Biological Defence CentreTěchonín, Czech Republic

Planned construction of a highly specialised medical facility providing diagnostics and laboratory identification of biological agents misused for combat and bioterrorist purposes with the capability to isolate and hospitalise persons with high consequence infectious disease was supposed to be one of the cornerstones of the biological defence system of the Czech Republic. This facility, referred to as the Biological Defence Centre (BDC), was established as a branch of the Central Military Health Institute (now the Military Health Institute) on the basis of the Regulation on the creation, reorganisation, relocation and abolition of units and facilities in the Army as of 1 April 2002. The construction of the Centre started the delivering of the international commitments of the „Prague Initiative“ (CZ-DGP 03 - Training and Education Centre for Protection against Weapons of Mass Destruction) and at the same time the national commitment to the new defence capabilities of the Alliance (CZ-BR 02 Specialised Infectious Diseases Hospital), adopted at the NATO Summit in 2002. The Government of the Czech Republic, by its Resolution No. 724/2003, approved the construction of the Biological Defence Centre as a project of strategic character related to the integration and membership of the Czech Republic in NATO. These founding documents are followed by others which are fundamental for the development and use of the Centre and which define its current role within the Czech Republic. These include, among others, Resolution of the National Security Council No. 38 of 15 October 2014 on the isolation of patients with suspected Ebola, Resolution of the Government of the Czech Republic No. 655 of 20 August 2015 on the further use of the BDC, and the subsequent additional Task Letters of the Minister of Defence and the Chief of the General Staff of the Czech Armed Forces

Comprehensive construction of the Centre began in 2001 with an initial plan to finish the entire complex in 2005, which failed, and the construction was suspended in 2006. At that time, the main part was completed, namely the Specialised Infectious Diseases Hospital (SIDH) with a building for the disposal of infectious waters and a building for quarantine stays for persons returning from foreign operations. After several years it was decided that the completion of the Centre was necessary, with a plan for its finalization in accordance with the Concept of the Development of the Military Medical Service until 2025. In addition to the above-mentioned buildings, the completion of the Centre also includes operational, technical and administrative buildings and a science and research building, including laboratories.

Biological Defence Centre TěchonínPremises of the Biological Defence Centre (Source: Biological Defence Centre Archive)

The Biological Defence Centre is a modern specialised military medical facility located in the village of Těchonín in Eastern Bohemia. It is incorporated in the command and control system within the structure of the Military Health Institute as a biological defence department and is directly subordinate to the director of the Institute. The Military Health Institute in Prague is the executive element of the military hygiene and anti-epidemic service and the biological defence system. The Specialised Infectious Diseases Hospital (SIDH) is an organic part of the BDC. The main tasks and objectives of the BDC are isolation and treatment of persons with particularly dangerous and exotic infections, ensuring quarantine stays for soldiers returning from foreign operations from epidemiologically risky areas, conducting biodefence research, training and education of Czech and NATO military and civilian specialists in the specific field of biological protection and providing storage and preparation of special medical, laboratory, detection and identification equipment. The BDC together with the National Centre for Isolation and Treatment of High Consequence Infectious Diseases of the Na Bulovce Hospital in Prague and the State Institute of Health form one of the pillars of the biological protection system for both military and civilan population of the Czech Republic. The collaboration among these institutions is set on the basis of the Czech Republic National Action Plan in case of an event subject to the International Health Regulations and the resulting Directive. The essential prerequisite for the use and development of these capabilities is close inter-ministerial cooperation with the Ministry of Health (International Health Regulations 2005) and the Ministry of Education, Youth and Sports (for science and research). Efforts to achieve the aims and objectives of the BDC to conduct health care culminated in 2016 with the conclusion of an inter-ministerial Implementation Agreement between the Ministry of Health and the Ministry of Defense and the obtaining authorization for the Military Health Institute to provide outpatient, acute inpatient and acute intensive health care services at the Specialized Infectious Diseases Hospital in Těchonín.

History

The village of Těchonín was not chosen for the location of the BDC by chance. The area has served for military purposes since the period before World War I. The current facility in Těchonín was established at the end of the 1960s as the Institute of Immunology and Microbiology of the Military Medical Academy as a special-purpose facility to study the effects of inhaled infections and to test imunoprophylactic means of protection against biological warfare agents. After joining the Biological Weapons Convention in 1972, research focused exclusively on the study of the body‘s immune responses and the effects of antiviral agents. After 1989, there was a significant reduction in research activities and key experts left the facility. In February 1994, the strain bank, which had been the basis for high quality scientific work, was dismantled by decision of the Ministry of Defence because of concerns about its security. After 2000, when biological threats and the concept of the biological defence system of the Czech Republic were reassessed, the development of the military facility into its current form began.

Specialized Infectious Diseases Hospital (SIDH)

The Specialised Infectious Diseases Hospital is currently the main facility of the Biological Defence Centre. The SIDH is a standby facility, the operation of which is initiated by starting the activation process, which is determined by the Activation Plan of the BDC Těchonín, Event No. 578-2/2014-6848. The building itself was originally used for research purposes and was selected for the establishment of an infectious diseases hospital for high consequence infectious diseases (HCID) because of its structural and technical parameters. The SIDH is designed to meet all the organisational, technical and staffing requirements to ensure isolation and care of patients with HCID at the highest level of biosafety and biosecurity standards. All sophisticated technologies had to be incorporated into the existing premises as well as the internal layout even with some compromises. The building is designed as a hospital with two wards on two separate floors. There is an inpatient non intensive care ward, which can accommodate up to 20 patients and the second ward for intensive care capable to admit up to 8 patients. The hospital has its own laboratories for basic heamatological, biochemical and microbiological testing. There is an autopsy room and a morgue for 6 corpses as well. Apart from clinical settings, there is a waste management technology area, storerooms, a laundry room, a waste incinerator and extensive air handling system compartments. The operation of each floor is controlled and monitored by a floor controller worker in addition to the central operating controlling centre, which is accessible only from the clean section. On the top of the building, there is a heliport situated, designed for landing of a helicopter currently of 7 tonnes maximum weight and is certified for day-night landings according to VFR. The infectious parts of the building are separated from the clean area with decontamination rooms. Material movement is always unidirectional, always leaving the infectious environment after sterilization and external decontamination. Personnel enter and exit through their own decontamination pass. Liquid wastes go through several levels of cleaning and decontamination, while solid wastes are destined for disposal in the incinerator. Air exchange is provided by a powerful air handling system with multi-stage filtration. The facility is built to be fully operational in the event of interruptions to water, gas and electricity supplies. All systems are multi-stage backed up. Maximum processes are fully automatic under the control of control center technicians. All personnel (including non medical staff) are obliged to wear the specified personal protective equipment (PPE) while working at infectous part of the hospital. The correct use of PPE must be regularly properly trained. Working in PPE places high demands on thermoregulation, concentration and strict adherence to all hygiene procedures, hence requires more frequent rotation of persons within a work shift. Due to the necessity to leave the infectious area by a relatively long decontamination process in a decontamination chamber designed for 2 persons, the number of workers inside the infectious area is limited regardless of the total number of patients, which further increases the intensity of work in the infectious area. The use of PPE also limits intercommunication, which is successfully solved by the use of communicators for all staff in the infectious section. Medical documentation is kept according to the legislation in force in a combined form - partly in paper form with the need to scan it into the clean section and partly electronically using the hospital information system. The results of laboratory tests are also inserted into the hospital system. In the clean area, there is a technician always present in the floor control operating centre to ensure the correct functioning of the technology and a ward manager nurse who monitors the ward via a camera system, participates in communication with medical staff and patients, provides the necessary materials and services from the clean area and manages the rotation of shifts and staff.

Building for quarantine stays

Another important facility of the Biological Defence Centre is the quarantine building, which can accommodate up to 100 people in several multi-bed rooms. There is also an isolation room for 3 patients. It is currently used for quarantine stays for soldiers after their return from foreign operations.

Research laboratory buildings

The activities of the Biological Defence Centre include biological research, which is carried out in local laboratories. Plans to build a new science and research facility that will meet the highest standards of modern science and the highest level of technical biosecurity are currently underway. At present, some of the laboratories of the specialised infectious diseases hospital are temporarily used for research work.

Mobile Hospitalisation Isolation Unit (MHIU)

The BDC also has a mobile, deployable field element called Mobile Hospitalization Isolatin Unit to isolate patients with high consequence infectious diseases. The unit consists of special isolation chambers with controlled negative pressure for the patients and a facility for the POCT laboratory , which can be placed either in tents or inside the building. The mobile hospitalisation unit includes, for instance, a decontamination tent, a waste water treatment system, a drinking water tanker, electrical generators and a control operating room. The MHIU at its maximal range could accommodate up to 24 patients for acute standard health care and 2 patients for ICU care. The unit is not equipped with wider logistics facilities and hence it must be embodied into the higher medical element during its deployment. Currently, the MHIU is partially deployed in a heated hall and serves as a back-up evacuation area in case of an emergency during activation of the SIDH.

StaffingPersonnel in PPE taking care of a patient in ICU isolation chamber (IsoArk), Exercise Vigorous Warrior 2017 (Source: Biological Defence Centre Archive)

Technology operation and service within the BDC, particularly SIDH, is provided by a staff of 39 employees of the Army-Service Company (AS-PO), which is an operational and technical administrator of some of the buildings and facilities within the Ministry of Defence department. Individuals for a backup team of technicians in the event of SIDH activation are selected from other sites under AS-PO management. Services such as cleaning and security are also provided by Ministry of Defence funded instituwhile catering service is outsourced. The staff of the BDC itself consists of professional medical personnel and members of the logistics, technical support and administrative workers. In total, there are 55 employees – 40 military and 15 civilian staff. Medical staff form 4 doctors, 18 nurses, 7 clinical and research laboratory personnel. In the event of SIDH activation the personnel of the 6th Medical Battalion of Military Medical Agency is to reinforce the BDC. A new feature is the establishment of Active Reserves (AR) unit, which should be fully capable to independently perform tasks in the SIDH and replace the professionals in the event of prolonged hospital operation. The BDC permanent medical staff performs a variety of tasks – they ensure quarantine stays of soldiers after their return from foreign operations, conduct necessary training for AR and other personnel earmarked to work in the SIDH, optimize work processes in the SIDH, create necessary professional guidelines and standards of care, participate in exercises involving MHIU and, last but not least, perform all-military duties. Given the focus of the SIDH, there is also a strong emphasis on professional competence, which they must maintain or improve through work in civilian medical facilities. For physicians, inpatient care specialties are preferred, especially infectious medicine and intensive care medicine, while for nurses, internships and training in intensive care are preferred. Clinical laboratory activities also need to be staffed by erudite personnel.

SIDH activation

As mentioned above The SIDH is a standby facility, the operation of which is initiated only by starting the activation process, which is anchored in the Activation Documentation approved from the level of the Chief of General Staff. Based on interagency agreement, activation must be initiated at the request of the Ministry of Health department within 2 hours after receipt of the signal. The SIDH must be able to achieve initial operational capability 12 hours after initiation, which means admition of 2 intensive care patients, 6 standard care patients, and 30 quarantine patients. There is a designated number of staff on alert for this purpose. At the 72nd hour after the start of activation, full operational capability is to be achieved, which means care for 8 intensive care patients, 20 standard care patients and 100 persons in quarantine.

Real life

Pandemic Covid 19
In the early days of the COVID 19 pandemic, there were discussions about activating SIDH. In the media, the hospital was presented as a classified facility, able to accommodate a large number of patients and relieve local health facilities. Given the situation where COVID 19 spread very quickly throughout the country, the activation of the SIDH was rightly assessed as extremely disadvantageous and unprofitable. Even assuming a reduction in the biosecurity level to open two wards would have required activating more personnel than permanent staff at a time when military medics, including BDC permanent staff, were being used to assist in covid wards of civilian medical facilities across the country and whose withdrawal would have severely weaken staffing of these well established facilities. In addition, the SIDH is primarily designed to isolate patients with HCID and does not have the extensive complement of services available in regular medical facilities that are not used for patients with HCID due to the high risk of spreading the infection (e.g., CT scans, cathetrization, endoscopic examination, surgery etc.). For COVID 19 patients, this inadequacy would have lead to a reduction in the quality of care. Despite that, during the pandemic the BDC contributed to the handling the issue. It has been used for extended quarantine stays for soldiers returning from operations in foreign countries. An important contribution of BDC health workers during the COVID 19 pandemic were training activities (face-to-face consultations, webinars, educational videos) in the use of PPE and assistance with setting up regimens and barrier measures in rest homes and some hospitals. This was initially a spontaneous activity of BDC health workers, which arose from the observation of the lack of information on this issue in the mentioned facilities, and eventually became one of the important tasks for a certain period of time and led to cooperation with Ministry of Labour and Social Affairs.

Short-term hosting of refugees

After sudden evacuation of the Afghan collaborators from their country after NATO troops withdawal, the BDC was succesfully and effectively used as a facility capable to accomodate these refugees temporarily and ensured a high standard of complex care to them.

Challenges

The activation of the SIDH is our biggest challenge. Due to the scale of the unique technologies used, it is difficult in terms of investment to ensure service and especially modernisation of the facility. The SIDH is not an active facility, therefore it does not have experienced staff for hospital administration. It is necessary to ensure a consultative service of experts from other medical specialties in case of need. To be adequately supplied in terms of equipment and materials in case of activation, we need apropriate numbers of logistical support staff, which is not rarely substituted by medical staff. In addition, even the staffing tables allocated to the facility have not been fully occupied. This may be due to the location of the facility in a less accessible region, and in case of physicians it might be also a consequence of the non-conceptual central planning of military medical doctors‘ specialties. The BDC faces the challenge of flexible provision with medical supplies and drugs in case of urgent need, as the military ordering system is relatively rigid. In order to set up the optimal way of working and procedures, it would be advantageous to obtain information on the course and organisation of care for real patients with HCID and the way on how other similar facilities operate, to avoid unnecessary mistakes and expending energy on devising procedures that could have already been successfully implemented and tested.

Conclusion

In conclusion, it is fair to admit that the BDC has not really been used for its main purpose (treating HCID) so far. However, this is logically due to the fact that it is a reserve military medical facility and in normal peacetime conditions the responsibility for the health care is carried by the Ministry of Health and the Chief of Hygiene of the Czech Republic and the civilian health care in the Czech Republic is at such a level that the need has not yet been arisen. Moreover, during the Ebola epidemic there was no importation of cases into the Czech Republic and we have the civilian first line facility to isolate and treat a few patients with HCID. The BDC was prepared however. On the other hand, the BDC has been realistically used several times, although for other but not less important purposes. The experienced medical staff of the BDC was successfully used in the civilian hospitals and social service institutions during the COVID-19 pandemic, see above. Further, the facility has been used to provide quarantine and medical care for the Afghan refugees after their evacuation to the Czech Republic. This shows how flexible the BDC capacity really is and that it can be used in many other unexpected situations in the current turbulent world. These facts and the unpredictability of future threats give the existence of this facility a clearly understandable and unquestionable credit.

_{Author:
LTC Larisa Solichová, M.D.
Biological Defence Centre Těchonín
Military Health Institute Czech Republic
email: solichoval@army.cz}

Date: 07/14/2022

Source: EMMS 2022