HA Contingency Plan

for Biological Agent Attack

(Revised 28 August 2008)

 Hospital Authority Title: HA Contingency Plan for Biological
Prepared by: HA Central Committee on Infectious Agent Attack
Diseases & Emergency Responses
Issue Date: Oct 2004
Revision no. : 1 (Dec 04)
Revision no. : 2 (28 Aug 08)

1. Title
HA Contingency Plan for Biological Agent Attack

2. Scope
To prepare health care professionals and Major Incident Control Centers (MICC) personnel with the
emergency response, management and control mechanism in times of biological agent attack. It
should be read together with the following documents:
i. HA Response Plan for Infectious Disease Outbreak
ii. HA Response Plan for Major Incidents
iii. HAHO Operations Circular No. 11/2008 – Reporting Mechanism for Infectious Diseases
iv. HA Contingency Plan for CBRN Incidents (working draft July 2008)
v. HA Operational Plan for HO MICC
vi. Sample Hospital HAZMAT Decontamination Contingency Plan
vii. HA Contingency Plan on Smallpox
viii. Relevant fact sheets on anthrax, smallpox, plague, botulism etc issued by HA CCIDER.

3. The Need for Concern

a) The main concern with intentional use of biological agents is that they cannot be predicted as to
where, when and what agents would be used. Therefore, a timely response depends heavily on an
efficient global intelligence network and risk assessment.

b) Such attacks may be noticed, as for the case of anthrax powder in mail letters, and management
of exposure and decontamination are required. They may, however, be covert, only to be noticed
when cluster of cases occur after the incubation period.

c) HA preparedness is essential as persons exposed to these biological agents are most likely to
seek medical care in hospital. In addition, persons who have been exposed elsewhere might be
incubating the disease and might seek medical attention during their visit to Hong Kong.

4. Definition of a biological agent attack

The Government has defined a biological agent attack as “the use, threatened use, or believed use
of biological agents for Terrorist or Criminal purposes”.

5. Biological Agents
a) Biological agents/ weapons can be described as those whose intended target effects are due to the
infectivity of disease caused by microorganisms and other replicative entities, including viruses,
infectious nucleic acids and prions.

b) There are numerous biological agents that can potentially be abused. However, for preparation
against such an incident, agents are targeted and categorized according to their public-health
impact to cause mass casualties, their ability to disseminate widely, their potential for person-to-
person spread, the availability of treatment options etc., into high risk agents.

c) The targeted agents, currently, are Bacillus anthracis, Yersinia pestis, smallpox and Clostridium
botulinum and its toxin.

6. Infection Control Aspect

The various fundamental elements required of a hospital to deal with such incidents are similar to
those required for prompt and efficient detection and management of any outbreak of infection which
include:

a) Clinical areas, especially AED and ICU:

i. should alert to cases compatible with diseases associated with these biological agents and
 the necessary precautions. Early suspicion based on signs and symptoms, and looking for
any unusual and sudden increase of cases compatible with the use of biological agents,
especially those with a history of travel and possible exposure in other parts of the world.
ii. should review cases of sudden death in otherwise healthy subjects to see if any possibility
with exposure to these biological agents.
iii. familiarize with the reporting and notification mechanism on effective notification of
such suspected cases, especially for those that are not notifiable diseases (Appendix II).
iv. should notify hospital laboratory/ Public Health Laboratory Centre (PHLC) of suspected
cases prior to sending any patient specimens for testing as there may be potential danger
to laboratory workers.
v. in transporting specimens, staff should follow the ‘Guideline on Transport of Clinical
Specimens and Infectious Substances’ (Revised in July 2006).
vi. familiarize with the arrangement with the PHLC of the Centre for Health Protection
(CHP) in submitting patient specimens and suspicious isolates promptly for confirmation.
b) Microbiology Laboratory
i. though specimen would be sent by the police to PHLSB of CHP in the first instance if
police consider the object suspicious, microbiology laboratory should also make available,
as far as possible, tests for the detection of biological agents and standardize testing
protocols (for details, please refer to Appendix I Section 6).
ii. should enhance training on techniques required in the detection and identification of these
biological agents.
iii. familiarize with the arrangement with the PHLC in submitting patient specimens and
suspicious isolates promptly for confirmation.
c) Hospital Infection Control Team (ICT):
i. should be aware of proper isolation and environmental decontamination procedures in
handling patients with suspected exposure or infection due to these biological agents.
ii. should arrange educational seminars to update staff in the necessary precautions in
infections due to these biological agents.
d) Pharmacy:
i. should make available the necessary drug items, including antibiotics, antitoxins and
vaccine, in case their uses are indicated.

7. Notification mechanism and Patient Management

a) Please refer to the attached checklist on management of patient suspected to be contaminated
with biological agents at AEDs (Appendix I).

b) The decontamination flow chart of Plan A & Plan B under the “Medical Management of
HAZMAT Incident Victim” is attached as Appendix III and VI for easy reference.

8. References
- Centers for Disease Control and Prevention, the Hospital Infection Control Practices Advisory
Committee (HICPAC). Recommendations for isolation precautions in hospitals. Am J Infect
Control 1996; 24:24-52.
- Tucker JB. National health and medical services response to incidents of chemical and biological
terrorism. JAMA 1997; 278:362-8.
- Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia as a biological agent. JAMA 2001;
285: 2763-2773.
- Franz D, Jahrling PB, Friedlander AM, McClain DJ, Hoover DL, Bryne WR, et al. Clinical
recognition and management of patients exposed to biological warfare agents. JAMA 1997;
278:399-411.
- Kortepeter MG, Parker GW Potential Biological Weapons Threat. EIDJ Vol 5 No 4 1999
 Appendix I
U

Checklist on management of patients suspected to be contaminated with U

biological agents that require immediate decontamination in AED U

Section Action
1. Scope 1.1 This document deals with patients suspected to be contaminated
with biological agents attending AED that requires immediate
decontamination, which is likely to be due to overt release.
1.2 Possible agents for biological attack include:
- Scheduled infectious diseases under Prevention and Control
of Disease Ordinance: Anthrax, Botulism, Cholera, Plague,
Smallpox, Typhoid Fever
- Other infectious diseases: Brucellosis, Staphylococcal
enterotoxin B, Tularemia and any other rare and fatal
infectious diseases

2. Notification 2.1 Notify HA Head Office Duty Officer (HODO), the Centre for
mechanism Health Protection (CHP) of Department of Health (DH), and
Police if biological agent attack is suspected
a) Use the attached form “Notification of Suspected Cases of
Biological Agent Attacks” and call HODO & CHP (CENO) /
MCO immediately before fax or email. (Appendix 2)

HODO 24 hr pager: 7116 3328 A/C 999

CHP (CENO)
Office hours* : CHP Central Notification Office (CENO)
Tel: 2477 2772
Outside office hours : CHP Medical Control Officer (MCO)
Pager 7116 3300 A/C 9179

* Office hours
(Monday: 9:00am – 1:00pm / 2:00pm – 6:00pm;
Tue – Fri: 9:00am – 1:00pm / 2:00pm – 5:45pm;
Sat/ Sun/ Public Holiday: Closed)

b) Follow the standing notification procedures for infectious diseases

in HAHO Operations Circular 11/2008 dated 14 July 2008.
 Section Action
2.2 Enter information in Accident & Emergency Information System
(AEIS) Disaster Helpdesk Module.

2.3 Patients turn up at AEDs without going through clearance at

the incident site are managed as follows:

a) Clinically non-suspicious – no further action

b) For clinically suspicious cases:
i. arrange appropriate PPE for staff protection;
ii. arrange decontamination of victims with appropriate level of
PPE if required
iii. inform Fire Service Department if mass decontamination is
required (see Section 8 & 9)
iv. notify HODO and CENO CHP and Police (see Section 2.1)
v. enter information in AEIS Disaster Helpdesk Module
vi. for objects brought into AED by the victim, refer to Section
11
vii. inform hospital Infection Control Team

2.4 For the management of clinical specimens (at site or hospital),

please see Section 14.

3. Despatch of medical 3.1 AED may need to despatch medical teams to incident sites. The
team(s) team should only stay at cold zone and handle “clean patients”.
3.2 The team may consider taking appropriate level of PPE just in case
there is change in wind direction or other unexpected accidents.

4. HODO to alert other 4.1 For suspected biological agent attacks involving only a few
hospitals victims, HODO will alert the concerned AED(s).
4.2 If the incident is confirmed and involve many victims who may
arrive at different AEDs, HODO will alert all relevant staff and
hospitals through Alert Channel to standby and prepare for
receiving these victims.
4.3 Head Office Major Incident Control Centre (HO MICC) will be
activated for overall coordination.
 Section Action
5. Clothes for victims 5.1 HA had agreed to supply emergency clothing to non-hospitalised
victims if asked by Police or Fire Services Department.
5.2 One major hospital of each cluster to supply 200 sets of clothes
and some plastic bags (QMH, PYNEH, QEH, PMH, TMH, PWH
& UCH).

6. Collection and testing 6.1 For biological attack, police will deliver the specimen to PHLSB
of Specimen of CHP if police consider the object suspicious.
6.2 If a specimen had been sent by the police to PHLC, CHP would
try to inform the concerned AED of the preliminary results. If no
phone call is received from CHP and it is known that a specimen
had been sent, MCO could be contacted at 7116 3300 A/C 9179
after waiting for 4 hours.

7. Transport of drugs 7.1 Hospital should keep stock of specific drugs and must have a
between hospitals mechanism to allow AEDs to have access to emergency medicine
stocks.
7.2 Hospital should liaise with HAHO Duty Pharmacist of Chief
Pharmacist’s Office at pager 7305 2171 if stock in own hospital
confirmed not enough.
7.3 HAHO Duty Pharmacist should source urgent drug supplies.
7.4 Hospital supplying drugs should arrange messenger to transport
the drugs to the hospital in need.
7.5 Hospital should prepare a standard memo to be carried by the
messenger explaining the purpose of the emergency delivery in
case problem is encountered during the journey.
 Section Action
8. Setting up of 8.1 Hospital should provide a limited decontamination apparatus at
decontamination hospitals prior to the setting up of FSD decontamination facilities.
facilities by FSD near 8.2 Hospitals can request FSD for assistance to set up a
hospitals decontamination facility.
8.3 To prepare for possible incidents, individual hospitals should liaise
with FSD to identify the site for mass decontamination in hospital
compound.
8.4 Hospitals are requested to arrange female staff to assist FSD in the
female decontamination units.

9. AEDs to assess 9.1 To identify location and assess time required for setting up
capacity for facilities (by hospitals itself and/or with assistance from FSD) and
decontamination the capacity available at the time.
9.2 To organize regular training and drills to ensure staff are familiar
with the procedures.

10. Decontamination of 10.1 Use water and soap. No need to use specific solution.
patients 10.2 Hospital should arrange new and clean clothes to patients after
decontamination.

11. Patients’ properties 11.1 Properties of patients should be collected by Police or hospital
security staff with proper labelling.
11.2 Pack clothes and other items in a pink plastic bag making
reference to the bio-hazard arrangement and with patient label.
11.3 Seek Police advice on arrangement of patients’ belongings.

12. Patient privacy 12.1 Individual hospitals should ensure patient privacy for victim
decontamination in hospitals. Set up appropriate cordon by
security guard and with police assistance if necessary.
 Section Action
13. Assess risk of 13.1 Clinicians to determine whether patients are high risk or low risk
patients base on clinical judgement and circumstantial information.
13.2 AEDs to discuss with Cluster or Hospital Infection Control
Officers (ICOs) in case of doubtful situation for suspected
biological agents. HODO will contact CHP for infection control
advice where deemed appropriate.

14. Clinical specimens at 14.1 HA will only take specimen(s) from patients if clinically
AEDs/ hospitals indicated.
14.2 Keep any specimen provided by patients for investigation. Police
will first decide whether an attack is likely. If it is decided that the
incident is a hoax, there will be no further action. If an attack is
likely, police will send the specimen to the Public Health
Laboratory Service Branch (PHLSB) of CHP for laboratory
diagnosis.
14.3 In transporting specimens, staff should follow the ‘Guideline on
Transport of Clinical Specimens and Infectious Substances’
revised in July 2006.

15. Drug treatment 15.1 Refer to relevant fact sheets if available.

15.2 HA and DH to provide mutual backup on drugs.

16. Discharge of Patient 16.1 For Anthrax, HA to follow-up patients who have started
prophylaxis.
16.2 Discharge advice to be given to all patients irrespective of follow-
up (Please refer to CHP website for details:
http://www.chp.gov.hk)
 Section Action
17. Contact tracing 17.1 The Communicable Disease Division, Surveillance &
Epidemiology Branch, CHP will do contact tracing for cases of
biological agent attacks and refer patients to HA for isolation and
treatment. Cluster or Hospital ICO will collaborate with CHP in
tracing in-hospital contacts.
17.2 For suspected case, CHP will follow-up patients who are
asymptomatic, including those who need post-exposure
prophylaxis but had not attended HA’s AED. CHP will refer
patients back to HA if patients have potential medical problems or
relevant symptoms.
18. Decontamination of 18.1 0.5 % Sodium hypochlorite (need more contact time) or 5%
hospital environment& Sodium hypochlorite can be used for hospital environment and
equipment equipment disinfection respectively.
18.2 After decontamination of the last victim, staff in Level C PPEi to
P

conduct a quick environmental decontamination. Then staff in

Level D PPEii to complete the rest of the decontamination process.
P P

18.3 Hospitals to ensure staff safety and provide the following PPEs

i. Level C PPE
- full body “CPF2” suit
- full face mask
- a pair of multi-gas cartridges (with appropriate filter)
- a pair of nitrile gloves
- a pair of PVC safety knee boots
- adhesive tapes

ii. Level D PPE

- protective suit
- half face mask
- protective goggle
- a pair of multi-gas cartridges(with appropriate filter)
- a pair of latex gloves
- a pair of boots

19. Disposal of water 19.1 The used water needs to be diluted many times.
used for decontamination 19.2 Use some neutralising agent such as 0.5% Na Hypochlorite to
detoxify the biological agents.
19.3 Consult Cluster/Hospital ICOs if in doubt.
 Section Action
20. Prevailing 20.1 Standard precautions and transmission-based precautions to be
arrangement of practised.
Admission to hospital 20.2 Inform Hospital Infection Control Team.
20.3 For the following diseases: plague, yellow fever, smallpox and
other agents of biological attack, patients should be sent to HA
Infectious Disease Centre (IDC) at Princess Margaret Hospital
(PMH).
20.4 If HA IDC will receive the first 50 cases before other designated
hospitals to admit the patients. Please refer to the arrangement on
‘Decanting and mobilisation of patients’ in the HA Response
Plan for Infectious Disease Outbreaks.

20.5 If inter-hospital transfers are required, please:

a) alert ambulance staff to take necessary precautions on infection

control.
b) spell out the nature of patient and receiving ward/department
of the patient when making request to FSD; and ensure proper
handover of patients to the ambulance crew on the patient
conditions.
c) For further details on inter-hospital ambulance transfers, please
make reference to HAHO Operations Circular no. 24/2005
dated 12 December 2005 on ‘Classification of Ambulance
Calls for Emergency Inter-hospital Transfers by FSD
Ambulance’.

21. Confirmation of the 21.1 Confirmation should be done by PHLC of CHP.

biological agents
22. Handling of dead 22.1 Follow the latest DH’s guideline on “Precautions for Handling and
patients Disposal of Dead Bodies” at the Infection Control Corner of CHP
website.

-End-
 Appendix II
U

Notification of Suspected Cases of Biological Attacks

(Please phone HODO and CENO/ MCO immediately before fax or email this reporting form)

Note: Reporting of infectious diseases should follow the prevailing HAHO Operations Circular
From:
Hospital Name :
Department/Ward/Unit :
Fax No. : Patient’s
Gum Label (Full label)
Tel No. :

Suspected Agent
Please tick as appropriate :
F Anthrax F Others : (please specify) :
- Possible biological agents are Botulism, Cholera, Plague, Smallpox, Typhoid Fever, Brucellosis,
Q fever, Staphylococcal enterotoxin B, Tularemia, Viral Hemorrhagic fevers and any other rare
and fatal infectious diseases
Suspected agent sample
Please tick as appropriate :
F Available F Not Available
Prophylaxis started in A&E
Please tick as appropriate :
F Yes F No

Contact History
Date and time of contacting the agent : / / (dd/mm/yy) at (time)
Place of contact : Mode of contact :
Symptoms :
Examination findings and investigation findings :

Reporting Doctor: ____________________________ _________________________ ______________________

(Name) (Signature) (Date)

Reply Slip from CHP

Test results by the Public Health Laboratory Centre of the Department of Health are as follows:
Specimen :

Microscopy :

Culture :

Remarks :

________________________________ ___________________________ ________________________

(Name of Microbiologist) (Signature) (Date and Time)

(Revised August 2008)

 Incident Site Appendix III
U

Hospital HAZMAT
Contingency Plan A
(Revised Aug 2008) Explosion/Spillage G. LAB
EOD/Police
PHLC
Victims Specimen
Self-arrive Contact Tracing

FSCC/ HKPF
Fax Initial and
Alert
Notification culture
Hospital On-site Decon. Form results
HODO & CENO/ MCO of CHP
Security by FSD
Victims
Staff
Hospital
Capacity depend on size
2R+8Y or 4R+16Y
Decon. Zone
AED AED AED
Backup by FSD
Sharing of antidotes
between AEDs Hospital
Activate Hospital HAZMAT Management
Clothing -Use H2O + soap
B B

Decontamination Contingency Pharmacy

Personal -Privacy Laboratory
Plan
belongings -Clothing, towel a. High index of suspicious Radiology
& slippers Specialties
b. Protect staff (Level D PPE + mask)
OT
c. Assess victims : Primary survey
Plastic bag After decon, ICU
d. Decontamination if necessary
with label -Use H2O to flush
B B

Security
equip. and floor e. Establish Diagnosis: Secondary survey
-Specimen swab if clinically indicated E&M
Clear by -Self-decon f. Security control : Cordon off/Order Supplies
Police -DOFF PPE g. Prompt treatment ICT
-refer to Fact Sheet
-Treatment if clinically indicated
-Prophylaxis depends on results from DH (for
Return to -Wait for result anthrax)
victims from CHP/ Gov. h. Infection control : Standard precautions and HA PA and
transmission-based precautions
Lab.
Hospital
i. Notify proper authorities :HODO, CHP
and Hospital management MRO (media
-Floor clean by H2O relations
j. Epidemiology:
B B

by staff with level D officer)

AEIS Disaster Module
PPE ICT For Media
CHP
Handling

Dead Admission into ward If Home with FU Home without FU

To Mortuary DAMA if require if not require
To IDC PMH if Plaque, Yellow fever,
Category
3 Precaution Smallpox or other agents of biological Call CHP prophylaxis prophylaxis
attack MCO
Prophylaxis of victims/staff: Vaccination/Antimicrobial (Fact sheet)
Initial Stand-down and Final Stand-down
 Self Arrive Victims Appendix VI
U

Hospital HAZMAT Incident

Instruct victims to
Contingency Plan B Check by Triage Nurse put suspicious object
(Revised Aug 2008) (OT Gown, Glove, Mask) or specimens into
plastic bag and seal
Triage nurse bring along up (or cover it up).
Triage Nurse put on OT cap
with plastic bag and bring EOD/Police
and respiration filter
victims to First Aid Post
(keep a safe distance from
Victims Specimens CHP PHLC
victim).
-Reassurance to victims
Fax Notification Form Contact Tracing
-Instruct patient to remove
his/her overcoat Backup from AED Nurse Station Initial and
-Get history and wait for (Patient registration)
culture results
Decon team arrive. a. Inform HODO and CENO/
MCO of CHP (Inform as
b. Inform Police appropriate)
Decon. Zone Prepare Decontamination Hospital
Management
+ activation of Hospital HAZMAT
Pharmacy
Clothing -Use H2O + B B
Decontamination Contingency Plan Laboratory
a. Assess victims : Primary survey
Personal soap Radiology
belongings -Privacy b. Decontamination if necessary
Specialties
-Clothing, towel c. Establish Diagnosis: Secondary survey OT
-Specimen swab if clinically indicated
& slippers ICU
Plastic bag After decon, d. Security control : Cordon off/Order
Security
with label -Use H2O to flush e. Prompt treatment
B B

E&M
equip. and floor -refer to Fact Sheets
Supplies
Clear by -Self-decon -Treatment if clinically indicated

Police -DOFF PPE -Prophylaxis depends on results from CHP (for

anthrax)

f. Infection control : Standard precautions and

Return to -Wait for result transmission-based precautions
victims from g. Notify proper authorities: HODO, CENO
PHLC/Govt. Lab and Hospital management HA PA and Hospital
-Floor clean by h. Epidemiology: MRO(media relations
H2O by staff with
B B

-AEIS Disaster Module officer)

level D PPE for media handling
-ICT

-CHP

Dead Admission into ward If Home with FU Home without FU

DAMA,
To mortuary To IDC PMH if Plaque, Yellow if require if not require
call CHP
Category 3 fever, Smallpox and other agents MCO prophylaxis prophylaxis
Precaution of biological attack

Prophylaxis of victims/staff: Vaccination/Antimicrobial (Fact sheets)

Legends:

AED Accident and Emergency Department

AEIS Accident & Emergency Information System
CENO Central Notification Office
CHP Centre for Health Protection
DAMA Discharge Against Medical Advice
Decon. Zone Decontamination Zone
DH Department of Health
DHHQ Department of Health Headquarters
EOD Explosive Ordnance Disposal
FAP First Aid Post (outdoor area for initial holding of HAZMAT victims)
FSCC Fire Services Control Center
FSD Fire Services Department
G. LAB. Government Laboratory
GOPD General Outpatient Department
HA Hospital Authority
HAIDC Hospital Authority Infectious Disease Center
HA PA Hospital Authority Public Affairs
HAZMAT Hazardous material
HODO Head Office Duty Officer
HOMICC Head Office Major Incident Control Center
HKPF Hong Kong Police Force
ICB Infection Control branch
ICU Intensive Care Unit
ICT Infection Control Team
MCO Medical Control Officer (Centre for Health Protection)
MRP Media Relations Person
OT Operation Theatre
PHLC Public Health Laboratory Center
PHLSB Public Health Laboratory Service Branch
PMH Princess Margaret Hospital
PPE Personal Protective Equipments
PRO Public Relation Officer
SEB Surveillance and Epidemiology Branch
SOPD Specialist Outpatient Department

Hospital Authority
28 August 2008