Bioterrorism: A Practical Lesson for Nursing

by Claudia Noe, BSN & Robert Koch, DNS, RN

Yesterday began like any other day in the emergency room. The waiting room was packed, all the rooms were full, and nurses and physicians scurried around to take care of all the patients. It was just a very average day when a sudden and eerie stillness crept over the entire unit. The medical director came over the loud speaker and called an emergency meeting of all personnel to the staff lounge immediately. We were informed that a suspected case of smallpox had been reported in the hospital and that no one was to leave the building pending further investigation. The National Guard, we were told, was stationed outside with orders to arrest anyone trying to leave the premises.

Although this is merely a fictional scenario of what could happen, bioterrorism is a real threat to our society today. The concept is not a new one. Using a bacterial or viral agent in warfare dates back to the 6th century when the English utilized smallpox as a weapon against the Native Americans. In more recent years, Germany allegedly used biological weapons during WWI to infect livestock destined for the United States cavalry. The Japanese experimented with many toxic chemicals during WWII (Holdstock, 1998). These early attempts at biological warfare were archaic and caused few casualties. Today, with more sophisticated biological weapons, the possible devastation to the human race is dumbfounding (Atlas, 1999).

With the Biological Weapons Convention of 1972, the United States and many other countries entered into an agreement to reduce the threat of biological agents (Atlas, 1999). Regardless of measures taken to deter the use of biological weapons, nations like Russia continued to develop and maintain such programs. Lucier (2001) reports that the amount of anthrax stockpiled in the Russian program has the potential to kill the world’s population four times over.

Anthrax

Several diseases are recognized as having bioterrorism potential. Anthrax is one disease predominating the media today. Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis. It most commonly occurs in hoofed mammals and can infect humans. Symptoms vary depending on how the disease was contracted but usually occur within seven days after exposure. The serious forms of human anthrax are cutaneous anthrax, intestinal anthrax, and inhalation anthrax. Cutaneous anthrax can begin as a raised itchy bump that develops into a painless ulcer, which soon becomes necrotic. Treatment is available and prognosis is favorable.

Intestinal anthrax may follow the consumption of contaminated food and is characterized by an acute inflammation of the intestinal tract. Initial signs of nausea, loss of appetite, vomiting, and fever are followed by abdominal pain, vomiting of blood, and severe diarrhea (Shelby County Government, 2001).

Initial symptoms of inhalation anthrax infection may resemble a common cold or flu. After several days without treatment, the symptoms may progress to severe breathing problems and shock. Inhalation anthrax is often fatal.

Direct person-to-person spread of anthrax is extremely unlikely, if it occurs at all. Therefore, there is no need to immunize or treat contacts of persons ill with anthrax, such as household contacts, friends, or coworkers, unless they also were also exposed to the same source of infection.

In persons exposed to anthrax, early antibiotic treatment is essential-delay decreases the chance for survival. Anthrax usually is susceptible to penicillin, doxycycline, and fluoroquinolones. An anthrax vaccine also can prevent infection. Vaccination against anthrax is not recommended for the general public to prevent disease and is not available. Vaccine supplies are limited and reserved for emergency medical personnel, firefighters, police, healthcare providers, and morticians (Hagstad, 2000).

Smallpox

Once thought eradicated, smallpox (Variola virus) spreads from one person to another by infected saliva droplets. The infected person is contagious from the first week of infection through the scabbing phase. The illness begins with fever, malaise, and backache. The rash appears within two to four days and evolves from macules to papules to vesicles to pustules and finally crusts. The initial skin abnormalities occur on the palms and soles and feel firm, like “BB shots.” The distribution tends to occur on the arms, hands, legs, and feet.

Routine vaccination ended in 1972 in the U.S. Although the vaccine was given to individuals decades ago, those who received it may still be protected from the virus (Rubin, 2001). Some believe that instead of preventing smallpox, vaccination can increase the liability to smallpox, and that the only way to abolish the disease is to do as Leicester did, leave off vaccination altogether and devote our energies to sanitation, and the isolation of such rare cases as they occur. More information on this controversy is available on the World Wide Web at http://www.mercola.com/2000/dec/31/smallpox_vaccine.htm There is no current treatment for the virus although patients with smallpox benefit from supportive therapy such as fluid administration, pain medication, and antibiotics for secondary infections (Shelby County Government, 2001).

Botulism

Another possible weapon in this gruesome war is botulism, a severe intoxication or food poisoning produced by Clostridium botulinum. Most cases are due to improperly prepared or canned foods. Symptoms of the illness are related to the nervous system. Blurred vision, poor reflexes, difficulty swallowing, general weakness, and labored breathing are included among the symptoms occurring as early as 12-36 hours following ingestion. The diagnosis is confirmed when blood or stool samples tests positive for the toxin. Some cases of botulism can be treated using an antitoxin, and all cases are in need of supportive care in a healthcare setting (Shelby County Government, 2001).

Next Steps

No foolproof method for avoiding biological weapons exists. The current question is not whether or not an attack will occur, but simply when it will occur and how to protect ourselves against an attack (Hagstad, 2000). President Bush’s informative speeches and warnings of the growing threat of terrorist attacks are merely the first step towards awareness (Drinkard, 2001).

The Centers for Disease Control (CDC) and state and local health authorities currently investigate cases of reported bioterrorism. The public health agencies along with the CDC established a web-based system for each state to report bioterrorism-related activities to track threats (Centers for Disease Control, 2001). If a disease outbreak should occur, a thorough investigation would be needed to assist healthcare professionals in identifying the pathogen and treating those affected. Although essential, using Universal Precautions while caring for individuals affected by bioterrorism agents may not be enough. In-depth bioterrorism training and education and defined plans of response are crucial (Williams, 2001).

Bioterrorism training must include every healthcare worker as well as firefighters and police. Schools of nursing should incorporate content within the curriculum that includes bioterrorism. Professionals need to respond in a knowledgeable way to care for populations who are victims of bioterrorism (Williams, 2001).

One publication, “Bioterrorism Readiness Plan: A Template for Healthcare Facilities,” is available on the World Wide Web at http://www.cdc.gov/ncidod/hip/Bio/bio.htm This resource can aid health care providers in planning and coordinating an appropriate response to bioterrorism. This document provides information on laboratory policies, reporting requirements, and tools to prepare health care professionals to respond to bioterrorist attacks. Another resource, Recognition of Illness Associated with the Intentional Release of a Biologic Agent Summary, is available at on the World Wide Web at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5041a2.htm

Hopefully, tomorrow will be an average day in the emergency rooms across America. However, since the September 11, 2001 attack, no day will ever be ordinary again. All healthcare professionals and United States citizens should stand alert and aware of the possibility of a bioterrorist threat. Although the biological war is an invisible and silent one, awareness and preparation are the best defenses.

Claudia Noe, BSN is a recent graduate of the Loewenberg School of Nursing at the University of Memphis. She currently works in an intensive care unit in Richmond, Virginia

Robert Koch, DNS, RN is an Assistant Professor at the Loewenberg School of Nursing, University of Memphis, and serves on TNA’s Editorial Board. He teaches Contemporary Issues and Trends

References

Atlas, R. (1999, June). Combating the threat of biowarfare and bioterrorism: Defending against biological weapons is critical to global security. Bioscience. Retrieved November 13, 2001 from the World Wide Web: http://www.findarticles.com/cf_0/m1042/6_49/54823664/print.jhtml
Drinkard, J. (2001, November 7). Bush warns of growing threat. USA Today, p. 1A.
Hagstad, D. (2000). Emergency. Bioterrorism. American Journal of Nursing, 100 (12), 33-35.
Holdstock, D. (1998). The plague wars…» chemical and biological weapons. Nursing Times, 94 (29), 38-39.
Lucier, J. (2001, October 15). The danger of biological war. Insight on the News. [Online].
Shelby County Government. (2001, October 22). Bioterrorism. [Online].
Center for Disease Control. (2001, November 9). Update: Investigation of bioterrorism-related anthrax and adverse events from antimicrobial prophylaxis. Mortality and Morbidity Weekly Report, 50 (44), 973-976.
Williams, B. (2001). Bioterrorism: Are we prepared? Tennessee Medicine, 94 (11), 413-417.