Controls

There are a variety of controls that should be implemented in order to protect workers from exposure to plague. Workers that may be affected, either during regular work activities or during an emergency response, include, but are not limited to, emergency responders, healthcare workers, laboratory personnel, and others. The Plague Disease and Plague as a Bioweapon sections of this Safety and Health Topic provide extensive information on the hazards associated with plague and applicable controls. Additional guidance specific to various types of workers, and associated issues on recognizing and controlling exposure to plague is provided in the following sections:

• Emergency Responders
• Healthcare Workers, Mortuary Workers, and Others
• Laboratory Workers
• Environmental Persistence, Identification, and Decontamination
• Public Health Response

What personal protective equipment should emergency responders use when responding to a potential bio-attack involving plague? How should workers decontaminate themselves if they think they have been exposed to plague?

In a covert attack involving aerosolized plague, there would be no emergency response activity involving emergency responders. The first evidence that a potential attack had occurred would be diagnosis of the disease among exposed individuals, which would happen several days after the actual release. However, it is possible that emergency responders would be required to respond to a bio-attack incident, such as notification regarding an aerosol dissemination device or other suspicious release. The following references provide additional information regarding PPE, decontamination, and other precautions for emergency responders to consider during such an incident.

• Interim Recommendations for the Selection and Use of Protective Clothing and Respirators Against Biological Agents. Centers for Disease Control and Prevention (CDC). Contains PPE guidance for emergency responders, including information on decontamination.

What PPE, infection control, and related precautions should healthcare workers use when treating patients with plague?

National infection control guidelines prescribe specific precautions to be taken when treating patients with known or suspected plague. These precautions include "Standard", "Droplet" and "Airborne" Precautions, under certain circumstances. Patient isolation and similar precautions may also be necessary. The following references provide detailed information regarding infection control procedures for plague.

• OSHA Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances. OSHA, (January 2005). Provides hospitals with practical information to assist them in developing and implementing emergency management plans that address the protection of hospital-based emergency department personnel during the receipt of contaminated victims from mass casualty incidents occurring at locations other than the hospital. Among other topics, it covers victim decontamination, personal protective equipment, and employee training, and also includes several informational appendices.
• Inglesby TV, Dennis DT, et al. Plague as a Biological Weapon: Medical and Public Health Management. Journal of the American Medical Association (JAMA). May 3, 2000;283(17):2281-90. Considers the prospect of an aerosol release of Y. pestis bacteria, and provides information on epidemiology, infection signs and symptoms, diagnosis and monitoring, vaccination, medical treatment, infection control, environmental decontamination, and more.
• Bioterrorism Readiness Plan: A Template for Healthcare Facilities. The Association for Professionals in Infection Control and Epidemiology (APIC) and the Centers for Disease Control and Prevention (CDC), (April 13, 1999). Provides information on infection control, patient treatment, post-exposure management, decontamination, prophylaxis, and laboratory procedures. Specific information on plague is contained in Section II, pp. 19-22.
• Medical Management of Biological Casualties Handbook, Ninth Edition. U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID). Contains specific information on a number of potential bioterrorist agents.

What precautions are necessary when handling the bodies of patients who have died from plague?

Similar infection control precautions, as listed previously for live individuals, should be implemented for the post-mortem care of plague patients. These precautions apply to all workers performing post-mortem procedures on plague patients, including healthcare workers, morticians, forensic personnel, or others.

• Inglesby TV, Dennis DT, et al. Plague as a Biological Weapon: Medical and Public Health Management. Journal of the American Medical Association (JAMA). May 3, 2000;283(17):2281-90. Considers the prospect of an aerosol release of Y. pestis bacteria, and provides information on epidemiology, infection signs and symptoms, diagnosis and monitoring, vaccination, medical treatment, infection control, environmental decontamination, and more.
• Bioterrorism Readiness Plan: A Template for Healthcare Facilities. The Association for Professionals in Infection Control and Epidemiology (APIC) and the Centers for Disease Control and Prevention (CDC), (April 13, 1999). Provides information on infection control, patient treatment, post-exposure management, decontamination, prophylaxis, and laboratory procedures. Specific information on plague is contained in Section II, pp. 19-22.

How should workers decontaminate themselves if they think they have been exposed to plague bacteria?

The risk of re-aerosolization of plague bacteria from contaminated persons is considered low. In situations where there may have been gross exposure to plague, personal decontamination can be performed by removing contaminated clothing and washing exposed skin with soap and water. Additional decontamination procedures can be found in the following document:

• Bioterrorism Readiness Plan: A Template for Healthcare Facilities. The Association for Professionals in Infection Control and Epidemiology (APIC) and the Centers for Disease Control and Prevention (CDC), (April 13, 1999). Provides information on infection control, patient treatment, post-exposure management, decontamination, prophylaxis, and laboratory procedures. Specific information on plague is contained in Section II, pp. 19-22.

What cleaning and disinfection procedures should be utilized in facilities that treat plague patients or handle the bodies of patients who have died from plague?

The principles of Standard Precautions are generally applied for the cleaning, disinfection, and sterilization of equipment and environmental control in facilities. For more information, refer to the following:

• Bioterrorism Readiness Plan: A Template for Healthcare Facilities. The Association for Professionals in Infection Control and Epidemiology (APIC) and the Centers for Disease Control and Prevention (CDC), (April 13, 1999). Provides information on infection control, patient treatment, post-exposure management, decontamination, prophylaxis, and laboratory procedures. Specific information on plague is contained in Section II, pp. 19-22.

What biosafety procedures should laboratory personnel utilize when handling materials potentially contaminated with plague?

Specific biosafety procedures, including PPE, engineering controls, and additional work practices have been established for handling plague bacteria in laboratories. Refer to the following references for more information.

• Biosafety. Centers for Disease Control and Prevention (CDC), Office of Safety, Health, and Environment. Provides links to material on biosafety regulations, references, and related material.
• Biosafety in Microbiological and Biomedical Laboratories (BMBL), 5th Edition. Centers for Disease Control and Prevention (CDC), (December 2009). This comprehensive reference on laboratory biosafety practices, including specific information on plague, is available in PDF sections.
• Hawley RJ, Eitzen EM Jr. Biological Weapons - A Primer for Microbiologists. Annual Review of Microbiology. Oct 2001;55:235-253. Provides biosafety information for laboratory and field personnel, including discussions on engineering controls, PPE, and decontamination methods.

How long would aerosolized plague from a bioweapon persist in the environment?

According to an analysis by the World Health Organization (WHO), in a worst case scenario, a plague aerosol would be effective and infectious for as long as one hour. Y. pestis is very sensitive to sunlight and heating and does not survive long outside its host.

Can plague be detected in the environment following a bioterrorist attack?

There are various methods that can be utilized for detecting bioterrorist agents, including plague. These include surface and air sample gathering techniques, followed by identification methods such as culture growth or polymerase chain reaction (PCR). However, plague bacteria is very fragile, would not persist for long in the environment, and therefore sampling and analysis would not be considered necessary. In the event of a bioterrorist attack involving plague, local, state, and federal responders would determine the need for sampling based on the specific circumstances associated with the release.

What environmental decontamination would be required following a release of aerosolized plague?

There is no evidence to suggest that environmental decontamination following an aerosol release is warranted. A plague aerosol would only remain viable for approximately 1 hour after release, long before the first cases of pneumonic plague would alert health personnel to a clandestine attack. The following references provide additional information on environmental detection, persistence, and decontamination of plague bacteria:

• Inglesby TV, Dennis DT, et al. Plague as a Biological Weapon: Medical and Public Health Management. Journal of the American Medical Association (JAMA). May 3, 2000;283(17):2281-90. Considers the prospect of an aerosol release of Y. pestis bacteria, and provides information on epidemiology, infection signs and symptoms, diagnosis and monitoring, vaccination, medical treatment, infection control, environmental decontamination, and more.

What actions would be taken by public health authorities in the event of a bioterrorist attack involving plague?

Various actions may be taken by public health authorities to treat and prevent further infections due to a release of plague bacteria. These measures may include mass distribution of medications, surveillance, quarantine, and communication procedures. The following references provide additional information.

• Plague. Centers for Disease Control and Prevention (CDC). Contains extensive information regarding plague, including specific resources on surveillance and investigation.
• Community-Based Mass Prophylaxis: A Planning Guide for Public Health Preparedness. Agency for Healthcare Research and Quality (AHRQ) Publication No. 04-0044, (August 2004). Includes information on surveillance, stockpiling, distribution, dispensing, follow up, and other planning and organizational concerns. Also describes the implementation of a comprehensive operational structure for dispensing/vaccination clinics based on the National Incident Management System (NIMS).
• Strategic National Stockpile (SNS). Centers for Disease Control and Prevention (CDC), Office of Public Health Preparedness and Response. Provides basic information on the SNS system.
• Barbera J, Macintyre A, et al. Large-Scale Quarantine Following Biological Terrorism in the United States: Scientific Examination, Logistic and Legal Limits, and Possible Consequences. Journal of the American Medical Association (JAMA). Dec 5, 2001;286(21):2711-7. Includes information on possible logistics, legal limits, and possible consequences of initiating quarantine procedures. Discusses quarantine vs. isolation, legislative framework, considerations in making quarantine decisions, and recommendations for developing a disease containment strategy.