Anthrax: Public health response plan for Australia

Appendix

Page last updated: 05 December 2012

Appendix


APPENDIX 1: Anthrax Case Definitions
APPENDIX 2: Patient specimen collection
APPENDIX 3: Anthrax vaccine information for laboratory staff
APPENDIX 4: Anthrax vaccine consent form
APPENDIX 5: Environmental sampling after ‘suspicious unidentified substances’ incidents
APPENDIX 6: Environmental sample analysis request sheet
APPENDIX 7: Initial specimen processing
APPENDIX 8: Culture of B. anthracis
APPENDIX 9: Environmental decontamination
APPENDIX 10: Key Contacts
APPENDIX 11: Acronyms
APPENDIX 12: References

APPENDIX 1: Anthrax Case Definitions

Reporting

Only confirmed cases should be notified.

Confirmed case

A confirmed case requires either:
  • laboratory definitive evidence; OR
  • laboratory suggestive evidence AND clinical evidence.

Laboratory definitive evidence

Isolation of Bacillus anthracis organisms, confirmed by a reference laboratory.

Laboratory suggestive evidence

Demonstration of Bacillus anthracis –like organisms by microscopic examination of stained smears; OR
  • Positive nucleic acid test for Bacillus anthracis.top of page

Clinical evidence

Cutaneous:
painless skin lesion evolving over 1–6 days from a papular through a vesicular stage, to a depressed black eschar invariably accompanied by oedema that may be mild to extensive; OR
Gastrointestinal:
abdominal distress characterised by nausea, vomiting, haematemesis, bloody diarrhoea, anorexia, abdominal pain, ascites and septicaemia, and followed by fever; OR
Oro-pharyngeal:
painless, necrotic oral or oro-pharyngeal ulceration which may be pseudo-membranous, accompanied by dysphagia, dyspnoea, cervical adenopathy and cervical oedema and fever; OR
Inhalational:
prodromal illness resembling viral infection followed by rapid onset of hypoxia, dyspnoea, cyanosis and high temperature, with radiological evidence of mediastinal widening and perhaps, pleural effusions; OR
Subcutaneous:
severe soft tissue infection, including necrotising fasciitis or severe cellulitis and abscess formation or severe sepsis in association with intravenous drug use; OR
Meningeal:
acute onset of high fever, convulsions, loss of consciousness and meningeal signs and symptoms in association with one of the other clinical syndromes.

APPENDIX 2: Patient specimen collection

Suspected cutaneous anthrax:

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  • For vesicular lesions, two swabs of vesicular fluid from an unopened vesicle, one for culture and the second for Polymerase Chain Reaction (PCR). Aseptically collect vesicular fluid on sterile dry swabs from previously unopened vesicles.
  • For eschars, the edge should be lifted carefully and two swab samples rotated underneath and submitted, one for culture and the second for PCR.
  • For ulcers, the base of the lesion should be sampled with two saline moistened swabs and submitted, one for culture and the second for PCR.
  • Blood cultures obtained prior to antimicrobial therapy, if the patient has evidence of systemic symptoms.
  • A full thickness punch biopsy of a papule or vesicle including adjacent skin should be obtained from all patients with a lesion being evaluated for cutaneous anthrax, to be submitted in 10 percent formalin for histopathology, special stains and immunohistochemistry (IHC). Biopsies should be taken from both vesicle and eschar, if present.
  • In patients not on antibiotic therapy or on therapy for <24 hours, a second biopsy specimen should be submitted for culture and PCR
  • Acute and convalescent serum samples for serologic testing.

Suspected inhalation anthrax:

  • Blood cultures obtained prior to antimicrobial therapy.
  • Pleural fluid, if present, for culture and PCR. Collect >1 ml of a pleural fluid into a sterile container
  • CSF, in patients with meningeal signs, for microscopy, culture and PCR.
  • Pleural and/or bronchial biopsies for IHC.
  • Acute and convalescent serum samples for serologic testing.
  • Autopsy tissues from fatal cases; See Post Mortem Specimens section (Page 11) and only proceed when sporulation has not occurred in the patient. For microbiology investigation and PCR analysis and histopathology, special stains, and IHC. The preferred specimens would be a minimum of 8 blocks and fixed tissue representing different pulmonary sites listed below:
    • Hilar lung with regional lymph nodes, bronchi, and trachea
    • Peripheral pulmonary parenchyma from both lungs
    • Specimens should be included from the major organs, particularly any organs showing significant gross or microscopic pathology.

Suspected gastrointestinal anthrax:

  • Blood cultures obtained prior to antimicrobial therapy.
  • Ascites fluid for culture and PCR.
  • Stool or rectal swab for culture and PCR. An aseptically collected stool sample may be obtained in addition to or instead of a rectal swab. Stool: collect 5-10g in a clean, sterile, leak-proof container. Rectal swab: insert swab 2.5cm beyond the anal sphincter. Rotate swab to sample anal crypts.
  • Oropharyngeal lesion, if present, for culture and PCR. Using a sterile moist swab (pre-moistened with sterile saline), aseptically swab surface and edges of suspected lesions in the oropharynx or buccal cavity, or on the tongue, tonsils or posterior pharyngeal wall, for culture and PCR.
  • Acute and convalescent serum samples for serologic testing.
  • CSF, in patients with meningeal signs, for microscopy, culture and PCR.
  • Autopsy tissues from fatal cases; See Post Mortem Specimens section (Page 11) and only proceed when sporulation has not occurred in the patient. For microbiology investigation and PCR analysis and histopathology, special stains, and IHC
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All specimens should be transported to the laboratory within an hour of collection, at room temperature. If a delay in processing is expected, specimens should be held at 2-8oC, or on wet ice, and processed within 24 hours. In addition, specimens that are not heavily contaminated should also be cultured in an enrichment broth and plated after 24 hours.

APPENDIX 3: Anthrax vaccine information for laboratory staff

There is no anthrax vaccine approved by the Therapeutic Goods Administration for human use in Australia. There are, however, vaccines made and approved for use in the United States of America and the United Kingdom, which may be available for use in Australia under exceptional circumstances. The US vaccine is known as Anthrax Vaccine Adsorbed (AVA) and is made by Bioport (Lansing, Michigan). The UK vaccine is produced by CAMR (Centre for Applied Microbiology and Research, Porton Down, UK). Neither is currently available in Australia for civilian use, but may, should circumstances change, be provided for the vaccination of laboratory staff at particular risk of exposure to B. anthracis in the course of their work.

Vaccination schedule

The US vaccine is given intramuscularly as a 0.5mL dose at 0, 2, and 4 weeks, with booster doses at 6, 12 and 18 months, followed by yearly 0.5ml boosters. The UK vaccine is given intramuscularly at 0, 3 and 6 weeks, with a fourth dose administered 6 months after the third, followed by yearly 0.5ml boosters.

Efficacy of the vaccine

Because of the rarity of the naturally occurring disease, few clinical trials have been undertaken with anthrax vaccine. One study in the early 1960s showed a protective efficacy of 92.5% against anthrax, predominantly the cutaneous form.

Adverse reactions to the vaccine

Adverse reactions to the vaccine are generally mild and self-limiting, and include a painful injection site, and less often, fever. In one study of the UK [22] vaccine, 18% of military personnel suffered incapacitation for up to 120 hours. In 74% of these (13% of the study group), pain at the injection site prevented lifting or driving for 48 hours. Serious adverse reactions are very rare (76 per 1.8 million doses in a US study), and not all causally associated with the vaccine. Two deaths were recorded but were not proven to be related to vaccine use.

Significance of the fact that anthrax vaccine is not registered for use in Australia

There has been no application under the Therapeutic Goods Act 1989 to register an anthrax vaccine for general use in Australia. Accordingly, the Therapeutic Goods Administration has not conducted a detailed evaluation of the safety and efficacy of the vaccine. For this reason, although vaccination of certain risk groups (e.g. some laboratory workers) may be desirable, it is necessary to obtain written informed consent from each person before vaccination commences.
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If you have any concerns about the vaccine or the vaccination procedure, you should ask about these before agreeing to be vaccinated.

APPENDIX 4: Anthrax vaccine consent form (sample only)


Surname: _________________________________________________________

Given names: ______________________________________________________

Address: __________________________________________________________

Date of birth: _____________________________Sex: _____________________

I, ______________________________________________________ (Full name)
hereby consent / do not consent * to the administration of anthrax vaccine for myself. (* strike out whichever is not applicable)

In addition, I confirm that I understand that this product is not included on the Australian Register of Therapeutic Goods, and that it is not approved for sale in Australia, but that it has been approved for importation.

I have read the information titled ‘Anthrax vaccine information sheet for laboratory staff’ and dated ____________ relating to the use of anthrax vaccine and understand the information presented.

I understand that I am being offered the AVA/CAMR* vaccine (* strike out whichever is not applicable).

I have discussed the use of this vaccine and the reasons that it is being offered to me with a medical officer, and have been offered the opportunity to ask questions.

I understand that I may refuse to accept anthrax vaccine without prejudicing my medical care, but that I may not be permitted to undertake certain work related activities for occupational health and safety reasons.

I understand that in accepting anthrax vaccine I do so without prejudicing my right to workers’ compensation entitlements and I have signed this form in the presence of a health-care professional.

Signed: ___________________________________Date:____________________

I confirm that I have discussed this vaccine and its use with the above-named person.

Signed: ___________________________________Date:____________________

Printed name: ______________________________________________________

Position/Designation: _________________________________________________
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APPENDIX 5: Environmental sampling after ‘suspicious unidentified substances’ incidents

Introduction

Following the suspected release of B. anthracis spores, it may be necessary to collect environmental samples for forensic and/or public health purposes.

Detailed instructions are contained within the National Counter-Terrorism Committee Suspicious Substances/Packages Assessment Guidelines, September 2011, as well as the Public Health Laboratories Network Guidelines on the handling of suspicious substances (“White powders”), September 2006.

Outlined below is a model process for collecting, packaging and delivery of samples for microbiological testing, although it is recognised that some procedures may vary between jurisdictions.

Emergency services responsibilities at the site

  • A risk assessment of the nature of the sample and its priority will be made by the emergency services, in consultation with police and intelligence agencies before collection.
  • It is the responsibility of the emergency services to sample the substance, and package and transport the sample to the laboratory in a safe manner (i.e. approved packaging).
  • All samples must be screened for explosives, radiation and chemicals prior to arrival at the microbiology laboratory.
  • If the sample is urgent, an emergency services officer should accompany the sample to the laboratory and the laboratory informed to expect the sample.
  • All requests for microbiological identification are to be approved in writing by an appropriate public health unit in the jurisdiction.
  • Emergency services are responsible for safe decontamination of the area after sampling.

Collection method

  • Any sampling should be conducted by persons who are competent in sample collection for the suspect agent wearing the appropriate personal protective clothing
  • Most PHLN laboratories prefer a small sample (no more than 2 g) of the suspicious substance. In order to reduce the risk of aerosolisation, suspicious powders should generally be prepared in the field using distilled water to provide added protection to medical laboratory scientists. Sampling requirements should be confirmed with the relevant PHLN laboratory.
  • The sample should be collected into a sterile yellow-top transparent container (MSU container, or 10mL centrifuge tube) for shipment to the laboratory. Small quantities may be collected using a sterile sampling brush or sterile (wooden) spatula.
  • When collecting material, every effort will be made to avoid surface contamination of the sampling container.

Sample packaging and labelling

  • Primary containers should be clearly labelled and placed in a rigid outer container that complies with packing instruction no. 602 of the IATA Dangerous Goods Regulations. The National Guideline mentions “Ziploc” bags. These are not safe as sole containers for transport. The sample must always be placed into a clean plastic container in accordance with IATA Dangerous Goods Regulations.
  • The transport container must be labelled clearly with all relevant identifier information.
  • The transport container should then be immersed in a 0.5% hypochlorite solution for a period of 10 minutes to decontaminate its outer surface.
  • The transport container should then be wiped down to remove residual hypochlorite and placed in an outer transport container.
  • For all submissions the outer transport container should be placed into a fresh leak proof non-contaminated outer plastic (clip seal or equivalent) bag suitable for handling without personal protective attire.
  • When necessary (e.g. when the sample is to be stored en route) continuity of evidence requires tamper evident sealing of the package.
  • The accompanying documents should be placed with the transport container and the ensemble prepared for dispatch to the receiving laboratory.
  • A properly completed laboratory request form (or similar) must accompany each separate sample ensemble.
  • The request form should contain a description of the incident and confirm that a risk assessment has been performed by a competent person, and the substance has been screened for chemical, explosive and radioactive hazards
  • The request form should indicate to whom the report is sent and to whom copies are sent. Full contact details of the receiving person/entity must be supplied.
  • Any materials used in the sampling process other than the materials going to the laboratory for analysis should be placed in an appropriate (biohazard) container for incineration.

Sample transport

The receiving laboratory must be notified prior to sample transport.top of page
  • The sample will be collected from the incident site, risk assessed and if necessary screened for potential hazards prior to transport by a designated police officer to preserve the chain of evidence.
  • The sample will be will be registered with a unique forensic number and transported by Police.
  • Upon arrival at the microbiology laboratory the sample will receive a unique laboratory number.
  • The sample will be given directly to a responsible staff member who will accept the specimen for processing.
  • The sample will be taken directly to the microbiology laboratory, bypassing Specimen Reception. The sample should be handed directly to the investigating microbiologist. The sample will be booked into a specific register for suspicious substance samples and the emergency services officer should make note of this information and the laboratory number assigned to the sample. Details of the incident and samples should be placed on an appropriate emergency services’ register so that laboratory results may be forwarded to a known location and person e.g. forensic register, police register. It is recognised that procedures will differ slightly between States.

Chain of custody

Each sample must be accompanied by a “chain of custody form”. In general the chain of custody form must contain:
  • Date and time of the incident.
  • Officer in charge of the incident.
  • Brief description of the incident.
  • Description of the sample contained within e.g., powder, granules.
  • Details of all parties having responsibility for collection, packaging and transport of the specimen.
  • Name of receiving laboratory person.
  • Time of receipt (as there may be a delay in transit).
  • Contact numbers for result communication.

Note: If it is only a sample of the suspect substance and not the whole item itself that is being tested at the PHLN laboratory, the sample can be destroyed during analysis. When there are only trace amounts of the substance in total, this must be documented on the request form so that the sample may be retained by police as evidence.

APPENDIX 6: Environmental sample analysis request sheet (sample only)

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Name of person requesting analysis: ___________________________________________

Your reference number: _____________________________________________________

Name of organisation: ______________________________________________________

Address of organisation: ____________________________________________________

Contact telephone number: ___________________ Fax number: ____________________

Contact email: ____________________________________________________________

Analysis required (sampler’s comments, known hazards): __________________________

________________________________________________________________________

The following must be answered before a sample can be accepted.

Result of screening assessment and how determined:

Who made this assessment? Name ____________________________________________

Does this sample contain explosive material?

Does the sample contain electronic circuitry?

Has a radiation test been carried out on the sample?

Has on-site chemical testing occurred?

Has the bioterrorism potential of this incident been assessed by a public health medical officer?
Name of medical officer: _____________________________________________________

Has a reference laboratory scientist been contacted?

Name of scientist: __________________________________________________________

Are there fatalities or people in hospital, on medication, isolated or quarantined?

Date submitted: ______________ Signature: ____________________________________

REQUEST APPROVED BY AUTHORISED PUBLIC HEALTH OFFICER

Name in full: ______________________________________________________________

Signature: ________________________________________________________________

Position: _________________________________________________________________

APPENDIX 7: Initial specimen processing

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APPENDIX 8: Culture of B. anthracis

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APPENDIX 9: Environmental decontamination

Planning the disinfection process

Following the deliberate release of B. anthracis spores, environmental clean-up and decontamination will be undertaken by emergency services personnel. The operational procedures and methods employed, including the disinfection technology, will be dependent on a number of factors. These include the size of the contaminated zone, the nature of the material contaminated, the cost-effectiveness of decontamination versus removal and destruction of contaminated items, and the sensitivity of contaminated items to the physical and chemical agents employed. For these reasons, disinfection strategies should be developed on a case-by-case basis, with the relevant State/Territory emergency services agency taking the lead role.
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All stakeholders should be consulted throughout the disinfection planning phase. These should include, as appropriate, owners and lessees of contaminated premises; police and security agencies; State and local government health and environmental protection authorities; staff representatives (e.g. unions); technical experts such as architects, engineers, microbiologists and air-conditioning experts; owners of personal property on the premises; and other affected members of the public.

A site safety plan should be developed to protect workers inside and outside the contaminated area, as well as the surrounding population. The manager overseeing the remedial work should notify employees, employee representatives and members of the public who may be affected, of the nature and scope of the work and its likely duration.

Due to the relative physical and chemical resistance of B. anthracis spores, disinfection is likely to be a multi-stage process, which may involve the use of several different processes and technologies. Primary considerations in selecting appropriate technologies are: the safety and effectiveness of the processes, and maintaining the functional integrity of the materials being disinfected. The various methods differ in their effectiveness on different materials—e.g. chemically reactive vs. chemically non-reactive, or porous vs. non-porous—and under different environmental conditions. Some processes may damage particular items. The best approach will have to be considered during the planning phase taking into account efficacy, product integrity and OH&S issues in respect of the operators and others who may come into contact with the contaminated materials. For example, some fumigants will adversely affect electronic devices; gamma radiation will be unsuitable for undeveloped photographic or X-ray film; and aqueous disinfectants will damage paper-based materials. In such situations, other methods should be considered, or a decision taken to destroy the item.

Although disinfection may be undertaken off-site, consideration should be given in the planning phase to the potential for spreading contamination, and to the costs of packaging and transporting contaminated materials. Should off- site disinfection be considered, the responsible authority will have to meet all State and local statutory requirements in respect of the packaging, labelling, transport and storage of biological hazards. The extent of contamination and the means whereby the organism was spread are critical in isolating affected areas and selecting appropriate decontamination methods. For example, if spores have been widely dispersed through an air-conditioning system, disinfection may involve extensive isolation and fumigation. In contrast, if the contamination is limited to a small area and spores are not likely to become airborne, then minimal isolation and disinfection methods may suffice.

The need to disinfect building systems such as air-conditioning systems and lift wells, personal effects, sensitive items such as computers and irreplaceable items such as historical archival material should also be considered in developing a disinfection plan. Techniques used on building surfaces or items may not be effective for disinfecting ventilation systems, and if spores have been dispersed into the air, disinfection of the ventilation system may be vital to the effectiveness of the program. Disinfection plans for personal items should be developed in consultation with their owners.

Consideration should also be given to the presence of potentially hazardous materials in personal effects or other workplace materials. In areas where there is a high potential for spread of contamination—e.g. ventilation systems, lift wells and high-traffic hallways—it may be appropriate to decontaminate those areas even though sampling may show no evidence of contamination.

Finally, the disinfection plan should include a carefully developed strategy for confirming that viable B. anthracis has been eliminated from the site, and that chemical residues from the disinfecting agents are removed or reduced to levels that meet statutory requirements.

Preparation for disinfection

In most situations, it will be necessary to isolate the contaminated area to prevent the spread of contamination by movement of workers or equipment. The nature of the isolation methods used will depend on factors such as the size of the affected area, the types of surfaces, and the extent of contamination. The decision to establish an isolation area should be taken in consultation with relevant experts such as architects, engineers and public health officers. If the area of contamination is small, discrete and confined to limited surfaces, it may suffice to cordon off the area. Larger areas can be
closed off using polypropylene sheeting, tape or other products. If needed, a higher level of isolation can be achieved by creating negative air pressure to prevent the outward flow of air. A negative pressure environment can be produced by using portable HEPA-filtered air units in the affected areas.

It may also be necessary to seal the air-conditioning ducts serving the affected area. Plastic sheeting, tape or other products may be used to minimise the movement of air in to or out of these ducts. The ducts may be sealed within the affected room or at external locations as long as the selected disinfection process (e.g. fumigation) will effectively disinfect the duct work between the room and the external seal. An air-conditioning specialist should be consulted before beginning this work.
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The disinfection process should address:
  • Hidden sources of contamination. Desktop computers and other objects with internal fans that draw air into the case have filters or electrostatic devices to control dust intake. These filters, the equipment chassis or some of the electronic components may be reservoirs of contamination. If the processes selected may damage the item or may not penetrate all locations, these items should be disinfected by a different process. Alternatively, excessive amounts of dirt or other organic material on the surface to be disinfected may decrease the effectiveness of the selected disinfection method. Using certain techniques, such as HEPA vacuuming, to remove some of the dirt and debris may reduce the need to perform more aggressive chemical decontamination. For example, accumulated dust inside the central processing unit due to the operation of internal fans in a desktop computer may adversely affect the efficacy of disinfection, and it may be advisable to open the case and clean the overtly dirty components before disinfecting the machine.
  • Removal of items. To reduce the potential spread of contamination, items should be decontaminated in place if possible. If the selected process will destroy an item that must be retained, then the item may be removed and disinfected elsewhere. In this situation, the item must be packaged, transported and stored in a manner which complies with jurisdictional statutory requirements.

Disinfection methods

Disinfection methods can be divided into three categories:
  • Surface disinfection methods are used to treat spores on hard, non-porous surfaces such as desks, walls and hard flooring.
  • Fumigation involves the use of an antimicrobial gas to destroy aerosolised spores and those adhering to surfaces.
  • Other decontamination products are primarily used in disinfection chambers or other specialised equipment. There are also physical methods such as peelable coatings, surface removal, dismantling and removal of selected components may be appropriate for materials unable to be decontaminated by other means.

Selection of the appropriate method will require an evaluation of the specific site conditions and nature of contamination. Other considerations include the conditions required for effective application (e.g. humidity for fumigations or pH for certain surface treatments), how the method will affect the area or item being treated, and the risks associated with use (e.g. physical, chemical and toxicological properties of the product).

Methods used on surfaces
Methods used to treat surfaces include vacuuming, which can be used on both porous and non-porous surfaces for the physical removal of spores, and liquid antimicrobial products (e.g. aqueous chlorine dioxide, sodium hypochlorite, and a combination of hydrogen peroxide and peroxyacetic acid), which are primarily used for non-porous surfaces to eliminate and/or reduce the number of spores.

High efficiency particulate (HEPA) vacuuming
Cleaning surfaces with a vacuum cleaner equipped with a HEPA filter fulfils two purposes: removal of dirt that may reduce the effectiveness of subsequent disinfection, and reduction of the number of spores to be killed by subsequent disinfection. A variety of vacuum assemblies are needed for the many surfaces and shapes to be treated.

Where possible the HEPA vacuum cleaner should be systematically applied to collect spores from the area of lowest contamination to the area of highest contamination, and from the highest to lowest elevation. The collected dust and material may be sampled to determine the presence of spores. After vacuuming, the area should be disinfected using another method and then sampled to determine whether any contamination remains.

A limitation of this method is that it only removes surface contamination (e.g. spores in the interior of a computer may not be removed effectively). The operator must also avoid allowing the exhaust to stir the air in the affected room.

Liquid antimicrobial products for impermeable surfaces
Liquid antimicrobial products may be used to inactivate spores on impermeable surfaces only. These products can be applied by pouring, mopping or spraying and include oxidising agents such as aqueous chlorine dioxide, sodium hypochlorite, hydrogen peroxide and peroxyacetic acid.

Several factors should be considered when deciding which liquid antimicrobial products to use and how to apply them. Each product affects surfaces differently in terms of corrosiveness, staining and residue. These products will be effective only if the directions for use of the product are followed precisely (e.g. mixing directions, application method and dosage rate, pre-cleaning of surfaces, and contact time).
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Fumigation
Fumigation is defined as the application of a gas to reduce or eliminate spores in an indoor area (e.g. a room or building). In addition to disinfecting a variety of surfaces, fumigants are able to disinfect airborne spores that surface disinfectant would miss. Examples of fumigants are chlorine dioxide and paraformaldehyde.

Selecting a specific fumigant requires an assessment of the chemical and physical properties of the various chemicals, their toxicological properties, and their compatibility with other materials. They also vary in the rate at which they dissipate and their ability to penetrate various materials.

Determining whether to use fumigation and which fumigant to use also requires an understanding of the preparation and application requirements.

The success of fumigation will depend on:
  • containing the fumigant by thoroughly sealing the area to be decontaminated
  • understanding how liquid spills or organic material may absorb or chemically inactivate the fumigant
  • developing means to distribute the fumigant evenly
  • achieving the required temperature, humidity, and other conditions prior to commencement of fumigation
  • monitoring the fumigant concentration to ensure that the required concentration is maintained for the required amount of time (taking into account potential loss of fumigant to organic items such as carpeting)
  • monitoring outside the area for leaks during the fumigation process and during subsequent aeration
  • following all directions and precautions specified by the manufacturer and statute for the product and in the site-specific disinfection plan
  • allowing sufficient time following fumigation for aeration (i.e. off-gassing) of fumigant and by-products formed during the treatment process, and
  • using qualified operators.

Other disinfection products
Methods that can be used to disinfect specific items outside the affected area or environment include chemical sterilisation and irradiation. Factors that have been used to evaluate these options include the cost and risk of transporting contaminated materials, the potential for spread of contamination, the availability of mobile equipment to bring the technology to the site, and the availability of facilities capable of performing the task.

Chemical sterilisation
In chemical sterilisation, chemicals such as ethylene oxide, chlorine dioxide or paraformaldehyde are used to kill spores on discrete items placed in a chamber. Sufficient aeration of the items following treatment is necessary to remove residual amounts of the sterilant and any toxic by-products that may have formed. For effective disinfection, specific conditions of temperature, relative humidity, concentration and duration of application must be observed for the particular sterilant used.

Irradiation
Numerous irradiation methods, including cobalt-60 and electron beam technologies, can be used to inactivate B. anthracis. These methods are likely to be available only off-site. They may destroy magnetic media or chemical (e.g. silver bromide) based photographic film, and are usually expensive.

Validation of the disinfection process

Expert advice should be sought as to suitable method(s) for validating the various disinfection or sterilisation processes used. Validation methods involving culture of material for B. anthracis should only be undertaken by public health reference laboratories.

For items disinfected in an off-site sterilisation or disinfection chamber, it may be appropriate to place surrogate spore test strips in the chamber along with the items. Expert microbiological advice should be sought as to the nature of the test strips, the number that should be used, and their placement in the chamber (or inside the items). Each situation should be assessed on a case-by- case basis. While, for example Bacillus stearothermophilus spore test strips may be appropriate for validation of a steam sterilisation process, they may not be appropriate for some other methods. B. stearothermophilus spores may be more sensitive to certain chemicals than are B. anthracis spores. Post-sterilisation validation tests may be necessary, based on microbiological advice.
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To determine whether disinfection of a site has been effective, a thorough round of environmental sampling should be performed following the disinfection process. Post-decontamination sampling strategies should be developed in consultation with an industrial hygienist. Samples should be cultured for B. anthracis by a public health reference laboratory.

Environmental sampling should be done in all disinfected sites, regardless of the disinfection method used. In areas that are disinfected by fumigation, it may be appropriate to place spore indicator strips in strategic locations prior to fumigation, to assess effectiveness of the process. Results of the culture of both environmental samples and biological indicators, if used, should be evaluated to determine the effectiveness of the process. If the first round of disinfection does not eliminate all viable B. anthracis spores, it may be advisable to use a different method for the second round of disinfection.

Reoccupation of the premises

On completion of the disinfection process, controls on access to the premises may be removed. Those using the premises should, however, be advised that while rigorous disinfection methods have been used to remove viable anthrax spores, and that follow-up validation of the process has been undertaken, there can be no absolute guarantee that all viable spores of B. anthracis have been eliminated. They should be advised that, while the risk of acquiring anthrax within the building is low, they should obtain medical advice promptly if they experience symptoms consistent with anthrax. Frequent communication with building occupants and users throughout the disinfection process provides transparency and builds trust, facilitating confidence in the efficacy of the work.

In consultation with microbiologists, public health officers and industrial hygienists, a periodic monitoring plan should be developed and implemented; including a ‘sunset clause’ for cessation of the program should no positive findings be made. This should include regular environmental sampling and culture for B. anthracis. Strategic sampling sites should be identified in the planning phase. These might include, for example, air-conditioning filters and the heat sinks or other internal components of computers where large amounts of dust accumulate.

APPENDIX 10: Key Contacts

Jurisdiction Contact details
Australian Government
Chief Medical Officer
Department of Health and Ageing
(02) 6289 8408
National Incident Room
(02) 6289 3030

ACT
Chief Health Officer
ACT Health
(02) 6205 2108

Northern Territory
Chief Health Officer
Northern Territory Department of Health and Families
(08) 8999 2768
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NSW
Chief Health Officer
NSW Health Department
(02) 9391 9181

Queensland
Chief Health Officer
Queensland Health
(07) 3234 1137

South Australia
Chief Health Officer
South Australia Health
(08) 8226 6006

Tasmania
Chief Health Officer
South Australia Health
(03) 6222 7729

Victoria
Chief Health Officer
Department of Health
(03) 9096 5174
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WA
Chief Health Officer
Department of Health
(08) 9222 2207

APPENDIX 11: Acronyms

  • ADF - Australian Defence Force
  • AFP - Australian Federal Police
  • AHMAC - Australian Health Ministers Advisory Committee
  • AHPPC - Australian Health Protection Principal Committee
  • AQIS - Australian Quarantine and Inspection Service
  • ARTG - Australian Register of Therapeutic Goods
  • ASIO - Australian Security Intelligence Organisation
  • AUSASSISTPLAN - Australian Government Overseas Disaster Assistance Plan
  • AUSVETPLAN - Australian Veterinary Emergency Plan
  • AVA - Anthrax vaccine adsorbed
  • BT - Bioterrorism
  • CAMR - Centre for Applied Microbiology and Research
  • CBRN - Chemical, Biological, Radiological and Nuclear
  • CBRN-INC - CBRN incident of national consequence
  • CCC - Crisis Coordination Centre
  • CCEAD - Consultative Committee on Emergency Animal Diseases
  • CDC - Centers for Disease Control and Prevention
  • CDNA - Communicable Diseases Network Australia
  • CDNA-JEG - Communicable Diseases Network Australia – Jurisdictional Executive Group
  • CHO(s) - Chief Health Officer(s)
  • CMO - Chief Medical Officer
  • CNS - Central nervous system
  • COMDISPLAN - Australian Government Disaster Response Plan
  • CPU - Central processing unit
  • CSF - Cerebrospinal fluid
  • CVO - Chief Veterinary Officer
  • CXR - Chest X-ray
  • DAFF - Department of Agriculture, Fisheries and Forestry
  • DFAT - Department of Foreign Affairs and Trade
  • DIAC - Department of Immigration and Citizenship
  • DoHA - Department of Health and Ageing
  • DoTARS - Department of Transport and Regional Services
  • EMA - Emergency Management Australia
  • FAQ - Frequently asked questionstop of page
  • FSANZ - Food Standards Australia New Zealand
  • HCW(s) - Health-care worker(s)
  • Health CBRN-INC Plan - Domestic Response Plan for Chemical, Biological and Radiological Incidents of National Consequence
  • HEPA - High efficiency particulate air
  • HIMU - Health Issues Media Unit
  • IATA - International Air Transport Association
  • IDC - Interdepartmental committee
  • IDER - Infectious Disease Emergency Response Working Group
  • IDETF - Inter-Departmental Emergency Task Force
  • IGA - Intergovernmental agreement
  • IHC - Immunohistochemistry
  • IM - Intramuscular
  • IV - Intravenous
  • LD1 - Lethal dose for 1% of exposed individuals
  • LD10 - Lethal dose for 10% of exposed individuals
  • LD50 - Lethal dose for 50% of exposed individuals
  • MSU - Mid-stream urine
  • N - Number
  • NATA - National Association of Testing Laboratories, Australia
  • NCTP - National Counter-Terrorism Plan
  • NHEMRN - National Health Emergency Media Response Network
  • NHEMS - National Health Emergency Management Sub-committee
  • NHS - National Health Security
  • NHSQL - National High Security Quarantine Laboratory
  • NIR - National Incident Room
  • NMS - National Medical Stockpile
  • o - Oral (by mouth)
  • OHS - Occupational Health and Safety
  • PC - Physical containment (laboratory facility classification)
  • PCR - Polymerase chain reaction
  • PEP - Post Exposure Prophylaxis
  • PHLN - Public Health Laboratory Network
  • PPE - Personal protective equipment
  • SITF - Special Incident Task Force
  • SOPs - Standard Operating Procedures
  • SSBA - Security Sensitive Biological Agent
  • TGA - Therapeutic Goods Administration
  • VAERS - Vaccine Adverse Event Reporting System
  • WHO - World Health Organization

    APPENDIX 12: References

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    1. Heyworth, B., et al., ‘Anthrax in the Gambia: an epidemiological study’, British Medical Journal, 1975. 4 (11 October): pp. 79-82.
    2. Brachman, P.S., A.M. Friedlander, and J.D. Grabenstein, ‘Anthrax vaccine’, in Vaccines, S.A. Plotkin and W.A. Orenstein, eds, 2004, Elsevier Inc.: pp. 887-903.
    3. Inglesby, T.V., et al., ‘Anthrax as a biological weapon: updated recommendations for management’. Journal of the American Medical Association, 2002. 287(17, 1 May): pp. 2236-52.
    4. Turnbull, P.C.B., ‘Anthrax’, in Zoonoses, S.R. Palmer, L. Soulsby, and D.I.H. Simpson, eds.1998: pp. 3-16.
    5. Meselson, M., et al., ‘The Sverdlovsk Anthrax Outbreak of 1979’, Science, 1994. 266(18 November): pp. 1202-8.
    6. Nhonoli, A.M., ‘Cutaneous anthrax in Moshi District’, East African Medical Journal, 1960. 37(1, January): pp. 37-43.
    7. Seboxa, T. and J. Goldhagen, ‘Anthrax in Ethiopia’, Tropical and Geographical Medicine, 1989. 41(2): pp. 108-12.
    8. Sirisanthana, T., et al., ‘Outbreak of oral-oropharyngeal anthrax: an unusual manifestation of human infection with Bacillus anthracis’, American Journal of Tropical Medicine and Hygiene, 1984. 33(1): pp. 144-50.
    9. Roche, K.J., M.W. Chang, and H. Lazarus, ‘Cutaneous anthrax infection’, New England Journal of Medicine, 2001. 345(22): p. 1611.
    10. Salmon, D., Special report on diseases of the horse, 1896, Government Printing Office, Washington DC. pp. 526-30.
    11. Dembek, ZF, editor; Medical Aspects of Biological Warfare. Office of the Surgeon General, Borden Institute. 2007
    12. Hupert, N., et al., ‘Accuracy of screening for inhalational anthrax after a bioterrorist attack’, Annals of Internal Medicine, 2003. 139: pp. 337-45.
    13. Peters, C.J. and D.M. Hartley, ‘Anthrax inhalation and lethal human infection’, The Lancet, 2002. 359(23 February): pp. 710-11.
    14. Wilkening, DA; Sverdlovsk revisited: Modeling human inhalation anthrax; PNAS 103(20:7589-94, 2006
    15. Jernigan, D.B., et al., ‘Investigation of bioterrorism-related anthrax, United States, 2001: epidemiologic findings’, Emerging Infectious Diseases, 2002. 8(10): pp. 1019-28.
    16. Holty JC, et al. Systematic review : a century of inhalational anthrax cases from 1900 to 2005; Annals of Internal Medicine144(4):270-280; 2006
    17. CIDRAP fact sheet; Anthrax: Current, comprehensive information on pathogenesis, microbiology, epidemiology, diagnosis, treatment and prophylaxis. Website accessed 2008.05.27
    18. Ndyabahinduka, D.G.K., et al., ‘An outbreak of human gastrointestinal anthrax’, Annali dell’Istituto di sanita, 1984. 20(2-3): pp. 205-8.
    19. Kanafani, Z.A., et al., ‘Endemic gastrointestinal anthrax in 1960s Lebanon: clinical manifestations and surgical findings’, Emerging Infectious Diseases, 2003. 9(5): pp. 520-5.
    20. Swartz, M.N., ‘Recognition and management of anthrax: an update’, New England Journal of Medicine, 2001. 345(No. 22, 29 November): pp. 1621-6.
    21. Phonboon, K., et al., ‘Anthrax outbreak in Udon Thani’, Communicable Disease Journal, 1984. 10: pp. 207-20.
    22. Lakshmi, N. and A.G. Kumar, ‘An epidemic of human anthrax: a study’, Indian Journal of Pathology and Microbiology, 1992. 35(1): pp. 1-4.
    23. National anthrax outbreak control team. An outbreak of anthrax among drug users in Scotland, December 2009 to December 2010. Health Protection Scotland 2011
    24. Knox D, Murray G, Millar M, et al. Subcutaneous anthrax in three intravenous drug users. J. of Bone & Joint Surg (Br) 2010;93-B,414-417
    25. Abramova, F.A., et al., ‘Pathology of inhalational anthrax in 42 cases from the Sverdlovsk outbreak of 1979’, Proceedings of the National Academy of Sciences, USA, 1993. 90(March): pp. 2291-4.
    26. Australian Government Department of Health and Ageing. Security Sensitive Biological Agents Regulatory Scheme Guideline 3: Handling a person or animal, or samples from a person or animal, affected by an SSBA. 2011. Available from SSBA Guidelines website.
    27. Australian Government Department of Health and Ageing. Security Sensitive Biological Agents Regulatory Scheme Guideline 8: Transporting SSBAs and suspected SSBAs. 2011. Available from SSBA Guidelines website.
    28. Therapeutic Guidelines: Antibiotic, 14th edition, 2010. Therapeutic Guidelines Limited
    29. CDC, ‘Use of anthrax vaccine in the United States: recommendations of the Advisory Committee on Immunization Practices’, MMWR, 2000. 49 (RR15): pp. 1-20.
    30. Sever, J.L., et al., ‘Safety of anthrax vaccine: a review by the Anthrax Vaccine Expert Committee (AVEC) of adverse events reported to the Vaccine Adverse Event Reporting System (VAERS)’, Pharmacoepidemiology and Drug Safety, 2002. 11: pp. 189-202.
    31. Hayes, S. and M. World, ‘Adverse reactions to anthrax immunisation in a military field hospital’, Journal of the Royal Army Medical Corps, 2000. 146: pp. 191-5.
    32. Enstone, J.E., et al., ‘Adverse medical events in British service personnel following anthrax vaccination’, Vaccine, 2003. 21: pp. 1348-54.
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