Regence BCBSO follows the guidelines set forth by the Oregon Health Services Division for the treatment of Anthrax. Download the guidelines here.

Useful links to bioterrorism information:

• Oregon Department of Human Services - Health Division
• The Centers for Disease Control and Prevention (CDC)
• American College of Physicians & American Society of Internal Medicine
• Food and Drug Administration (FDA)

The National Guideline Clearinghouse™ (NCG) is a public resource for evidence-based clinical practice guidelines, NGC is sponsored by the U.S. Agency for Healthcare Research and Quality in partnership with the American Medical Association and the American Association of Health Plans. The following links have been compiled by NGC:

• Centers for Disease Control and Prevention
  • Smallpox vaccination and adverse reactions. Guidance for clinicians.
• Center for Civilian Biodefense Strategies, School of Medicine, Johns Hopkins University
  • (1) Botulinum toxin as a biological weapon: medical and public health management. (2) Botulinum toxin as a biological weapon. (Addendum).
  • (1) Smallpox as a biological weapon: medical and public health management. (2) Smallpox as a biological weapon. (Addendum).
• NGC Guideline Synthesis:
  • Smallpox Vaccination.

CDC Special Smallpox Preparedness Program Update

• Clinician Communication Briefing 6 Summary

Clinical Evaluation Tools for Smallpox Vaccine Adverse Reactions

The Centers for Disease Control and Prevention (CDC) and its partners in the Clinical Immunization Safety Assessment (CISA) network have developed Clinical Evaluation Tools to help health care providers manage patients with potential adverse reactions from smallpox vaccination in the absence of circulating smallpox virus (pre-event setting). These Clinical Evaluation Tools are based on studies conducted before routine childhood US smallpox vaccination was discontinued in 1972 and on expert opinion; they are not entirely evidence-based. The Tools may not apply to all patients with smallpox vaccine adverse reactions and are not intended to substitute for evaluation by a trained clinician. These tools are designed for use during face-to-face patient encounters and are not designed to be telephone triage tools, although they may be useful as a companion to other telephone triage materials. These tools can be used by field clinicians to assess patients with suspected adverse events following smallpox vaccination.

To view these Clinical Evaluation Tools, please visit the CDC web site. The following clinical tools are available:

• Assessment of dermatologic reactions localized to the smallpox vaccination site
• Assessment of dermatologic reactions distant from the vaccination site in toxic/non-toxic contacts and vaccines

CDC anticipates that a neurologic tool (headaches to encephalopathy) and an ophthalmic tool (conjunctivitis to keratitis and mucosal splashes) will be posted in the following weeks.

Centers for Disease Control and Prevention Issues Health Alert on Severe Acute Respiratory Disease Syndrome
Interim Information and Recommendations for Health Care Providers

The Centers for Disease Control and Prevention (CDC) and the World Health Organization have received reports of patients with severe acute respiratory syndrome (SARS) from Canada, China, Hong Kong Special Administrative Region of China, Indonesia, Philippines, Singapore, Thailand, and Vietnam. The cause of these illnesses is unknown and is being investigated. Early manifestations in these patients have included influenza-like symptoms such as fever, myalgias, headache, sore throat, dry cough, shortness of breath, or difficulty breathing. In some cases these symptoms are followed by hypoxia, pneumonia, and occasionally acute respiratory distress requiring mechanical ventilation and death. Laboratory findings may include thrombocytopenia and leukopenia. Some close contacts, including healthcare workers, have developed similar illnesses. In response to these developments, CDC is initiating surveillance for cases of SARS among recent travelers or their close contacts.

Case Finding
Clinicians should be alert for persons with onset of illness after February 1, 2003 with:

• Fever (>38° C)

AND

• One or more signs or symptoms of respiratory illness including cough, shortness of  breath, difficulty breathing, hypoxia, radiographic findings of pneumonia, or respiratory distress

AND

• One or more of the following:
  • History of travel to Hong Kong or Guangdong Province in People's Republic of China, or Hanoi, Vietnam, within seven days of symptom onset
  • Close contact with persons with respiratory illness having the above travel history. Close contact includes having cared for, having lived with, or having had direct contact with respiratory secretions and body fluids of a person with SARS.

Diagnostic Evaluation
Initial diagnostic testing should include chest radiograph, pulse oximetry, blood cultures, sputum Gram's stain and culture, and testing for viral respiratory pathogens, notably influenza A and B and respiratory syncytial virus. Clinicians should save any available clinical specimens (respiratory, blood, and serum) for additional testing until a specific diagnosis is made. Clinicians should evaluate persons meeting the above description and, if indicated, admit them to the hospital. Close contacts and healthcare workers should seek medical care for symptoms of respiratory illness.

Infection Control
If the patient is admitted to the hospital, clinicians should notify infection control personnel immediately. Until the etiology and route of transmission are known, in addition to standard precautions(1), infection control measures for inpatients should include:

• Airborne precautions (including an isolation room with negative pressure relative to the surrounding area and use of an N-95 respirator for persons entering the room)
• Contact precautions (including use of gown and gloves for contact with the patient or their environment)

Standard precautions routinely include careful attention to hand hygiene.  When caring for patients with SARS, clinicians should wear eye protection for all patient contact.

To minimize the potential of transmission outside the hospital, case patients as described above should limit interactions outside the home until the epidemiology of illness transmission is better understood. Placing a surgical mask on case patients in ambulatory healthcare settings, during transport, and during contact with others at home is prudent. 

Treatment
Because the etiology of these illnesses has not yet been determined, no specific treatment recommendations can be made at this time. Empiric therapy should include coverage for organisms associated with any community-acquired pneumonia of unclear etiology, including agents with activity against both typical and atypical respiratory pathogens (2). Treatment choices may be influenced by severity of the illness. Infectious disease consultation is recommended.

Reporting
Healthcare providers and public health personnel should report cases of SARS as described above to their state or local health departments.

For more information contact your state or local health department or the CDC Emergency Operations Center, 770-488-7100.   Updated information will be available at the CDC Web site.

References

1. Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996;17:53-80, and Am J Infect Control 1996;24:24-52.
2. Bartlett JG, Dowell SF, Mandell LA, File Jr, TM, Musher DM, and Fine MJ.  Practice Guidelines for the Management of Community-Acquired Pneumonia in Adults.  Clin Infect Dis 2000;31:347-82. 

HEALTH ALERT NOTICE

FOR INTERNATIONAL TRAVELERS ARRIVING IN OR RETURNING TO THE USA FROM HONG KONG AND GUANGDONG PROVINCE,  PEOPLE'S REPUBLIC OF CHINA, AND HANOI, VIETNAM

TO THE TRAVELER:  During your recent travel, you may have been exposed to cases of severe acute respiratory disease syndrome. You should monitor your health for at least 7 days. If you become ill with fever accompanied by cough or difficulty in breathing, you should consult a physician. To help your physician make a diagnosis, tell him or her about your recent travel to these regions and whether you were in contact with someone who had these symptoms.

TO THE PHYSICIAN: The patient may have recently traveled to Hong Kong or Guangdong Province in the People's Republic of China or Hanoi, Vietnam, where cases of atypical pneumonia have been identified. If you suspect atypical pneumonia (also being called severe acute respiratory disease syndrome [SARS]), please contact your city, county, or state health officer (see the CDC Web site or call the CDC Emergency Operations Center 770-488-7100).

For public inquiries, call Centers for Disease Control and Prevention (CDC) hotline: English 888-246-2675,
Español 888-246-2857, TTY 866-874-2646.