nurs 214.bioterrorism

BioterrorismBioterrorism

Written by:Written by:

Diane King, RN, BSN, PHN, CENDiane King, RN, BSN, PHN, CEN

San Jose State UniversitySan Jose State University

School of NursingSchool of Nursing

NURS 214NURS 214


The awareness of the use of biological and The awareness of the use of biological and chemical weapons have created concern on the chemical weapons have created concern on the national and international level. national and international level.

“ “Military and civilian medical and public health Military and civilian medical and public health professionals must become proficient in professionals must become proficient in recognizing that a biological attack has recognizing that a biological attack has occurred, activating the appropriate agencies occurred, activating the appropriate agencies and personnel to investigate the event, treating and personnel to investigate the event, treating casualties, and preventing spread of casualties, and preventing spread of diseasedisease.”(http://www.usamriid.army.mil/education/index.htm.”(http://www.usamriid.army.mil/education/index.htm). ).


What is Bioterrorism?What is Bioterrorism?The intentional release of a The intentional release of a toxin, virus, bacteria or germ toxin, virus, bacteria or germ (agent) to cause a serious illness (agent) to cause a serious illness or deathor deathCan be immediate or long term Can be immediate or long term (may take days or weeks to (may take days or weeks to observe symptoms)observe symptoms)

BioterrorismBioterrorism ““High-risk targets for acts of terrorism include High-risk targets for acts of terrorism include

military and civilian government facilities, military and civilian government facilities, international airports, large cities, and high-international airports, large cities, and high-profile landmarks.profile landmarks.

Terrorists might also target large public Terrorists might also target large public gatherings, water and food supplies, utilities, and gatherings, water and food supplies, utilities, and corporate centers. corporate centers.

Further, terrorists are capable of spreading fear Further, terrorists are capable of spreading fear by sending explosives or chemical and biological by sending explosives or chemical and biological agents through the mail”agents through the mail”(http://www.fema.gov/areyouready/terrorism_general_info.shtm)(http://www.fema.gov/areyouready/terrorism_general_info.shtm)

Bioterrorism AgentsBioterrorism Agents

““Category A diseases as described by the Category A diseases as described by the Center for Disease Control and Prevention Center for Disease Control and Prevention (CDC)are: (CDC)are:

AnthraxAnthrax TularemiaTularemia PlaguePlague SmallpoxSmallpox Botulism Botulism Viral hemorrhagic fever” Viral hemorrhagic fever”

(http://www.nih.gov/news/pr/mar2002/niaid-14.htm(http://www.nih.gov/news/pr/mar2002/niaid-14.htm

AnthraxAnthrax

HistoryHistory ””A disease caused by a bacterium, A disease caused by a bacterium, Bacillus Bacillus

anthracis,anthracis, it has existed for hundreds of years it has existed for hundreds of years and still occurs naturally in both animals and and still occurs naturally in both animals and humans in many parts of the world, including humans in many parts of the world, including Asia, southern Europe, sub-Sahelian Africa and Asia, southern Europe, sub-Sahelian Africa and parts of Australia.parts of Australia.

There are three forms of anthrax in humans: There are three forms of anthrax in humans: cutaneous, ingestion and inhalational.” cutaneous, ingestion and inhalational.” (http://www.who.int/csr/delibepidemics/disease/en(http://www.who.int/csr/delibepidemics/disease/en))

AnthraxAnthrax

EpidemiologyEpidemiology

8,000-50,000 spores (aerosol), transmitted 8,000-50,000 spores (aerosol), transmitted by inhalation, Ingestion, or inoculationby inhalation, Ingestion, or inoculation

AnthraxAnthrax

Patient IsolationPatient IsolationStandard barrier isolation precautions. Standard barrier isolation precautions.

Patients do not require isolation rooms. Patients do not require isolation rooms. Not transmissible person to personNot transmissible person to person Incubation 1-6 daysIncubation 1-6 daysDuration 3-5 days (usually fatal if Duration 3-5 days (usually fatal if

untreated)untreated)

AnthraxAnthrax

Clinical manifestationsClinical manifestationsFeverFeverMalaiseMalaiseCoughCoughRespiratory distressRespiratory distress

AnthraxAnthrax

TreatmentTreatment CiprofloxinCiprofloxin DoxycyclineDoxycycline If vaccine available, 3 doses of anthrax vaccineIf vaccine available, 3 doses of anthrax vaccine ””The recent reports of anthrax exposure have The recent reports of anthrax exposure have

spawned numerous websites and emails selling spawned numerous websites and emails selling Ciprofloxacin (Cipro) and other antibiotics for Ciprofloxacin (Cipro) and other antibiotics for treatment. The Federal Trade Commission treatment. The Federal Trade Commission (FTC) warns that fraudsters often follow the (FTC) warns that fraudsters often follow the headlines, tailoring their offers to prey on headlines, tailoring their offers to prey on consumers' fears and vulnerabilities ” consumers' fears and vulnerabilities ” (http://www.ftc.gov/bcp/edu/pubs/consumer/alerts/alt104.shtm)(http://www.ftc.gov/bcp/edu/pubs/consumer/alerts/alt104.shtm)

AnthraxAnthrax

Use as a biological weaponUse as a biological weapon

Spores remain viable in soil for many Spores remain viable in soil for many yearsyears

AnthraxAnthrax

Documented OutbreaksDocumented Outbreaks

““The worst documented outbreak of The worst documented outbreak of inhalation anthrax in humans occurred in inhalation anthrax in humans occurred in Russia in 1979, when anthrax spores were Russia in 1979, when anthrax spores were accidentally released from a military accidentally released from a military biological weapons facility near the town of biological weapons facility near the town of Sverdlovsk, killing at least 66 people. Sverdlovsk, killing at least 66 people.

AnthraxAnthrax

Most people weren't aware of this Most people weren't aware of this weapon until the fall of 2001, when letters weapon until the fall of 2001, when letters containing anthrax spores sent via the containing anthrax spores sent via the U.S. Postal Service resulted in 22 cases U.S. Postal Service resulted in 22 cases of anthrax infection. Eleven people were of anthrax infection. Eleven people were infected with cutaneous anthrax. Eleven infected with cutaneous anthrax. Eleven others were infected with inhalation others were infected with inhalation anthrax, resulting in five deaths. “anthrax, resulting in five deaths. “

(http://www.ncbi.nlm.nih.gov/pubmed)

AnthraxAnthrax

SourceSource::http://www.bt.cdc.gov/agent/anthrax/anthrax-images/cutaneous.asphttp://www.bt.cdc.gov/agent/anthrax/anthrax-images/cutaneous.asp

AnthraxAnthrax


ourceource::httphttp

AnthraxAnthrax


TularemiaTularemia

HistoryHistory F. tularensisF. tularensis was discovered in 1911 during an was discovered in 1911 during an

outburst of rabbit fever, when the disease killed outburst of rabbit fever, when the disease killed a large number of ground squirrels in the area of a large number of ground squirrels in the area of Tulare Lake in California. Tulare Lake in California.

There are two predominant subspecies: There are two predominant subspecies: F. F. tularensis tularensistularensis tularensis (type A), which is found in (type A), which is found in North America, is more virulent than North America, is more virulent than F. F. tularensis palaearcticatularensis palaearctica (type B), which occurs in (type B), which occurs in Asia, Europe, and North America. Asia, Europe, and North America.

TularemiaTularemia


10-50 organisms (aerosol)10-50 organisms (aerosol)

TularemiaTularemia

Patient IsolationPatient IsolationStandard precautions. Respiratory Standard precautions. Respiratory

isolation is not required.isolation is not required.Not transmissible person to personNot transmissible person to person Incubation 3-6 daysIncubation 3-6 daysDuration is 2 weeksDuration is 2 weeks

TularemiaTularemia

Clinical manifestations depend on the route of Clinical manifestations depend on the route of entry and the virulence of the agent. entry and the virulence of the agent.

Typically includes: fever, headache, malaise, Typically includes: fever, headache, malaise, weight loss, non-productive cough.weight loss, non-productive cough.

There are six forms of tularaemia in humans: There are six forms of tularaemia in humans: ulceroglandular, glandular, oropharyngeal, ulceroglandular, glandular, oropharyngeal, oculoglandular, respiratory and typhoidal.” oculoglandular, respiratory and typhoidal.” (http://www.who.int/csr/delibepidemics/disease/en)(http://www.who.int/csr/delibepidemics/disease/en)

TularemiaTularemia

TreatmentTreatmentStreptomycinStreptomycinGentamycinGentamycinAntibiotic prophylaxis is most effective if Antibiotic prophylaxis is most effective if

begun within 24 hoursbegun within 24 hours

TularemiaTularemia

Documented OutbreaksDocumented Outbreaks ““In summer 2000, an outbreak of tularemia In summer 2000, an outbreak of tularemia

in Martha's Vineyard resulted in one in Martha's Vineyard resulted in one fatality.fatality.

An outbreak of tularemia occurred in An outbreak of tularemia occurred in Kosovo in 1999-2000.” Kosovo in 1999-2000.” (http://www.ncbi.nlm.nih.gov/pubmed)

TularemiaTularemia

Documented OutbreaksDocumented Outbreaks ““In 2004, three researchers at Boston University Medical In 2004, three researchers at Boston University Medical

Center were accidentally infected with Center were accidentally infected with F. tularensisF. tularensis, after , after apparently failing to follow safety proceduresapparently failing to follow safety procedures

In 2005, small amounts of In 2005, small amounts of F. tularensisF. tularensis were detected in were detected in the Mall area of Washington, DC the morning after an the Mall area of Washington, DC the morning after an anti-war demonstration on September 24, 2005anti-war demonstration on September 24, 2005

In July 2007, an outbreak was reported in the Spanish In July 2007, an outbreak was reported in the Spanish autonomous region of Castile and Leonand traced to the autonomous region of Castile and Leonand traced to the plague of voles infesting the region .” plague of voles infesting the region .”

(http://www.ncbi.nlm.nih.gov/pubmed)

TularemiaTularemia


10-50 organisms (aerosol)10-50 organisms (aerosol)

PlaguePlague

HistoryHistory ””An infectious disease of animals and humans An infectious disease of animals and humans

caused by a bacterium, caused by a bacterium, Yersinia pestis,Yersinia pestis, which is which is transmitted between rodents by rodent fleas or transmitted between rodents by rodent fleas or to people through infected rodent flea bites. to people through infected rodent flea bites.

It can also be transmitted to humans through It can also be transmitted to humans through direct contact with infected animal tissue. direct contact with infected animal tissue.

There are three main forms of plague in There are three main forms of plague in humans: bubonic, septicemic and pneumonic.” humans: bubonic, septicemic and pneumonic.” (http://www.who.int/csr/delibepidemics/disease/en)(http://www.who.int/csr/delibepidemics/disease/en)

PlaguePlague


<100 organisms (aerosol)<100 organisms (aerosol)

PlaguePlague

Patient Isolation Patient Isolation Strict respiratory isolation with droplet Strict respiratory isolation with droplet

precautions (gown, gloves, and eye precautions (gown, gloves, and eye protection) until patient has received at protection) until patient has received at least 48 hours of antibiotic therapy and least 48 hours of antibiotic therapy and shows clinical improvement.shows clinical improvement.

Highly transmissible person to personHighly transmissible person to person

PlaguePlague

Patient IsolationPatient Isolation Incubation period 2-3 daysIncubation period 2-3 daysDuration of illness 1-6 days (usually fatal)Duration of illness 1-6 days (usually fatal)

PlaguePlague

Clinical manifestationsClinical manifestationsHigh feverHigh feverChillsChillsHeadacheHeadacheProductive cough-watery then bloodyProductive cough-watery then bloody

PlaguePlague

TreatmentTreatmentStreptomycinStreptomycinGentamycinGentamycinChloramphenicolChloramphenicolAntibiotic prophylaxis is recommended for Antibiotic prophylaxis is recommended for

all persons exposed to the aerosol or all persons exposed to the aerosol or persons in close physical contact with a persons in close physical contact with a confirmed caseconfirmed case

PlaguePlague

Use as a biological weaponUse as a biological weapon<100 organisms (aerosol)<100 organisms (aerosol)

PlaguePlague

Documented OutbreaksDocumented Outbreaks ““From 165-1950 (Biblical times)From 165-1950 (Biblical times)The Third Pandemic, originated in China The Third Pandemic, originated in China

(1855–1950s).” (1855–1950s).” (http://www.ncbi.nlm.nih.gov/pubmed)

SmallpoxSmallpox


Highly infectious after aerosolizationHighly infectious after aerosolizationPerson-to-person transmission can occur Person-to-person transmission can occur

via droplet nuclei or aerosols expelled via droplet nuclei or aerosols expelled from the oropharnx and by direct contactfrom the oropharnx and by direct contact

Contaminated clothing or bed linens can Contaminated clothing or bed linens can also spread the virus.also spread the virus.

SmallpoxSmallpox

HistoryHistory

“ “An acute contagious disease caused by An acute contagious disease caused by VariolaVariola virus, a member of the orthopoxvirus family.” virus, a member of the orthopoxvirus family.” (http://www.who.int/csr/delibepidemics/disease/en(http://www.who.int/csr/delibepidemics/disease/en

SmallpoxSmallpox

Patient IsolationPatient Isolation

Strict isolation in negative pressure room Strict isolation in negative pressure room from onset of rash until scabs separatefrom onset of rash until scabs separate

Laundry and waste should be autoclaved Laundry and waste should be autoclaved before being laundered or incineratedbefore being laundered or incinerated

Incubation 12-14 daysIncubation 12-14 daysDuration is 4 weeksDuration is 4 weeks

SmallpoxSmallpox

Clinical manifestationsClinical manifestationsNon-specific flu-like prodrome (malaise, Non-specific flu-like prodrome (malaise,

fever, headache), 2-3 days later is rashfever, headache), 2-3 days later is rashThen synchronously evolving Then synchronously evolving

maculopapular rash progressing to maculopapular rash progressing to vesicles then pustulesvesicles then pustules

Lesions more predominant on the face Lesions more predominant on the face and extremities than on the trunkand extremities than on the trunk

SmallpoxSmallpox

TreatmentTreatment

CidofovirCidofovirVaccine available & most effective if given Vaccine available & most effective if given

within 3 days of exposurewithin 3 days of exposure

SmallpoxSmallpox


Assumed low (10-100 organisms aerosol)Assumed low (10-100 organisms aerosol)

SmallpoxSmallpox

Documented Outbreaks Documented Outbreaks ““The global eradication of smallpox was The global eradication of smallpox was

certified in 1979, based on intense certified in 1979, based on intense verification activities in countries.”verification activities in countries.”

(http://www.who.int/csr/delibepidemics/disease/en(http://www.who.int/csr/delibepidemics/disease/en

SmallpoxSmallpox

Source: Public Health Images Library (PHIL) ID # 3. CDC/Cheryl TyronSource: Public Health Images Library (PHIL) ID # 3. CDC/Cheryl Tyron

SmallpoxSmallpox

Public Health Images Library (PHIL) ID # 284. Source: CDC/James HicksPublic Health Images Library (PHIL) ID # 284. Source: CDC/James Hicks

SmallpoxSmallpox

Public Health Images Library (PHIL) id# 131. Source: CDC/Barbra RicePublic Health Images Library (PHIL) id# 131. Source: CDC/Barbra Rice

Botulism (food sources)Botulism (food sources)

HistoryHistory ””A rare but serious paralytic illness caused by a nerve A rare but serious paralytic illness caused by a nerve

toxin that is produced by the bacteriumtoxin that is produced by the bacterium Clostridium Clostridium botulinum. botulinum. Botulism toxin can be inhaled or ingested via Botulism toxin can be inhaled or ingested via contaminated food or water. There are five clinical contaminated food or water. There are five clinical categories: categories:

foodborne botulismfoodborne botulism wound botulismwound botulism infant botulisminfant botulism adult infectious botulismadult infectious botulism inadvertent, following botulinum toxin injection.”inadvertent, following botulinum toxin injection.”

(http://www.who.int/csr/delibepidemics/disease/en)(http://www.who.int/csr/delibepidemics/disease/en)

BotulismBotulism


Botulism neurotoxins (A-F) could be Botulism neurotoxins (A-F) could be transmitted by aerosol or contamination of transmitted by aerosol or contamination of food and water suppliesfood and water supplies

BotulismBotulism

Patient IsolationPatient IsolationNon transmissible from person to personNon transmissible from person to person Incubation is 12-36 hoursIncubation is 12-36 hoursDeath in 24-72 hoursDeath in 24-72 hoursLasts months if not lethalLasts months if not lethal

BotulismBotulism

Clinical manifestationsClinical manifestationsDry throatDry throatBlurred visionBlurred visionSlurred speechSlurred speechDifficulty swallowingDifficulty swallowingProgressive descending symmetrical Progressive descending symmetrical

paralysisparalysis

BotulismBotulism

Treatment Treatment Antitoxin (limited supply & only available Antitoxin (limited supply & only available

from the Division of Communicable from the Division of Communicable Disease Control, California Department of Disease Control, California Department of Health Services)Health Services)

Supportive careSupportive care

BotulismBotulism

Use as a biological weaponUse as a biological weaponCould be released as an aerosol or used Could be released as an aerosol or used

to contaminate water or food suppliesto contaminate water or food supplies ““Iraq deployed 12,000 liters of botulinum Iraq deployed 12,000 liters of botulinum

toxin in over 100 munitions during the Gulf toxin in over 100 munitions during the Gulf War in 1991” (Recognizing Bioterrorism War in 1991” (Recognizing Bioterrorism Agents, 2000. Santa Clara County Health Agents, 2000. Santa Clara County Health Department Zebra Information Binder)Department Zebra Information Binder)

BotulismBotulism

Documented OutbreaksDocumented Outbreaks ““In April 1991, 91 hospitalized patients in Cairo In April 1991, 91 hospitalized patients in Cairo

were reported to the Egyptian Ministry of Health were reported to the Egyptian Ministry of Health with botulism intoxication. with botulism intoxication.

Cases of botulism in the northern province of Cases of botulism in the northern province of Iran were studied in March and April 1997. Iran were studied in March and April 1997.

In the late 1996, an outbreak of botulism In the late 1996, an outbreak of botulism affected eight young people in Italy.” affected eight young people in Italy.” (http://www.ncbi.nlm.nih.gov/pubmed)(http://www.ncbi.nlm.nih.gov/pubmed)

PreventionPrevention

““Local drinking water and waste water Local drinking water and waste water systems could be potential targets for systems could be potential targets for terrorist or other criminal acts. “terrorist or other criminal acts. “(http://cfpub.epa.gov/safewater/watersecurity/publicInvolve.cfm)(http://cfpub.epa.gov/safewater/watersecurity/publicInvolve.cfm)

External LinksExternal Links ““Raw, unedited footage of terrorism events and Raw, unedited footage of terrorism events and

people's reaction to those events can be very people's reaction to those events can be very upsetting, especially to children. upsetting, especially to children.

We do not recommend that children watch We do not recommend that children watch television news reports about such events, television news reports about such events, especially if the news reports show images over especially if the news reports show images over and over again about the same incident.and over again about the same incident.

Young children do not realize that it is repeated Young children do not realize that it is repeated video footage, and think the event is happening video footage, and think the event is happening again and again.” again and again.” (http://www.redcross.org/services/disaster/0,1082,0_589_,00.html)(http://www.redcross.org/services/disaster/0,1082,0_589_,00.html)

ReferencesReferencesAmerican Red CrossAmerican Red Cross

http://www.redcross.org/services/disaster/0,1082,0_589_,00.htmlhttp://www.redcross.org/services/disaster/0,1082,0_589_,00.html

Center for Disease Control Center for Disease Control http://www.bt.cdc.gov/agent/anthrax/anthrax-images/cutaneous.asphttp://www.bt.cdc.gov/agent/smallpox/smallpox-images/smallpox3.htm Source:CDC/Cheryl TyronSource:CDC/Cheryl Tyron. Public Health Images Library (PHIL) ID # 3. Public Health Images Library (PHIL) ID # 3. http://www.bt.cdc.gov/agent/smallpox/smallpox-images/smallpox3.htm Source: CDC/James HicksSource: CDC/James Hicks. Public Health Images Library (PHIL) id# 284.Public Health Images Library (PHIL) id# 284. http://www.bt.cdc.gov/agent/smallpox/smallpox-images/smallpox3.htm Source: CDC/Barbra RiceSource: CDC/Barbra Rice. Public Health Images Library (PHIL) id# 131. Public Health Images Library (PHIL) id# 131. http://phil.cdc.gov/Phil/details.asphttp://phil.cdc.gov/Phil/details.asp

•Environmental Protection AgencyEnvironmental Protection Agencyhttp://cfpub.epa.gov/safewater/watersecurity/publicInvolve.cfmhttp://cfpub.epa.gov/safewater/watersecurity/publicInvolve.cfm

•Federal Trade CommissionFederal Trade Commissionhttp://www.ftc.gov/bcp/edu/pubs/consumer/alerts/alt104.shtmhttp://www.ftc.gov/bcp/edu/pubs/consumer/alerts/alt104.shtm

•Federal Emergency Management AgencyFederal Emergency Management Agencyhttp://www.fema.gov/areyouready/terrorism_general_info.shtmhttp://www.fema.gov/areyouready/terrorism_general_info.shtm

ReferencesReferences

National Institiute of HealthNational Institiute of Healthhttp://www.nih.gov/news/pr/mar2002/niaid-14.htmhttp://www.nih.gov/news/pr/mar2002/niaid-14.htmhttp://www.ncbi.nlm.nih.gov/pubmedhttp://www.ncbi.nlm.nih.gov/pubmed

Santa Clara County Health DepartmentSanta Clara County Health Department:: Bioterrorism information for clinicians zebra packet. Bioterrorism information for clinicians zebra packet. November 4, 2000.November 4, 2000.

U.S. Army and Medical Research Institute of U.S. Army and Medical Research Institute of Infectious DiseaseInfectious Disease

http://www.usamriid.army.mil/education/index.htmhttp://www.usamriid.army.mil/education/index.htm World Health OrganizationWorld Health Organization

http://www.who.int/csr/delibepidemics/diseasehttp://www.who.int/csr/delibepidemics/disease

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