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With advancements of science and developments in microbial genetics, there is heightened concern regarding the abuse of these discoveries for acts of terrorism and war. Effective preparedness is a crucial asset to have in the management of an attack.  Nurses and other healthcare practitioners play a vital role in this preparedness. It is essential that they have some knowledge of the prevention and control practices as well as knowledge of the various biological, chemical, nuclear, and radioactive agents that may be used in a potential intentional attack. Arming healthcare providers with expertise in preparedness, management, and treatment will allow for a smoother transition of action if a public health emergency ensues. It is vital for nurses to understand bioterrorism in nursing as nurses would play a major role in treatment of individuals affected by such an event. 

Introduction

The threat of biological warfare may seem like a farfetched idea, something only one may see in a movie. However, with the recent events of our world, it seems more and more likely. With advancements of science and developments in microbial genetics, there is heightened concern regarding the abuse of these discoveries for acts of terrorism and war. Although regulations and procedures are securing the exposure or release of such pathogens in research laboratories exist, there is still risk involved. 

Effective preparedness for bioterrorism in nursing staff is a crucial asset to have in the management of an attack.  Nurses and other healthcare practitioners play a vital role in this preparedness. It is essential that they have some knowledge of the prevention and control practices as well as knowledge of the various biological, chemical, nuclear, and radioactive agents that may be used in a potential intentional attack. Arming healthcare providers with expertise in preparedness, management, and treatment will allow for a smoother transition of action if a public health emergency ensues.  

“Bioterrorism is the intentional release or threat of release of biologic agents (i.e., viruses, bacteria, fungi, or their toxins) to cause disease or death among the human population or food crops and livestock to terrorize a civilian population or manipulate a government (1).” 

Preparedness for bioterrorism in nursing staff will improve the ability to detect and control other infectious diseases.  

“Weapons of mass destruction are atomic explosive weapons, radioactive material weapons, lethal chemical, and biological weapons, that are intended to harm a large number of people (2).” 

Characteristics of Bioterrorist attack (1): 

• The infectious agent used is likely to be uncommon and not prevalent to the region.  
• May be genetically modified to make it resistant to vaccines and medications.  
• It was produced in a way that enhances its transmission.  
• Has the characteristics of a mass casualty event. 
• Have a short and predictable incubation period. 
• The target population should have little or no immunity against the organism. 
• Little or no treatment should be available with the native population. 
• It can be either covert or announced and can be caused by any pathogenic microorganism.  

 Weapons of mass destruction have the potential to (2): 

• Produce a single moment of enormous destructive effect capable of killing millions of civilians, jeopardizing the natural environment, and altering the lives of future generations through their effects.  
• Cause death or serious injury of people through toxic or poisonous chemicals  
• Disseminate disease-causing organisms or toxins to harm or kill humans, animals or plants.  
• Deliver nuclear explosive devices, chemical, biological, or toxin agents to use them for hostile purposes or in armed conflict. 

Classification of Biological Weapons  

Several bioterrorist agents that are classified as the most dangerous include anthrax, botulism, plague, smallpox, tularemia, and viral hemorrhagic fevers. Bioterrorist attacks can also come in the form of food or waterborne agents (1). Biological weapons are classified into different categories by the Center for Disease Control (CDC). Agents of bioterrorism are classified into three groups Category A, Category B, and Category C. They are based on the agents’ priority to cause a risk to national security and how easily they can be disseminated.  

Category A: High Priority Agents

• Easily disseminated  
• Cause high mortality  
• Cause public panic and social disruption  
• Require special action for public health preparedness 

Category B: Second Highest Priority Agents

• Moderately easily to disseminate  
• Cause moderate morbidity  
• Require enhanced disease surveillance and public health diagnostic capacity (3, 4, 5) 

Category C: Third Highest Priority Agents

• Could be engineered for mass dissemination in the future  
• Have potential for high morbidity mortality and major health impact  

Agents of Bioterrorism (3, 4, 5) 

Biological Agents 

Anthrax  

Anthrax is a severe infection caused by the bacterium Bacillus anthracis. In 2001, 22 cases of the disease were reported in the United States after anthrax spores were sent through the mail. Anthrax can be contracted in three different ways. Each type of infection has differing signs and symptoms. Person-to-person transmission of this disease is rare. It can also be naturally occurring as a result of contact with anthrax-infected animals such as sheep and cattle (6). 

Cutaneous Anthrax: the anthrax spores enter the skin through a cut or abrasion, leading to swollen itchy sores on the skin (6). 

• Incubation: 1-14 days after exposure  
• Symptoms: The lesion presents as a painless, pruritic papule on the exposed areas of the skin. Vesicles may develop. After rupture, black eschar develops. 
• Diagnostic testing: Blood culture, gram stain, culture of vesicular fluid. Blood and pleural fluid cultures should be obtained.
  Mortality: If left untreated, this infection has a mortality rate of 20 % 
• Treatment: antibiotic therapy such as penicillin or doxycycline for 7-10 days (6).

Inhalational Anthrax: Develops when anthrax is inhaled through the lungs. T he inhaled anthrax spores travel to the alveoli. Spores can remain dormant up to 60 days (6).  

• Symptoms: During the initial phase of inhaled infection, patients may have very unspecific symptoms such as fever, sweats, fatigue, non-productive cough, dyspnea, vomiting, hemorrhagic meningitis and shock.  
• Diagnostic Testing: Rapid diagnostic test (nasal swab) should be performed in patients suspected of exposure to anthrax to confirm the diagnosis and determine antibiotic sensitivities. CT scanning should be considered if anthrax is suspected.  WBC is typically normal or slightly elevated. Laboratory resources from the CDC can provide confirmatory testing.  
• Treatment: Oral or IV antibiotic ciprofloxacin or doxycycline. Anthrasil is a human immune globulin used in combination with antibiotics (6). 
• Mortality: 45%.

Gastrointestinal anthrax: This is very rare. This occurs from eating undercooked meat from an infected animal. Symptoms include nausea, loss of appetite, vomiting, and fever (6). 

• Incubation: 1-7 days after exposure 
• Mortality: 50% without treatment with treatment 40% (6). 
• Vaccine for all types of Anthrax:  BioThrax (7). 

Plague  

The plague also known as the “black death,” is caused by Tersinia pestis and has claimed millions of lives throughout history. The plague most commonly presents as the bubonic form but can also appear in sepsis or pneumonic form. There are approximately 10-15 cases of the plague in the United States per year (6).  

The most common route of infection in humans involves the transmission of the bacteria following a plague-infected fleabite. Person to person transmission does not occur in bubonic or septicemic plague form. However, pneumonic plague is highly contagious. If the plague is aerosolized as a weapon, it could be extremely deadly (6).  

• Incubation: Period: 2-8 days after exposure 
• Symptoms: Symptoms present with a sudden onset of fever, chills, weakness, and swollen lymph nodes (bubo). 
• Mortality: Pneumonic plague has an almost 100% mortality rate if not rapidly treated with antibiotics  
• Treatment: streptomycin, gentamicin, ciprofloxacin, and doxycycline  
• Vaccine: There is currently no vaccine (7) 

Smallpox 

The last reported case of smallpox occurred in 1977 in the United States, and it has two different forms. The deliberate introduction to this highly contagious disease could cause a worldwide pandemic in a matter of weeks (6). 

• Incubation Period: 12-14 days  
• Symptoms: Symptoms presently abruptly with a high fever, headache, backache, and malaise. Patients will then develop a maculopapular rash on the face. The rash also develops on the palms of the hands and soles of the feet.  
• Mortality: 55% with treatment. Almost 100% without treatment.  
• Treatment: TYPOXX- is the first drug with an indication for the treatment (6). 
• Vaccine: CBER (7) 

Tularemia 

Tularemia is caused by the bacteria Francisella tularensis. It is also known as the “mild plague”. It is incredibly infectious, and simple contact with a culture plate can result in illness. The bacteria causing tularemia have many natural reservoirs, including rabbits, squirrels, muskrats, and cats. The primary source of infection for humans is domesticated rabbits. Tularemia can present in ulceroglandular, glandular, oculoglandular, oropharyngeal, typhoidal, or pneumonic forms (6).  

Person to person contact does not occur. Bioterrorist dispersal could result in many pleuropneumonic cases. Without antibiotics, tularemia would progress to extreme respiratory failure and death (6).  

• Incubation: Period: 1-14 days  
• Symptoms: The symptom onset is rapid with fever, headache, myalgia, sore throat, nausea, vomiting, diarrhea, and dry or productive cough.  
• Mortality: in United States is less than 2%.  
• Treatment: aminoglycosides, macrolides, fluroquinolones, and chloramphenicol (6). 
• Vaccine: There is currently no vaccine available (7).  

Botulinum Toxin  

Botulism is caused by Clostridium botulinum, which is a naturally occurring substance in soil. The toxin is derived from a spore-forming bacterium that has neuroparalytic effects. Most cases of botulism result from contaminated food. The most likely bioterrorism action with botulism would include contamination of food and aerosolization. The infection results from the absorption through a mucosal surface, with the intestine absorption being more common than through the lungs (6). 

• Symptoms: Initial presentation includes GI upset that rapidly progresses to cranial nerve abnormalities. Progressive bilateral descending paralysis ensures followed by respiratory failure and death.  
• Mortality: Less than 5 % if treated but approaches 60% if untreated 
• Treatment: Supportive critical care with assisted ventilation, prevention of secondary infection (6). 
• Vaccine: Botulism Immune Globulin Intravenous (7). 

Viral Hemorrhagic Fever  

There have been geographically isolated viruses, including Lassa, Ebola, Marburg, and Dengue that fall into the category of infectious agents for viral hemorrhagic fevers. The vectors of these viruses include rodents, mosquitoes, and ticks. Aerosolization is a more likely mode of terrorist dissemination (6). 

• Incubation period: 2-21 days 
• Symptoms: Abrupt onset of fever, myalgia, malaise, headache, vomiting, abdominal pain, and diarrhea. A maculopapular rash develops on the trunk, usually within five days. Later clinical symptoms include hepatic failure, renal failure, neurologic deficits, hemorrhagic diathesis, shock, and multi-organ dysfunction.  
• Treatment: Treatment is supportive. Ribavirin (Virazole) has shown minimal success in the treatment of patients with hemorrhagic fevers. The CDC has recommended giving this to patients with suspected viral hemorrhagic fever pending final diagnosis (6). 
• Vaccine: Ervebo (7)

Chemical Agents 

Chemical agents are another type of biological warfare that exists and pose a threat to health and safety. Most chemical agents are liquids that are turned into vapors. When used as a weapon, they could be easily spread by explosion or spray. Chemical agents are extremely toxic chemicals that are lethal or have incapacitating effects on humans (19). 

• They are cost–effective  
• They may be used at lower levels of concentration to cause panic or disorder 
• Chlorine, phosgene, and cyanides are widely used in the process of chemicals or pharmaceuticals  
• They can be easily transported in the form of water bottles, cold drink cans, ampules, or pens  
• The effect of intentional release varies depending upon the compound’s toxicity, its volatility, concentration, the route of exposure, the duration of exposure, and the environment.  

Classification of Chemical Agents

Chemical warfare agents have differing characteristics and belong to various classes of compounds. They are classified in several different ways, but in general, are classified on their physiological effects produced on humans. They are classified as: 

Blister Agents (vesicants)

• Inhaled or absorbed through the skin  
• They can affect the eyes, airways, skin, and GI tract  
• They can cause large blisters that resemble burns (8) 

Example: Mustard Gas- If exposed, it can take up to 4-8 hours before experiencing symptoms (13)

Treatment involves lotions, eye drops, and pain medication. If an infection develops, antibiotics can be used (13). There is no antidote for mustard toxicity.  

Blood Agents (Cyanogenic agents)

• These are generally inhaled and distributed through the blood  
• They do not affect the blood but rather inhibit the production of blood components 
• Lead to suffocation from delayed or lack of oxygen transport (12) 

Treatment involves oxygen and mechanical ventilation. Treatment aims to dissociate the cyanide ion from the cytochrome oxidase-cyanide complex. This is accomplished by the administration of binders like amyl nitrite, sodium nitrite, and DMAP (14).

Nerve Agents

• Cause hyperactivity of muscles and organs 
• Absorbed through skin, lungs, or by liquid or vapor exposure  
• Can affect eyes, nose, airways, GI tract, muscles, and CNS (12) 
• They are highly toxic and can cause death from a few minutes to a few hours after exposure (19). 

Example: Sarin and VX. Exposure can cause interruption of breathing, muscle weakness, loss of consciousness, convulsions, and death (15)

There is no antidote for nerve agent poisoning (15).

Pulmonary Agents

• Inhaled through lungs  
• Irritating to airway passages  
• In extreme cases, the membranes swell, and the lungs become filled with liquid, and death results from lack of oxygen.  
• Chlorine and phosgene are examples of this class 
• The treatment of phosgene poisoning is palliative. The objective treatment is the prevention of pulmonary edema and the effects of anoxia. This may involve mechanical ventilation and administration of cortisone and sodium bicarb (16).

Riot-Control Agents

• These are compounds that cause temporary incapacitation by irritation of the eyes (Tearing and blepharospasm) as well as irritation of the upper respiratory tract 
• Also known as “tear gas” 

The treatment requires immediate decontamination of clothing and eyes (19).

Psychomimetic Agents

• Chemical agents that consistently produce changes in thought, perception, or mood without causing disturbances in the autonomic nervous system or severe disability  
• LSD is the most well-known member of this group 
• Affected individuals cannot follow a series of instructions or lack concentration  

General supportive management of the patient includes decontamination of skin. The most significant risks to a patient’s life are injuries from their erratic behavior (18).

Toxins

• Poisonous chemical compounds synthesized in nature by living organisms such as bacteria, fungi, terrestrial or marine animals.  
• There are two groups: Protein toxins and non-protein toxins  
• Toxins as agents of warfare are restricted to assassinations or localized terrorist attacks 
• The two most crucial toxin threats are botulinum toxin and Staphylococcus Enterotoxins B. 
• The treatment for toxins is passive immunization with antitoxins (19). 

Radioactive & Nuclear Agents 

“A Radiological Dispersal Device (RDD) is any device that causes the purposeful dissemination of radioactive material without a nuclear detonation.” This can be in the form of a “Dirty Bomb” or other dispersal methods. Radioactive Sources can be solid, aerosol, gas, or liquid (20).  

• Dirty Bomb = Explosive method of dispersion 
• Explosion = radioactive and nonradioactive shrapnel and radioactive dust; radiation contamination, radiation exposure, physical injury, burns, and panic and fear (20). 

Other dispersal methods can involve passive or active dispersion of unsealed radioactive sources. For example, dropping them on water or soil or dropping them from an airborne device (20).  

 A nuclear weapon is a device that uses a nuclear reaction to create an explosion. When a nuclear weapon explodes, it emits four types of energy: a blast wave, intense light, heat, and radiation. Nuclear weapons can be in the form of bombs or missiles (21). The energy to cause a nuclear explosion comes from splitting the two radioactive materials Uranium 235 and Plutonium-239. The bombs that were dropped on Hiroshima and Nagasaki, Japan, in World War II are examples of nuclear explosions. 

When a nuclear weapon explodes, it creates a fireball. Within this fireball, everything is vaporized and carried upward, creating a mushroom-shaped cloud. The material within the once vaporized substance cools into dust particles that drop back down to earth, known as fallout. The fallout is radioactive and contaminates anything that it comes into contact with (21).

Dangers of a Nuclear Weapon

A nuclear weapon, if used, would cause extreme destruction, death, and injury to a large area. Those close to the blast could experience injury or death from the explosion, burns from the heat and fire, blindness from intense light, and radiation sickness.  

People further from the blast but in range of fallout could experience effects of radiation sickness, contaminated food and water, and external or internal contamination from the fallout (21).

Radiation Exposure – Acute Radiation Syndrome (ARS)

Physical Findings Suggestive of ARS:

 *Acute Radiation exposure is the result of a radiological or nuclear incident. 

There are four sub–syndromes of Acute Respiratory Syndrome:  

1. Hematopoietic

Changes in blood cell counts will reflect the radiation dose. Lymphocytes, neutrophils, red cells, and platelets respond to radiation in different ways. The interpretation of lab values will depend on how long after radiation exposure the lab values were measured. Faster drops in absolute lymphocyte count and the absolute neutrophil count will reflect a higher dose of exposure (11). 

2. Gastrointestinal

Nausea and or vomiting can occur soon after the brain, upper GI tract, and whole-body irradiation. Radiation can cause GI mucosal damage and damage to bone marrow elements. Both of these factors can cause GI blood loss. Consider treatment with anti-diarrheal meds, fluid replacement, and antimicrobial agents (22).  

3. Cutaneous

Skin changes that occur earliest (hours to weeks) after exposure include erythema, swelling, edema, blistering, and skin sensitivity. Skin changes that could occur later (days to weeks) after exposure include skin desquamation, hair loss, and skin necrosis.  

The management of cutaneous radiation injuries must be highly individualized. Management may include: wound debridement, fluid replacement, pain management, use of corticosteroids, antimicrobial therapy, and growth factors to enhance granulation (22). 

4. Neurovascular

An increase and decrease in blood pressure and body temperature can occur hours after significant radiation exposure. These changes may reflect clinical infection and CNS irradiation. Fatigue, headache, and anorexia can also happen as well as cognitive and neurological deficits. Consider treatment with glucocorticoids if shock or increased intracranial pressure is present, consider mannitol, control body temperature, and blood pressure, consider CNS imaging (22). 

Blast Injury

Primary blast injury can cause extreme barotrauma affecting air-filled organs leading to pulmonary damage, rupture of tympanic membranes, and rupture of hollow viscera (fatal). A secondary blast injury can lead to fragmentation injuries and penetrating trauma. A tertiary blast injury can be caused by structural collapse or people being thrown by blast force wind. This can lead to crushing injuries, blunt trauma, fractures, amputations, and open or closed brain injuries (23).  

Thermal/Burn Injury

Thermal burn injuries occur by direct absorption of thermal energy through exposed skin. It can lead to burn casualties, eye injuries, and retinal scarring (23).  

Long term effects of radiation:

• Delayed effects of acute radiation exposure  
• Specific organ effects depending on where a given isotope is incorporated 
• Carcinogenesis 
• Mutagenesis (23) 

Management of Patients with Radiation Exposure

If you were presented with a patient with potential radiation exposure, here is a list of things to consider:  

• Look for early clinical signs and symptoms of Acute Radiation Syndrome (see chart above) 
• Use Radiation Bio Dosimetry Tools to estimate whole–body radiation dose (22): 
  • Obtain CBC with differential and platelet count  
  • Input absolute lymphocyte counts into Interactive Calculator to estimate whole–body radiation dose 
  • Repeat CBC every 24 hours if possible, to increase the accuracy of the dose estimate and management  
  • Consider myeloid cytokines and antibiotics if whole–body dose estimate is ≥ 2 (22).

Personal Protective Equipment (PPE)

“Personal protective equipment refers to clothing and respiratory coverings designed to shield an individual from chemical, biological, and physical hazards (24).”  

The type of protection required depends on the incident and the duration of exposure that is anticipated. In general, PPE is more effective against chemical agents because biological agent incidents are not likely to be evident until well after the agent’s release (24).   

There is a Personal Protective Equipment classification system that is used in describing the varying levels of protection:  

 *Information in text box retrieved from Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response (24) 

Types of Protection

There are several types of protective equipment, each with its own sets of requirements and uses. Listed are the various common elements of PPE (24):  

Respiratory:

Appropriate respirators should be used to protect against adverse health effects that may be caused by breathing contaminated air 

Eye/Face:

Eye and face protection will protect the user from hazards of potential flying fragments, sparks, or chemical splashes  

Skin:

Skin protection should be used if a user has potential exposure to harmful substances  

Noise:

Ear protection such as earplugs or earmuffs can prevent hearing damage. Exposure to high noise levels can cause hearing loss or impairment. 

PPE Management

PPE requires the implementation of a management program for education and safety purposes. Training for PPE involves the proper mechanics of donning and doffing PPE, the maintenance and care of PPE, the limitations, and the appropriate disposal after use (24).  

PPE Specifically for Biological Agents

A terrorist attack of biological agents presents different needs for PPE than a chemical attack agent. Unless there is pre-incident intelligence of a biological agent, a biological attack would be covert (24). Many of the biological agents have incubation times ranging from hours to weeks between exposure and clinical symptoms; if an aerosolized agent had been used, it is likely to have dissipated from the area before recognition of first responders (24).  

Apart from smallpox, and plague bacteria, person-to-person transmission of the diseases rarely occur if “universal precautions are maintained (e.g., gloves, gown, mask, and eye protection).” The majority of patients that have been affected by other biological agents can be cared for without specialized isolation rooms or ventilation systems. The hemorrhagic virus infections may be transmissible with blood or aerosol. Therefore, respiratory protection for responders caring for these patients would be required (3). 

If pre-incident intelligence puts rescue personnel at the scene of a release, the same PPE they would employ for a chemical incident will protect from biological agents (24).  

PPE for Radiation Exposure

In all cases where radiation is suspected, first responders should wear personal radiation dosimeters that allow them to read the dose and or accumulated dose in real–time (20,24). 

In the event the first responder is exposed to radiation only even with a high risk of contamination and non-radiation hazards have been excluded, Level C PPE will provide sufficient respiratory and dermal protection. However, in the event a first responder is exposed to a high-risk event of exposure, PPE gives no protection against high energy, highly penetrating forms of ionizing radiation (20).  

Syndromic Surveillance & Reporting Procedures 

Because of the heightened concern of bioterrorism’s potential possibility in our nation and across the world, public health agencies are currently testing new surveillance methods of early detection of illness resulting from a bioterrorism-related pandemic (12). Unlike traditional systems that utilize voluntary reporting from clinical providers to acquire data, syndromic surveillance continuously acquires data through protocols and automated routines. For example, Washington DC syndromic surveillance system collects emergency department data from hospitals within the area. Based on chief complaints, the system identifies possible high priority bioterrorism agents (15). 

Establishing a Diagnosis

Establishing a diagnosis of a potential bioterrorist weapon is essential to a positive and efficient public health response. The diagnosis will guide treatment, medication management, and vaccinations. Diagnosis of a bioterrorist attack can be made through syndromic surveillance or clinical reporting (12).  

Through Syndromic Surveillance

Many symptoms of biological weapons present with nonspecific symptoms in the preliminary stages. Patients with these illnesses seek patient care and are more than likely assigned a nonspecific diagnosis such as “viral syndrome.” The data on patients fitting various syndromic criteria is sent to the health department. This process flags a statistical detection threshold that has been exceeded. At this point, Epidemiologists determine if a preliminary investigation is warranted for further evaluation (25).  

If they deem further investigation necessary, say, for example, a blood culture is taken from several patients. Within several hours a culture yields a presumptive diagnosis of anthrax, therefore, producing a full-scale public health response.  

Through Clinician Reporting

Some patients that have been exposed to a biological agent may have short incubation periods.  

Example: A patient is unknowingly exposed to inhalational anthrax. Respiratory distress occurs in this one person and is hospitalized. The patient is routinely admitted to the hospital and blood cultures are drawn. Within several hours a diagnosis of anthrax Is made. The patient’s physician informs the local health department yielding a full-scale response.  

Health Alert Network

“The Health Alert Network (HAN) is the CDC’s primary method of sharing information regarding urgent public health incidents with public health information officers; federal, state, territorial, tribal, and local public health practitioners; clinicians; and public health laboratories (25).”  

The HAN also collaborates with these groups to develop protocols and relationships that will ensure a solid foundation if the rapid distribution of public health information occurs. The HAN is a national program that provides vital information to state and local levels. The HAN messaging system transmits Health Alerts, advisories, updates, and information services to over one-million recipients (25). 

Health Alert Network Message Types (25)

*The information in this box comes directly from the CDC from information on the Health Alert Network 

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