CLINICAL HISTORY & EXPOSURE CONSIDERATIONS
OUTBREAK RESPONSE CHECKLIST
Items to consider for creation of a unit specific outbreak response checklist: Ensure preparation for deployments based on most current medical intelligence.
FOR IMMEDIATE ACTION
Identification and Distribution:
Situation: Brief description of the outbreak, including cause (if known) and location. Common things are common: Consider your CCMD of operation and think of endemic illnesses. However, the possibility of an intentional bio-event should be in the differential based on METT-TC(I) [mission, enemy, terrain and weather, troops and support available, time available, civil considerations, and informational considerations].
Mission: Prompt recognition, identification, and the steps to control the outbreak. Identification of cases and prevention of further spread by establishing PPE policy and isolation plans. Base your approach on operational intelligence from your S2 or military medical intelligence if available.
Timings: Effective date and time of any guidance or events of concern. Consider time in theater vs. endemic Incubation periods. A compressed or lack of incubation period is seen with intentional or artificial outbreaks. Presence of a large and rapid case fatality with atypical patterns. Recent unusual events (Fly overs of unknown aircraft or drones, wet or moist surfaces without history of precipitation). Consider wind direction and casualty locations. Analyze the outbreak with respect to outdoor vs. indoor work location or proximity and relation to the HVAC system. What is the source of food and water? Centralized (i.e. U.S. Government provided or locally sourced)
Orders
Identification of cases: Provide any specific guidance. This might include equipment requirements and reporting, personal protective equipment specifications, etc. Provide direction for case identification such as referencing and attaching a case definition. Provide guidance on reporting suspected cases and on the process for confirming cases. Provide guidance on contact tracing (such as questionnaires and interviews). Consider calling specialty advice or U.S. Army Medical Command hot lines. If not established already, start a disease/fever surveillance system.
Reporting
Surveillance system reporting. Amplify information: Inform higher units/PM channels. Provide reporting instructions and follow-up.
Controls
Provide guidance on: Personal hygiene, personal protective equipment, environmental sanitation/disinfection, Isolation of infected individuals, and quarantining of close contacts and exposed individuals as appropriate. Stress the importance of reporting for medical evaluation and care as well as limiting workplace exposures. Reinforce personal and communal hygiene measures IN ALL AREAS such as providing respiratory hygiene stations and cough etiquette. Reinforce and train medical personnel on appropriate standard and transmission-based precautions with tailored donning and doffing procedures to the available PPE. Work to cohort sick or infected populations to prevent spread such as use of dedicated bathrooms and berthing areas, designated eating areas, and restriction to limit group gatherings such as avoid in person meetings, gyms, social events, etc. Identify contaminated areas and manage consequences to prepare for necessary disinfection and waste management.
Actions on outbreak
Confirm outbreak if not already. Implement local outbreak control plan—establish outbreak control team. Implement concurrent control measures (seek advice from issuing HQ FHP where required). Monitor and provide updates. If indicated, consider medical counter measures based on suspected CBRN agent. Consult on need for evacuation or augmentation with specialty CBRNE teams.
Summary
The management of bioincidents will vary according to the severity of the outbreak, population at risk, and vulnerability to spread. It may range from the provision of advice, providing formation to the outbreak control team or the employment of MCM. In any case, deployed medical staff must ensure that an executable and coordinated outbreak control plan is in place and MTFs are able to promptly investigate and control an outbreak of communicable disease.
TCCC CARD BIOTHREAT ADDITION
Consider adding the below information to the TCCC card if biothreat suspected:
Clinical Presentations for Medics to consider when filling out TCCC cards: It is best to have a syndromic approach to the initial work up, Protect self and team. Don PPE.
Initial overview: R/O trauma and need TCCC intervention.
Vital signs: Note presence of Fever, elevated Respiratory and heart rates, Oxygen saturation (qSOFA or NEWS).
Airways: Ventilation/oxygenation: access oropharynx and upper airways, R/O tension pneumothorax and flail chest. Interstitial process?
General: Level of consciousness (alert and oriented, walking, talking without assistance). Level of effort to survive. Note any variation from the norm. Presence of fever, chills, nausea, vomiting, malaise.
Respiratory: Rate, depth of breathing, ventilation, cough (productive or not), lung/breath sounds.
Circulation: R/O major hemorrhage or bleeding, general volume status, capillary refill, note presence of lymphadenopathy.
Neurological: Timing (acute vs. insidious changes), mental status (GCS), Paralysis, Paresthesia’s, Central vs peripheral weakness. Seizure activity or history of seizure activity?
Skin: dry/wet/sweating, Rash: localized or generalized, ecchymosis or bleeding from mucus membranes (eyes, nose, ears, mouth or gums, anus, penis or vagina) are there petechia (generalized or focal) color of the skin, is jaundice present, check the conjunctiva and note findings. Are there bullae or blisters (generalized or focal)?
Gastroenterology: Vomiting (address and prevent aspiration, note hematemesis, etc. of vomitus), access presence of a surgical abdomen. Organomegaly vs. distension. Diarrhea (frequency, contents).
Musculoskeletal: R/O gross trauma and address. Weakness, spasm, fasciculations.
ASSESSMENT & MANAGEMENT OF ASYMPTOMATIC, POTENTIALLY EXPOSED PERSONNEL
DoD personnel should be trained and equipped to managed potentially exposed personnel, in order to preserve life, critical missions and protect the population. This section is designed for a prolonged care environment associated with a large scale bioincident and limited PEP MCM supplies. This flowchart is not scenario or biothreat specific but is intended to provide a simple framework that could be used to create unit specific SOPs to prioritize receipt of PEP based on clinical judgement.
Variations in practice will inevitably and appropriately occur when clinicians consider the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of this flowchart is responsible for evaluating the appropriateness of applying it in the setting of any clinical situation. This flowchart does not supersede any DoD policy.