With regard to management of an exposed population, there is no vaccine available in the United States for pneumonic plague. Accordingly, your hospital executives and public health authorities need to have an operations plan that must include procedures on both decontamination and infection control. Speaking of decontamination, once the aerosolized Y pestis has settled on the skin, clothing, or other personal effects, there is no longer a threat of reintroducing the spores into the air. Nonetheless, there is still a threat of bubonic infection through the skin, so decontamination is imperative. The disaster plan should include the following procedures for all new arrivals when there is reasonable certainty that an attack has occurred:
- Instruct patients to remove all clothing and personal effects and place them in a labeled plastic bag.
- Instruct patients to shower thoroughly using soap.
- Instruct personnel to wear caps, masks, gloves, and gowns when handling contaminated objects.
- Cleanse environmental surfaces with chlorine bleach diluted in water, one part to nine.
Second, regarding control and treatment, since we are dealing with an airborne disease, decontamination will not stop the process of infection if it has already begun. Therefore, health-care workers must isolate all infected individuals. Otherwise, the nurses, doctors, other health-care workers, and rest of the community will also become ill. In addition to the patient being placed in a private room, standard respiratory isolation protocols include personnel wearing head cover, mask, gown, and gloves within three feet of the patient and washing their hands before and after contact.
In case of a terrorist attack, the lack of available private rooms would necessitate placing large numbers of infected people in quarantine. This means placing people together for whom there is a reasonable certainty of recent exposure to the same infective substance. For that reason, the terrorism response plan should have predesignated facilities such as gymnasiums and the other types of large, spacious buildings discussed earlier. Furthermore, one important requirement would be the installation of a ventilation system that could filter out droplets that are as small as five microns in diameter. This kind of effort would also require identifying people in the community who express a willingness to volunteer their services in case such situations arose.
To continue, the treatment of pneumonic or bubonic plague is simple and effective. The first choice is doxycycline, 100 mg twice daily for adults and 5 mg per kilogram of body weight in two doses for children. The second choice is ciprofloxacin (Cipro), 500 mg twice daily for adults and 20 to 30 mg per kilogram of body weight in two doses for children. The treatment should begin as soon as there is a reasonable certainty that exposure has occurred.
Finally, diagnostic confirmation requires positive cultures from blood or sputum. That handling of specimens should be restricted to biosafety level 2 or 3 (BSL-2 or -3) laboratories. Again, the plan should include instructions to contact the FBI (or other designated authority) to coordinate the pickup and processing of specimens for testing.