrorism events have occurred in the United States during 1998-1999, but these were determined to have been "hoaxes;" that is, there were no true exposures to bioterrorism agents 1. A healthcare facility's Bioterrorism Readiness Plan should include details for management of both types of scenarios: suspicion of a bioterrorism outbreak potentially associated with a covert event and announced bioterrorism events or threats. The possibility of a bioterrorism event should be ruled out with the assistance of the FBI and state health officials.

1.   Syndrome-based criteria
Rapid response to a bioterrorism-related outbreak requires prompt identification of its onset. Because of the rapid progression to illness and potential for dissemination of some of these agents, it may not be practical to await diagnostic laboratory confirmation. Instead, it will be necessary to initiate a response based on the recognition of high-risk syndromes. Each of the agent-specific plans in Section II includes a syndrome description (i.e., typical combination of clinical features of the illness at presentation), that should alert healthcare practitioners to the possibility of a bioterrorism-related outbreak.

2.   Epidemiologic features
Epidemiologic principles must be used to assess whether a patient's presentation is typical of an endemic disease or is an unusual event that should raise concern. Features that should alert healthcare providers to the possibility of a bioterrorism-related outbreak include:

  • A rapidly increasing disease incidence (e.g., within hours or days) in a normally healthy population.
  • An epidemic curve that rises and falls during a short period of time.
  • An unusual increase in the number of people seeking care, especially with fever, respiratory, or gastrointestinal complaints.
  • An endemic disease rapidly emerging at an uncharacteristic time or in an unusual pattern.
  • Lower attack rates among people who had been indoors, especially in areas with filtered air or closed ventilation systems, compared with people who had been outdoors.
  • Clusters of patients arriving from a single locale.
  • Large numbers of rapidly fatal cases. 2
  • Any patient presenting with a disease that is relatively uncommon and has bioterrorism potential (e.g., pulmonary anthrax, tularemia, or plague). 3

D.  Infection Control Practices for Patient Management

The management of patients following suspected or confirmed bioterrorism events must be well organized and rehearsed. Strong leadership and effective communication are paramount.

1.   Isolation precautions
Agents of bioterrorism are generally not transmitted from person to person; re-aerosolization of these agents is unlikely 4. All patients in healthcare facilities, including symptomatic patients with suspected or confirmed bioterrorism-related illnesses, should be managed utilizing Standard Precautions. Standard Precautions are designed to reduce transmission from both recognized and unrecognized sources of infection in healthcare facilities, and are recommended for all patients receiving care, regardless of their diagnosis or presumed infection status 5. For certain diseases or syndromes (e.g., smallpox and pneumonic plague), additional precautions may be needed to reduce the likelihood for transmission. See Section II for specific diseases and requirements for additional isolation precautions.

Standard Precautions prevent direct contact with all body fluids (including blood), secretions, excretions, nonintact skin (including rashes), and mucous membranes. Standard Precautions routinely practiced by healthcare providers include:

  • Handwashing
    Hands are washed after touching blood, body fluids, excretions, secretions, or items contaminated with such body fluids, whether or not gloves are worn. Hands are washed immediately after gloves are removed, between patient contacts, and as appropriate to avoid transfer of microorganisms to other patients and the environment. Either plain or antimicrobial-containing soaps may be used according to facility policy.
  • Gloves
    Clean, non-sterile gloves are worn when touching blood, body fluids, excretions, secretions, or items contaminated with such body fluids. Clean gloves are put on just before touching mucous membranes and nonintact skin. Gloves are changed between tasks and between procedures on the same patient if contact occurs with contaminated material. Hands are washed promptly after removing gloves and before leaving a patient care area.
  • Masks/Eye Protection or Face Shields
    A mask and eye protection (or face shield) are worn to protect mucous membranes of the eyes, nose, and mouth while performing procedures and patient care activities that may cause splashes of blood, body fluids, excretions, or secretions.
  • Gowns
    A gown is worn to protect skin and prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, excretions, or secretions. Selection of gowns and gown materials should be suitable for the activity and amount of body fluid likely to be encountered. Soiled gowns are removed promptly and hands are washed to avoid transfer of microorganisms to other patients and environments.

2.   Patient placement
In small-scale events, routine facility patient placement and infection control practices should be followed. However, when the number of patients presenting to a healthcare facility is too large to allow routine triage and isolation strategies (if required), it will be necessary to apply practical alternatives. These may include cohorting patients who present with similar syndromes, i.e., grouping affected patients into a designated section of a clinic or emergency department, or a designated ward or floor of a facility, or even setting up a response center at a separate building. Designated cohorting sites should be chosen in advance by the IC Committee (or other appropriate decision-making body), in consultation with facility engineering staff, based on patterns of airflow and ventilation, availability of adequate plumbing and waste disposal, and capacity to safely hold potentially large numbers of patients. The triage or cohort site should have controlled entry to minimize the possibility for transmission to other patients at the facility and to staff members not directly involved in managing the outbreak. At the same time, reasonable access to vital diagnostic services, e.g., radiography departments, should be maintained.

3.   Patient transport
Most infections associated with bioterrorism agents cannot be transmitted from patient-to-patient. Patient transport requirements for specific potential agents of bioterrorism are listed in Section II. In general, the transport and movement of patients with bioterrorism-related infections, as for patients with any epidemiologically important infections (e.g., pulmonary tuberculosis, chickenpox, measles), should be limited to movement that is essential to provide patient care, thus reducing the opportunities for transmission of microorganisms within healthcare facilities.

4.   Cleaning, disinfection, and sterilization of equipment and environment
Principles of Standard Precautions should be generally applied for the management of patient-care equipment and environmental control.

  • Each facility should have in place adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces and equipment, and should ensure that these procedures are being followed.
  • Facility-approved germicidal cleaning agents should be available in patient care areas to use for cleaning spills of contaminated material and disinfecting non-critical equipment.
  • Used patient-care equipment soiled or potentially contaminated with blood, body fluids, secretions, or excretions should be handled in a manner that prevents exposures to skin and mucous membranes, avoids contamination of clothing, and minimizes the likelihood of transfer of microbes to other patients and environments.
  • Policies should be in place to ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed, and to ensure that single-use patient items are appropriately discarded.
  • Sterilization is required for all instruments or equipment that enter normally sterile tissues or through which blood flows.
  • Rooms and bedside equipment of patients with bioterrorism-related infections should be cleaned using the same procedures that are used for all patients as a component of Standard Precautions, unless the infecting microorganism and the amount of environmental contamination indicates special cleaning. In addition to adequate cleaning, thorough disinfection of bedside equipment and environmental surfaces may be indicated for certain organisms that can survive in the inanimate environment for extended periods of time. The methods and frequency of cleaning and the products used are determined by facility policy.
  • Patient linen should be handled in accordance with Standard Precautions. Although linen may be contaminated, the risk of disease transmission is negligible if it is handled, transported, and laundered in a manner that avoids transfer of microorganisms to other patients, personnel and environments. Facility policy and local/state regulations should determine the methods for handling, transporting, and laundering soiled linen.
  • Contaminated waste should be sorted and discarded in accordance with federal, state and local regulations.
  • Policies for the prevention of occupational injury and exposure to bloodborne pathogens in accordance with Standard Precautions and Universal Precautions should be in place within each healthcare facility. 5

5.   Discharge management
Ideally, patients with bioterrorism-related infections will not be discharged from the facility until they are deemed noninfectious. However, consideration should be given to developing home-care instructions in the event that large numbers of persons exposed may preclude admission of all infected patients. Depending on the exposure and illness, home care instructions may include recommendations for the use of appropriate barrier precautions, handwashing, waste management, and cleaning and disinfection of the environment and patient-care items.

6.   Post-mortem care
Pathology departments and clinical laboratories should be informed of a potentially infectious outbreak prior to submitting any specimens for examination or disposal. All autopsies should be performed carefully using all personal protective equipment and standards of practice in accordance with Standard Precautions, including the use of masks and eye protection whenever the generation of aerosols or splatter of body fluids is anticipated. Instructions for funeral directors should be developed and incorporated into the Bioterrorism Readiness Plan for communication. 5

E.  Post Exposure Management

1.   Decontamination of Patients and Environment
The need for decontamination depends on the suspected exposure and in most cases will not be necessary. The goal of decontamination after a potential exposure to a bioterrorism agent is to reduce the extent of external contamination of the patient and contain the contamination to prevent further spread. Decontamination should only be considered in instances of gross contamination. Decisions regarding the need for decontamination should be made in consultation with state and local health departments. Decontamination of exposed individuals prior to receiving them in the healthcare facility may be necessary to ensure the safety of patients and staff while providing care. When developing Bioterrorism Readiness Plans, facilities should consider available locations and procedures for patient decontamination prior to facility entry.

Depending on the agent, the likelihood for re-aerosolization, or a risk associated with cutaneous exposure, clothing of exposed persons may need to be removed. After removal of contaminated clothing, patients should be instructed (or assisted if necessary) to immediately shower with soap and water. Potentially harmful practices, such as bathing patients with bleach solutions, are unnecessary and should be avoided. Clean water, saline solution, or commercial ophthalmic solutions are recommended for rinsing eyes. If indicated, after removal at the decontamination site, patient clothing should be handled only by personnel wearing appropriate personal protective equipment, and placed in an impervious bag to prevent further environmental contamination. Decontamination requirements for specific potential agents of bioterrorism are listed in Section II. 6

Development of Bioterrorism Readiness Plans should include coordination with the FBI field office. The FBI may require collection of exposed clothing and other potential evidence for submission to FBI or Department of Defense laboratories to assist in exposure investigations.

2.   Prophylaxis and post-exposure immunization
Recommendations for prophylaxis are subject to change. Current recommendations for post-exposure prophylaxis and immunization are provided in Section II for relevant potential bioterrorism agents. However, up-to-date recommendations should be obtained in consultation with local and state health departments and CDC. Facilities should ensure that policies are in place to identify and manage health care workers exposed to infectious patients. In general, maintenance of accurate occupational health records will facilitate identification, contact, assessment, and delivery of post-exposure care to potentially exposed healthcare workers.

3.   Triage and management of large scale exposures and suspected exposures
Each healthcare facility, with the involvement of the IC committee, administration, building engineering staff, emergency department, laboratory directors and nursing directors, should clarify in advance how they will best be able to deliver care in the event of a large scale exposure. Facilities should incorporate into their Bioterrorism Readiness Plan processes for triage and safe housing and care for potentially large numbers of affected individuals. Facility needs will vary with the size of the regional population served and the proximity to other healthcare facilities and external assistance. Triage and management planning for large-scale events may include:

  • Establishing networks of communication and lines of authority required to coordinate on-site care.
  • Planning for cancellation of non-emergency services and procedures.
  • Identifying sources able to supply available vaccines, immune globulin, antibiotics, and botulinum anti-toxin (with assistance from local and state health departments).
  • Planning for the efficient evaluation and discharge of patients.
  • Developing discharge instructions for patients determined to be non-contagious or in need of additional on-site care, including details regarding if and when they should return for care or if they should seek medical follow-up.
  • Determining availability and sources for additional medical equipment and supplies (e.g., ventilators) that may be needed for urgent large-scale care.
  • Planning for the allocation or re-allocation of scarce equipment in the event of a large-scale event (e.g., duration of ventilator support of terminally afflicted individuals).
  • With assistance from the Pathology service, identifying the institution's ability to manage a sudden increase in the number of cadavers on site. 3,7

4.   Psychological aspects of bioterrorism
Following a bioterrorism-related event, fear and panic can be expected from both patients and healthcare providers. Psychological responses following a bioterrorism event may include horror, anger, panic, unrealistic concerns about infection, fear of contagion, paranoia, social isolation, or demoralization. IC professionals should develop prior working relationships with mental health support personnel (e.g., psychiatrists, psychologists, social workers, clergy, and volunteer groups) and assist in their collaboration with emergency response agencies and the media. Local, state, and federal media experts can provide assistance with communications needs.

When developing the facility Bioterrorism Readiness Plan, consider the following to address patient and general public fears:

  • Minimize panic by clearly explaining risks, offering careful but rapid medical evaluation/treatment, and avoiding unnecessary isolation or quarantine.
  • Treat anxiety in unexposed persons who are experiencing somatic symptoms (e.g., with reassurance, or diazepam-like anxiolytics as indicated for acute relief of those who do not respond to reassurance).

Consider the following to address healthcare worker fears:

  • Provide bioterrorism readiness education, including frank discussions of potential risks and plans for protecting healthcare providers.
  • Invite active, voluntary involvement in the bioterrorism readiness planning process.
  • Encourage participation in disaster drills.

Fearful or anxious healthcare workers may benefit from their usual sources of social support, or by being asked to fulfill a useful role (e.g., as a volunteer at the triage site). 8

F.  Laboratory Support and Confirmation

This part of the document is subject to updates due to current work underway to improve the diagnostic capacity of laboratories to isolate and identify these agents. Facilities should work with local, state and federal public health services to tailor diagnostic strategies to specific events. Currently the Bioterrorism Emergency Number at CDC is at the Emergency Response Office, NCEH, 770/488-7100.

1.   Obtaining diagnostic samples
See specific recommendations for diagnostic sampling for each agent. Sampling should be performed in accordance with Standard Precautions. In all cases of suspected bioterrorism, collect an acute phase serum sample to be analyzed, aliquotted, and saved for comparison to a later convalescent serum sample.

2.   Laboratory criteria for processing potential bioterrorism agents
To evaluate laboratory capacity in the United States, a proposal is being made to group laboratories into one of four levels, according to their ability to support the diagnostic needs presented by an event. The proposed laboratory levels in the planning stages are:

  • Level A:   Clinical laboratories - minimal identification of agents
  • Level B:   County/State/other laboratories - identification, confirmation, susceptibility testing
  • Level C:   State and other large facility laboratories with advanced capacity for testing - some molecular technologies
  • Level D:   CDC or select Department of Defense laboratories, such as U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) - Bio Safety Level (BSL) 3 and 4 labs with special surge capacity and advanced molecular typing techniques.

3.   Transport requirements
Specimen packaging and transport must be coordinated with local and state health departments, and the FBI. A chain of custody document should accompany the specimen from the moment of collection. For specific instructions, contact the Bioterrorism Emergency Number at the CDC Emergency Response Office, 770/488-7100. Advance planning may include identification of appropriate packaging materials and transport media in collaboration with the clinical laboratory at individual facilities.

Patient, Visitor, and Public Information

Clear, consistent, understandable information should be provided (e.g., via fact sheets) to patients, visitors, and the general public. During bioterrorism-related outbreaks, visitors may be strictly limited.

A well-designed healthcare facility Bioterrorism Readiness Plan should clarify the lines of authority and flow of communication. To minimize the anticipated responses of fear, confusion and anger, healthcare facilities should plan in advance the methods and channels of communications to be used to inform the public. IC professionals working with the IC committee and administration should coordinate in advance with state and local health agencies, local emergency services, and local broadcast media systems to decide how communication and action across agencies will be accomplished. Failure to provide a public forum for information exchange may increase anxiety and misunderstanding, increasing fear among individuals who attribute non-specific symptoms to exposure to the bioterrorism agent.



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