Course Book : #105 - Bioterrorism Preparedness

Bioterrorism Preparedness

2 contact hours

Course # 105

Author: Monica Oram, RN, BSN

 

This course is intended for the reader to be able to achieve the following objectives:

  1. Understand the role of healthcare workers in preparing for bioterrorism activity

  2. Understand what bioterrorism is

  3. Identify five biological agents to be concerned about

  4. How to be prepared and stay alert

  5. What to do if an attack takes place

 

 

What is bioterrorism?

 

Bioterrorism is best described as the intentional release of harmful bacteria, viruses or germs, (called agents) released into the air or environment. Bioterrorism, like all forms of terrorism, aims to injure or kill people, cause panic or fear, and disrupt daily routines. Bioterrorism is different from other forms of terrorism in the aspect that unlike other attacks, a biological attack could take days or weeks to notice. By that time, many people may have been infected.

 

Many people have stated, “It is not a question of IF it can happen, it is a question of WHEN it will happen.” Biological weapons are the oldest form of the nuclear, biological, and chemical triad of weapons of mass destruction. Any organism or toxin found in nature that can be used to kill, incapacitate, or impede an adversary can be used as a biological weapon.

 

Bioterrorism is the use of a biological weapon against a living organism. The act of bioterrorism can range from hoaxes to an individual’s use of a biological agents in an attempt to produce mass destruction. One can not know when an act of bioterrorism can take place, but we can learn how to become prepared to handle such a situation.

 

On September 11, 2001, America became devastated and our security was shattered, perhaps forever, when foreign terrorists hijacked domestic airliners and crashed into the World Trade Center in New York City and the Pentagon in Arlington, Virginia. America was barely able to absorb the tragedy of the World Trade Center disaster, when Anthrax slowly invaded the most unlikely place: The United States Postal System. At the height of the anthrax scare, the United States postal service was receiving as many as 500 hoaxes or reports of incidents related to Anthrax every day. As a result, the use of weapons of mass destruction as a hoax is now considered a felony.

On September 25th,2001 the World Health Organization issued a statement that warned government agencies to strengthen their capacity to respond to attacks by chemical or biological weapons and to prepare for the possibility of attacks. Biological weapons are easy to acquire, manufacture, and use. A small amount can kill hundreds of thousands of people without harm to property. They are easy to conceal, transport, and disseminate.

Since the tragedy of 9/11, everyday vocabulary has included bioterrorism, emergency preparedness, weapons of mass destruction, and other words that reflect the recent acts of terror, fear about the future, and the role that further terrorist acts may play. Fears are reinforced every day as the mass media continues to explore and report new threats that are emerging, by observing increased security measures and armed guards at airports, and even opening the mail.

 

 

Three main forms of biological warfare were used before the twentieth century. Enemy food and water supplies were contaminated, Microorganisms and toxins were placed in the weapons systems, and fabrics were biologically inoculated with disease such as smallpox and shipped to major businesses and corporations for distribution to the communities.

 

The threat of bioterrorism today, is not much different from the attacks and actions conducted by terrorists for decades. Some research of documented terrorist activity using biological warfare has even dated back to as far as

1763! In this case, one of the earliest examples of bioterrorism in North America was the distribution of smallpox infected blankets at Fort Pitt. (Now known as Pittsburgh, Pa.) to start an epidemic among Chief Pontiac’s forces in 1763.

 

The difference of now compared to then, is that nuclear and biological warfare has become much more advanced and sophisticated over time with advancing technology.

 

 

Bioterrorism is definitely unpredictable in nature. The possibility of biological or chemical terrorism should not be ignored because the consequences of being unprepared will definitely have a devastating impact on America. Bioterrorism has been a part of the world for a very long time.

 

Definition of Key Terms

 

Emergency- refers to an extraordinary event or situation that requires existing community resources for rapid response.

 

Disaster- refers to an event or situation of a larger magnitude and of greater duration than an emergency. A disaster takes a toll on human basic needs such as water, food, sanitation, and shelter.

 

Natural disaster- defined by the World Health Organization as “ecological disruptions or threats that exceed the adjustment capacity of the affected community” They are natural disasters that are acts of nature, such as hurricane, flood, and earthquakes.

 

Man made disasters- events or situations that are caused by humans. Examples are environmental contamination of water, commercial waste, war and the events and acts of terrorism.

 

Weapons of mass destruction- includes biological, chemical, nuclear, or explosive material/devices and any combination of these, that can widely and rapidly adversely affect human life.

 

Some Documented Acts Of Terrorism

  • In 1945, an anthrax outbreak in Iran resulted in the death of approximately one million sheep.

  • In 1979, the former Soviet Union accidentally released an aerosolized form of anthrax spores from a military facility. The release caused approximately 79 cases of infectious inhalation of Anthrax. The death toll was 68.

  • Between 1979 and 1985, more than 10,000 humans have contracted anthrax exposure around the world.

  • As recently as 1995, the release of sarin ( a nerve gas) was released into a Tokyo subway. This terrorist attack killed 12 victims. The same terrorist group was linked to releasing anthrax and botulism in an aerosolized form throughout Tokyo.

  • In October 2001, evidence of bioterrorism hit Florida when a man was positively confirmed to have Anthrax in his cerebrospinal fluid. The autopsy indicated that the cause of death was inhalation of Anthrax.

  • Additional cases of Anthrax inhalation have been found in New Jersey, and the Nation’s capital in Washington, DC.

 

These cases, and others have prompted a need for public awareness. It has prompted a need for community education and a need to educate healthcare professionals about such bioterrorist disasters.

 

Biological Agents

 

Biological agents include, but are not limited to Anthrax, Smallpox, Botulism, Tularemia, and plagues.

 

Quick overview of each

Anthrax- Anthrax spores may be spread by direct skin contact or through the air. Some symptoms of cutaneous (skin) exposure include itching and boils. Symptoms of inhalation of Anthrax may be similar to the flu, but without congestion. Anthrax is not contagious.

 

Smallpox- Smallpox could be spread through the air. The first symptoms usually include a high fever, fatigue and body aches. These are usually followed by a rash, about 2-3 days later. This rash is generally most noticeable on the face, legs and arms. Smallpox is contagious and victims need to be isolated.

 

Botulism- Botulism may be spread through the air or by contaminated food. Symptoms include trouble seeing, breathing and swallowing. Botulism is not contagious.

 

Tularemia- Tularemia is spread through the air. Symptoms are similar to the flu. It is not known to be contagious.

 

Plague- The plague can be spread by infected fleas on rodents, or through the air. Symptoms include trouble seeing, breathing, or swallowing.

The plague is contagious.

Federal, state and local health-care and law enforcement agencies are forming plans to deal with these and other agents.

 

Anthrax

 

What is Anthrax?

Anthrax is an acute infectious disease caused by a bacterium called Bacillus anthracis. Anthrax most commonly occurs in livestock, but is known to infect humans as well. Anthrax is most common in agricultural regions where it occurs in animals. Although anthrax can be found globally, it is more often a risk in countries with less standardized and effective public health programs. Areas currently listed as high risk include South and Central America, Southern and Eastern Europe, Asia, Africa, the Caribbean, and the Middle East.

 

When Anthrax affects humans, it is usually due to an occupational exposure to infected animals. Workers who are exposed to dead animals and animal products (industrial anthrax) from other countries where anthrax is more common may become infected with B. Anthracis. Anthrax in animals rarely occurs in the United States and human anthrax is also rare, though there is a widespread concern due to bioterrorism. Anthrax spores can survive in soil for years and are resistant to extreme environmental conditions and can remain viable for decades, making it an excellent choice as an effective weapon.

 

How Anthrax is transmitted

Anthrax infection can occur in three forms.

  1. Inhalation ( pulmonary)

  2. Cutaneous ( skin)

  3. Gastrointestinal

 

Since anthrax can live in the soil for decades, animals become infected by grazing in contaminated pastures. Humans can become infected with Anthrax by handling infected animals or by inhaling anthrax spores from contaminated animals or animal products. Anthrax can also be spread by eating undercooked meat of infected animals.

 

Pulmonary anthrax is associated with bioterrorism exposure to aerosolized spores. Mortality is high despite antibiotic treatment if this type of anthrax is not treated before the onset of respiratory symptoms. Many will not be treated until symptoms appear, therefore making it very deadly.

 

A biological attack of anthrax would most likely occur with anthrax spores by aerosol delivery. Aerosol delivery is the most effective way to achieve extensive population exposure.

 

Cutaneous exposure can include handling of contaminated wool hides or hair in textile industries. This has become known as “wool handler’s disease” Cutaneous anthrax is not usually fatal if treated with antibiotics in a timely manner.

 

Gastrointestinal anthrax is usually fatal after it has progressed to toxemia and sepsis. Most commonly it is transmitted by ingestion of contaminated meat.

 

Common symptoms associated with Anthrax exposure

 

Inhalation Anthrax ( pulmonary) Initial symptoms may resemble the common cold. Inhalation anthrax can incubate for 2-60 days after pulmonary exposure. After several days, the symptoms progress to severe breathing problems and shock. Inhalation anthrax usually results in death in 1-2 days after onset of acute symptoms, if antibiotics are not initiated soon after exposure. This is a problem, because when the symptoms start to appear, it is to late for effective treatment. Symptoms begin with a non-specific type of flu like symptoms, with a brief interim of improvement. Approximately 2-4 days after initial symptoms, acute symptoms develop such as abrupt onset of respiratory failure, which is fatal 1-2 days after these symptoms arise.

 

Cutaneous anthrax (skin exposure) presents as localized itching, which resembles an insect bite. followed by papular lesions that blister and turn into painless ulcers, usually 1-3 cm in diameter within 2-6 days, then it turns into a depressed black eschar. Most anthrax skin exposure infections occur when the bacterium enters a cut or abrasion on the skin. Though absorption is also a way of transmission through the pores of the skin.

Death can be prevented with appropriate antibiotic therapy.

The incubation time for cutaneous anthrax exposure is 1-7 days for symptoms to arise.

 

Gastrointestinal anthrax 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. This type of anthrax exposure usually results in death after symptoms of toxemia and sepsis become prominent. The incubation period for gastrointestinal anthrax exposure is 1-7 days for symptoms to present.

 

Direct person to person contact of anthrax most likely does not occur. It is spread by inhalation, direct skin contact or ingestion of anthrax spores.

Transmission of cutaneous anthrax is possible but considered unlikely. Standard precautions should be implemented and open wounds should be covered with dressings.

 

Anthrax is diagnosed by isolating B. anthracis from the blood, skin lesions, or respiratory secretions or by measuring specific antibodies in the blood of suspected cases.

 

Treatment and Prevention

The treatment of choice includes the use of antibiotic Ciprofloxin.

Treatment needs to be done by prophylaxis management of cipro 500mg twice a day and continued until anthrax exposure is ruled out. If exposure is confirmed, then it needs to continue for about 8 more weeks. Other antibiotics used include levofloxacin, and ofloxicin.

 

The cell free anthrax vaccine should be given after a confirmed exposure to anthrax. Three doses of this vaccine are required, followed by three more and an annual booster to maintain immunity.

The first dose is administered immediately after confirming diagnosis. The second dose is given again in two weeks, and finally at four weeks the third dose is given. Then the person is given an injection at 6, 12, and 18 months following exposure. Then an annual booster thereafter.

There is currently only one vaccine for humans licensed in the United States. Because anthrax is considered to be a potential agent to be used in bioterrorism attack, the Department of Defense recently announced that it will begin vaccination of US Military personnel. Among civilians it will not be given unless exposure is confirmed. Though, the federal officials are recommending vaccinations for first responders and postal workers. The vaccine is said to be 95% effective in protecting against cutaneous anthrax exposure. It is not clearly known of percentage rate of effectiveness in regards to gastrointestinal and inhalation exposure to anthrax.

The Bioport Company in Michigan is currently the only manufacturer of the anthrax vaccine. There is only short supply of the vaccine available.

 

Smallpox

 

Smallpox is an acute viral illness caused by the variola virus. Smallpox is a bioterrorism threat due to its potential to cause severe morbidity in a non-immune population and because it can be transmitted via airborne route. A single case is considered a public health emergency.

 

Smallpox was declared eradicated in 1970. Now there is national concern that smallpox will hit the US again through acts of bioterrorism. The US stopped civilian vaccination in 1972. Now vaccinations may be a necessity. Smallpox can be easily manufactured in large quantities.

It is estimated that the current supply of smallpox vaccines is limited, but it is estimated that there are between 7.5 and 18 million doses of the vaccine in the CDC repository and 20 million doses stored at the World Health Organization. Federal officials have been negotiating with private drug companies to produce up to 300 million more doses by the end of 2004.

 

The variola virus is essentially a disease of tissue destruction. Viral particles are inhaled into the lungs. Patients are infectious 3-6 days after the appearance of fever. Patients may present with malaise, fatigue, fever, vomit, headache and backache. 2-3 days later, lesions appear which quickly evolve into macules to papules to pustular vesicles. The rash typically begins on the face and extremities, remaining abundant in these areas.

Smallpox can be transmitted widely by air and direct contact with the lesions. Patients are considered infectious if they are sneezing, coughing, or have a rash or lesions.

 

One confirmed case is considered to be a national emergency and a public health concern. Public health officials are to be notified immediately. The person should be isolated in a negative air pressure isolation room for at least 3 weeks, or until all lesions and scabs have separated from one another.

 

Those vaccinated prior to 1972 should be aware that the vaccine is estimated to be protective for a period of 10 years.

This will mean that even though some Americans were vaccinated for smallpox in the past, they will need to be revaccinated if smallpox becomes an epidemic. The vaccine is not currently available to civilians in the US. The CDC can obtain the vaccine when it is necessary.

 

Botulism

Foodborne botulism is a serious paralytic illness caused by a nerve toxin produced by the bacterium Clostridium Botulinum. It is caused by eating foods that contain the botulism toxin. This toxin may not give a bad taste or odor to foods. In humans, a characteristic flaccid paralysis occurs when the botulinem toxin inhibits the release of acetylcholine. Botulism is produced in spores that are present worldwide in soil and marine sediment. The most common form is food borne botulism, but there is an airborne type that also exists. Both forms may be a method of bioterrorism attack.

 

The symptoms include severe flu like symptoms, diarrhea, vomit, the patient may have no fever, they may experience respiratory problems due to paralysis of respiratory muscles.

 

It is predicted that if a bioterrorist attack happens by way of botulism, it will be aerosolized over livestock feed. For example, a dust cropping airplane could spread botulism through the air with the intention of contaminating the food source of grazing animals. After eating the meat, humans would become infected with the microorganism. The incubation time after aerosolization would be approximately 12-36 hours after ingestion. 24 - 72 hours after exposure, neurological symptoms will begin to appear.

 

Botulism is not transmitted from person to person.

 

Inhalation Botulism in the event of a bioterrorist attack would be substantially a major problem because the botulism toxin through inhalation is 15,000 times more toxic than nerve agents.

 

A vaccine is in the experimental stages at this point. It was developed by the Department of Defense. It is only available on an investigational basis. The vaccination should be given at the onset of exposure, again in two weeks, and then at four weeks after exposure. Routine immunization is not recommended unless exposure is confirmed.

 

Tularemia

 

The fear and concern with tularemia is that it can become an epidemic of bioterrorism attack by being spread and dumped from the air onto American soil. It will then infect humans and animals. Many wild animals will become infected. ( rabbits, squirrels, muskrats, beavers, deer, rodents, and the like) Tularemia is not spread from person to person, but it is spread from inoculation of the skin or mucous membranes with blood or tissue while handling or skinning a hunted animal, from fluids in infected fleas or ticks, or being bitten by infected fleas and ticks.

 

Symptoms include sudden high fever, chills, headaches, muscle aches, joint pain, dry cough, progressive weakness and then pneumonia. Symptoms usually appear in 3-5 days after exposure.

 

A vaccine is under review by the FDA, but none is currently available in the United States.

 

Plagues

 

Plague is most commonly transmitted by infected fleas, resulting in lymphatic and blood infections. Such as bubonic plague and septicemia plague)

 

A bioterrorist attack with this microorganism would most likely be airborne, causing a pneumonic plague.

The clinical manifestations would include fever, cough, chest pain, coughing blood, and a confirmed chest x-ray for pneumonia. Plague is usually transmitted by infected rodents, but aerosolized droplets are a mode of transmission. Incubation time is about 2-8 days. The incubation period for pneumonic plague is much shorter, 1-3 days because of pulmonary exposure. Mortality rate is 100% if not treated within 12-24 hours.

There is a vaccination for bubonic plague, but here is no vaccine effective for pneumonic plague. The bubonic vaccine is not available in the US. No vaccine exists for any other types of plague.

Ricin Poisoning

 

Another real concern in biological bioterrorism is the spread of ricin. Ricin is a stable toxin made from the mash that remains from castor beans for oil. Castor oil was once used as a laxative, but is now mainly used as an industrial lubricant and for manufacturing leather products.

The concern with bioterrorism is that it can be sprayed over the US and is a toxic, potent nerve gas. It is deadly and is transmitted by inhalation, ingestion, or injection of the poison. Respiratory symptoms will develop in as few as three hours.

 

Bioterrorism preparedness

 

With only a very few exceptions, most hospitals and healthcare facilities are not equipped to handle the mass destruction of a bioterrorist attack. There simply are not enough rooms, decontamination equipment, or protection suits available to safeguard the spread of disease throughout the hospital. The healthcare system would be saturated with hundreds of victims.

 

In response to the public outcry for the government to “do something”, antibiotics have been stockpiled, vaccines are being produced in mass quantities for mass inoculations, and government money is pouring into research projects ranging from early warning systems, to longer term research on antidotes.

 

Be prepared. One can never be really prepared for a bioterrorist attack, as an attack would most likely happen without any warning. There are ways in which you can reduce the risks of an attack.

Stay alert, especially in public places. Report any packages or bags left unattended or anyone acting suspiciously. Know the location of emergency exits. Never accept a package from a stranger.

 

A lot of uncertainty comes with the threat of a terrorist attack. Being aware is a big step toward feeling in control.

Hospital and healthcare providers must communicate with the appropriate internal and external personnel, including community agencies when confronted with an actual or potential bioterrorist attack or threat. Most facilities now have a plan in place to deal with bioterrorism. Find out what your plan is in the place you work.

 

Bioterrorism outbreaks are an element of surprise, generally unannounced. Detection becomes increasingly important for accurate assessment of unusual disease clusters or symptoms. Physician’s are then faced with the challenge of working with the symptoms and ruling out potential agents one by one.

 

Death toll will undoubtly be high, and a frantic hysteria will definitely be among us.

Although the likelihood of biological attack is unknown, significant preparation is underway by America. Many believe America is vulnerable. Many people have purchased equipment for protection against bioterrorism attack. Without prior knowledge of an attack, healthcare workers are also vulnerable and prone to fear. Many diseases caused by weaponized biological agents present with symptoms that can be misleading as a natural occurrence, rather than an act of terrorism. Hospital emergency rooms need to be very alert to large numbers of people presenting for treatment with similar signs and symptoms. Closely monitoring and observing these disease patterns may help save lives. Public education is also essential. Public information can help to minimize the spread of chemical contamination or infectious diseases caused by people fleeing from an area of panic.

 

As the United States prepares to deal with bioterrorism, the CDC recommends that nurses and healthcare providers monitor the CDC website for the latest news in bioterrorism information. www.bt.cdc.gov

The CDC’s plan includes public health communication systems, an infrastructure comprised of local, state and federal agencies. These systems are in place to rapidly respond to a threat to our nation. A large scale attack of a virus, aerosolized agent, nerve gas or other chemical agent would be overwhelming. Preparation plans are essential in the pre-planning stages to be ready and informed.

 

CDC is the first line of defense in the federal response to bioterrorism. Established in 1946 to combat malaria, typhus and other infectious diseases, the agency now has over 8,500 employees. The CDC headquarters is located in Atlanta, Ga. The bioterrorism Emergency Number at the CDC is 770-488-7100.

 

 

References:

Most of this article was comprised from the CDC website information for public access.
www.bt.cdc.gov

 

BIOPORT (Producers of anthrax vaccine) 517-327-1500

 

CDC, Biological and Chemical terrorism, Strategic planning workshop April, 2000

 

Federal Emergency Management Agency
www.fema.gov

 

Center for Disease Information
Washington, DC
202-332-0600

 

Chemical and Biological Arms Control
www.cbaci.org

Homeland Health
www.homelandhealth.com

Bioterrorism Preparedness

2 contact hours

Course # 105

Author: Monica Oram, RN, BSN

 

This course is intended for the reader to be able to achieve the following objectives:

  1. Understand the role of healthcare workers in preparing for bioterrorism activity

  2. Understand what bioterrorism is

  3. Identify five biological agents to be concerned about

  4. How to be prepared and stay alert

  5. What to do if an attack takes place

 

 

What is bioterrorism?

 

Bioterrorism is best described as the intentional release of harmful bacteria, viruses or germs, (called agents) released into the air or environment. Bioterrorism, like all forms of terrorism, aims to injure or kill people, cause panic or fear, and disrupt daily routines. Bioterrorism is different from other forms of terrorism in the aspect that unlike other attacks, a biological attack could take days or weeks to notice. By that time, many people may have been infected.

 

Many people have stated, “It is not a question of IF it can happen, it is a question of WHEN it will happen.” Biological weapons are the oldest form of the nuclear, biological, and chemical triad of weapons of mass destruction. Any organism or toxin found in nature that can be used to kill, incapacitate, or impede an adversary can be used as a biological weapon.

 

Bioterrorism is the use of a biological weapon against a living organism. The act of bioterrorism can range from hoaxes to an individual’s use of a biological agents in an attempt to produce mass destruction. One can not know when an act of bioterrorism can take place, but we can learn how to become prepared to handle such a situation.

 

On September 11, 2001, America became devastated and our security was shattered, perhaps forever, when foreign terrorists hijacked domestic airliners and crashed into the World Trade Center in New York City and the Pentagon in Arlington, Virginia. America was barely able to absorb the tragedy of the World Trade Center disaster, when Anthrax slowly invaded the most unlikely place: The United States Postal System. At the height of the anthrax scare, the United States postal service was receiving as many as 500 hoaxes or reports of incidents related to Anthrax every day. As a result, the use of weapons of mass destruction as a hoax is now considered a felony.

On September 25th,2001 the World Health Organization issued a statement that warned government agencies to strengthen their capacity to respond to attacks by chemical or biological weapons and to prepare for the possibility of attacks. Biological weapons are easy to acquire, manufacture, and use. A small amount can kill hundreds of thousands of people without harm to property. They are easy to conceal, transport, and disseminate.

Since the tragedy of 9/11, everyday vocabulary has included bioterrorism, emergency preparedness, weapons of mass destruction, and other words that reflect the recent acts of terror, fear about the future, and the role that further terrorist acts may play. Fears are reinforced every day as the mass media continues to explore and report new threats that are emerging, by observing increased security measures and armed guards at airports, and even opening the mail.

 

 

Three main forms of biological warfare were used before the twentieth century. Enemy food and water supplies were contaminated, Microorganisms and toxins were placed in the weapons systems, and fabrics were biologically inoculated with disease such as smallpox and shipped to major businesses and corporations for distribution to the communities.

 

The threat of bioterrorism today, is not much different from the attacks and actions conducted by terrorists for decades. Some research of documented terrorist activity using biological warfare has even dated back to as far as

1763! In this case, one of the earliest examples of bioterrorism in North America was the distribution of smallpox infected blankets at Fort Pitt. (Now known as Pittsburgh, Pa.) to start an epidemic among Chief Pontiac’s forces in 1763.

 

The difference of now compared to then, is that nuclear and biological warfare has become much more advanced and sophisticated over time with advancing technology.

 

 

Bioterrorism is definitely unpredictable in nature. The possibility of biological or chemical terrorism should not be ignored because the consequences of being unprepared will definitely have a devastating impact on America. Bioterrorism has been a part of the world for a very long time.

 

Definition of Key Terms

 

Emergency- refers to an extraordinary event or situation that requires existing community resources for rapid response.

 

Disaster- refers to an event or situation of a larger magnitude and of greater duration than an emergency. A disaster takes a toll on human basic needs such as water, food, sanitation, and shelter.

 

Natural disaster- defined by the World Health Organization as “ecological disruptions or threats that exceed the adjustment capacity of the affected community” They are natural disasters that are acts of nature, such as hurricane, flood, and earthquakes.

 

Man made disasters- events or situations that are caused by humans. Examples are environmental contamination of water, commercial waste, war and the events and acts of terrorism.

 

Weapons of mass destruction- includes biological, chemical, nuclear, or explosive material/devices and any combination of these, that can widely and rapidly adversely affect human life.

 

Some Documented Acts Of Terrorism

  • In 1945, an anthrax outbreak in Iran resulted in the death of approximately one million sheep.

  • In 1979, the former Soviet Union accidentally released an aerosolized form of anthrax spores from a military facility. The release caused approximately 79 cases of infectious inhalation of Anthrax. The death toll was 68.

  • Between 1979 and 1985, more than 10,000 humans have contracted anthrax exposure around the world.

  • As recently as 1995, the release of sarin ( a nerve gas) was released into a Tokyo subway. This terrorist attack killed 12 victims. The same terrorist group was linked to releasing anthrax and botulism in an aerosolized form throughout Tokyo.

  • In October 2001, evidence of bioterrorism hit Florida when a man was positively confirmed to have Anthrax in his cerebrospinal fluid. The autopsy indicated that the cause of death was inhalation of Anthrax.

  • Additional cases of Anthrax inhalation have been found in New Jersey, and the Nation’s capital in Washington, DC.

 

These cases, and others have prompted a need for public awareness. It has prompted a need for community education and a need to educate healthcare professionals about such bioterrorist disasters.

 

Biological Agents

 

Biological agents include, but are not limited to Anthrax, Smallpox, Botulism, Tularemia, and plagues.

 

Quick overview of each

Anthrax- Anthrax spores may be spread by direct skin contact or through the air. Some symptoms of cutaneous (skin) exposure include itching and boils. Symptoms of inhalation of Anthrax may be similar to the flu, but without congestion. Anthrax is not contagious.

 

Smallpox- Smallpox could be spread through the air. The first symptoms usually include a high fever, fatigue and body aches. These are usually followed by a rash, about 2-3 days later. This rash is generally most noticeable on the face, legs and arms. Smallpox is contagious and victims need to be isolated.

 

Botulism- Botulism may be spread through the air or by contaminated food. Symptoms include trouble seeing, breathing and swallowing. Botulism is not contagious.

 

Tularemia- Tularemia is spread through the air. Symptoms are similar to the flu. It is not known to be contagious.

 

Plague- The plague can be spread by infected fleas on rodents, or through the air. Symptoms include trouble seeing, breathing, or swallowing.

The plague is contagious.

Federal, state and local health-care and law enforcement agencies are forming plans to deal with these and other agents.

 

Anthrax

 

What is Anthrax?

Anthrax is an acute infectious disease caused by a bacterium called Bacillus anthracis. Anthrax most commonly occurs in livestock, but is known to infect humans as well. Anthrax is most common in agricultural regions where it occurs in animals. Although anthrax can be found globally, it is more often a risk in countries with less standardized and effective public health programs. Areas currently listed as high risk include South and Central America, Southern and Eastern Europe, Asia, Africa, the Caribbean, and the Middle East.

 

When Anthrax affects humans, it is usually due to an occupational exposure to infected animals. Workers who are exposed to dead animals and animal products (industrial anthrax) from other countries where anthrax is more common may become infected with B. Anthracis. Anthrax in animals rarely occurs in the United States and human anthrax is also rare, though there is a widespread concern due to bioterrorism. Anthrax spores can survive in soil for years and are resistant to extreme environmental conditions and can remain viable for decades, making it an excellent choice as an effective weapon.

 

How Anthrax is transmitted

Anthrax infection can occur in three forms.

  1. Inhalation ( pulmonary)

  2. Cutaneous ( skin)

  3. Gastrointestinal

 

Since anthrax can live in the soil for decades, animals become infected by grazing in contaminated pastures. Humans can become infected with Anthrax by handling infected animals or by inhaling anthrax spores from contaminated animals or animal products. Anthrax can also be spread by eating undercooked meat of infected animals.

 

Pulmonary anthrax is associated with bioterrorism exposure to aerosolized spores. Mortality is high despite antibiotic treatment if this type of anthrax is not treated before the onset of respiratory symptoms. Many will not be treated until symptoms appear, therefore making it very deadly.

 

A biological attack of anthrax would most likely occur with anthrax spores by aerosol delivery. Aerosol delivery is the most effective way to achieve extensive population exposure.

 

Cutaneous exposure can include handling of contaminated wool hides or hair in textile industries. This has become known as “wool handler’s disease” Cutaneous anthrax is not usually fatal if treated with antibiotics in a timely manner.

 

Gastrointestinal anthrax is usually fatal after it has progressed to toxemia and sepsis. Most commonly it is transmitted by ingestion of contaminated meat.

 

Common symptoms associated with Anthrax exposure

 

Inhalation Anthrax ( pulmonary) Initial symptoms may resemble the common cold. Inhalation anthrax can incubate for 2-60 days after pulmonary exposure. After several days, the symptoms progress to severe breathing problems and shock. Inhalation anthrax usually results in death in 1-2 days after onset of acute symptoms, if antibiotics are not initiated soon after exposure. This is a problem, because when the symptoms start to appear, it is to late for effective treatment. Symptoms begin with a non-specific type of flu like symptoms, with a brief interim of improvement. Approximately 2-4 days after initial symptoms, acute symptoms develop such as abrupt onset of respiratory failure, which is fatal 1-2 days after these symptoms arise.

 

Cutaneous anthrax (skin exposure) presents as localized itching, which resembles an insect bite. followed by papular lesions that blister and turn into painless ulcers, usually 1-3 cm in diameter within 2-6 days, then it turns into a depressed black eschar. Most anthrax skin exposure infections occur when the bacterium enters a cut or abrasion on the skin. Though absorption is also a way of transmission through the pores of the skin.

Death can be prevented with appropriate antibiotic therapy.

The incubation time for cutaneous anthrax exposure is 1-7 days for symptoms to arise.

 

Gastrointestinal anthrax 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. This type of anthrax exposure usually results in death after symptoms of toxemia and sepsis become prominent. The incubation period for gastrointestinal anthrax exposure is 1-7 days for symptoms to present.

 

Direct person to person contact of anthrax most likely does not occur. It is spread by inhalation, direct skin contact or ingestion of anthrax spores.

Transmission of cutaneous anthrax is possible but considered unlikely. Standard precautions should be implemented and open wounds should be covered with dressings.

 

Anthrax is diagnosed by isolating B. anthracis from the blood, skin lesions, or respiratory secretions or by measuring specific antibodies in the blood of suspected cases.

 

Treatment and Prevention

The treatment of choice includes the use of antibiotic Ciprofloxin.

Treatment needs to be done by prophylaxis management of cipro 500mg twice a day and continued until anthrax exposure is ruled out. If exposure is confirmed, then it needs to continue for about 8 more weeks. Other antibiotics used include levofloxacin, and ofloxicin.

 

The cell free anthrax vaccine should be given after a confirmed exposure to anthrax. Three doses of this vaccine are required, followed by three more and an annual booster to maintain immunity.

The first dose is administered immediately after confirming diagnosis. The second dose is given again in two weeks, and finally at four weeks the third dose is given. Then the person is given an injection at 6, 12, and 18 months following exposure. Then an annual booster thereafter.

There is currently only one vaccine for humans licensed in the United States. Because anthrax is considered to be a potential agent to be used in bioterrorism attack, the Department of Defense recently announced that it will begin vaccination of US Military personnel. Among civilians it will not be given unless exposure is confirmed. Though, the federal officials are recommending vaccinations for first responders and postal workers. The vaccine is said to be 95% effective in protecting against cutaneous anthrax exposure. It is not clearly known of percentage rate of effectiveness in regards to gastrointestinal and inhalation exposure to anthrax.

The Bioport Company in Michigan is currently the only manufacturer of the anthrax vaccine. There is only short supply of the vaccine available.

 

Smallpox

 

Smallpox is an acute viral illness caused by the variola virus. Smallpox is a bioterrorism threat due to its potential to cause severe morbidity in a non-immune population and because it can be transmitted via airborne route. A single case is considered a public health emergency.

 

Smallpox was declared eradicated in 1970. Now there is national concern that smallpox will hit the US again through acts of bioterrorism. The US stopped civilian vaccination in 1972. Now vaccinations may be a necessity. Smallpox can be easily manufactured in large quantities.

It is estimated that the current supply of smallpox vaccines is limited, but it is estimated that there are between 7.5 and 18 million doses of the vaccine in the CDC repository and 20 million doses stored at the World Health Organization. Federal officials have been negotiating with private drug companies to produce up to 300 million more doses by the end of 2004.

 

The variola virus is essentially a disease of tissue destruction. Viral particles are inhaled into the lungs. Patients are infectious 3-6 days after the appearance of fever. Patients may present with malaise, fatigue, fever, vomit, headache and backache. 2-3 days later, lesions appear which quickly evolve into macules to papules to pustular vesicles. The rash typically begins on the face and extremities, remaining abundant in these areas.

Smallpox can be transmitted widely by air and direct contact with the lesions. Patients are considered infectious if they are sneezing, coughing, or have a rash or lesions.

 

One confirmed case is considered to be a national emergency and a public health concern. Public health officials are to be notified immediately. The person should be isolated in a negative air pressure isolation room for at least 3 weeks, or until all lesions and scabs have separated from one another.

 

Those vaccinated prior to 1972 should be aware that the vaccine is estimated to be protective for a period of 10 years.

This will mean that even though some Americans were vaccinated for smallpox in the past, they will need to be revaccinated if smallpox becomes an epidemic. The vaccine is not currently available to civilians in the US. The CDC can obtain the vaccine when it is necessary.

 

Botulism

Foodborne botulism is a serious paralytic illness caused by a nerve toxin produced by the bacterium Clostridium Botulinum. It is caused by eating foods that contain the botulism toxin. This toxin may not give a bad taste or odor to foods. In humans, a characteristic flaccid paralysis occurs when the botulinem toxin inhibits the release of acetylcholine. Botulism is produced in spores that are present worldwide in soil and marine sediment. The most common form is food borne botulism, but there is an airborne type that also exists. Both forms may be a method of bioterrorism attack.

 

The symptoms include severe flu like symptoms, diarrhea, vomit, the patient may have no fever, they may experience respiratory problems due to paralysis of respiratory muscles.

 

It is predicted that if a bioterrorist attack happens by way of botulism, it will be aerosolized over livestock feed. For example, a dust cropping airplane could spread botulism through the air with the intention of contaminating the food source of grazing animals. After eating the meat, humans would become infected with the microorganism. The incubation time after aerosolization would be approximately 12-36 hours after ingestion. 24 - 72 hours after exposure, neurological symptoms will begin to appear.

 

Botulism is not transmitted from person to person.

 

Inhalation Botulism in the event of a bioterrorist attack would be substantially a major problem because the botulism toxin through inhalation is 15,000 times more toxic than nerve agents.

 

A vaccine is in the experimental stages at this point. It was developed by the Department of Defense. It is only available on an investigational basis. The vaccination should be given at the onset of exposure, again in two weeks, and then at four weeks after exposure. Routine immunization is not recommended unless exposure is confirmed.

 

Tularemia

 

The fear and concern with tularemia is that it can become an epidemic of bioterrorism attack by being spread and dumped from the air onto American soil. It will then infect humans and animals. Many wild animals will become infected. ( rabbits, squirrels, muskrats, beavers, deer, rodents, and the like) Tularemia is not spread from person to person, but it is spread from inoculation of the skin or mucous membranes with blood or tissue while handling or skinning a hunted animal, from fluids in infected fleas or ticks, or being bitten by infected fleas and ticks.

 

Symptoms include sudden high fever, chills, headaches, muscle aches, joint pain, dry cough, progressive weakness and then pneumonia. Symptoms usually appear in 3-5 days after exposure.

 

A vaccine is under review by the FDA, but none is currently available in the United States.

 

Plagues

 

Plague is most commonly transmitted by infected fleas, resulting in lymphatic and blood infections. Such as bubonic plague and septicemia plague)

 

A bioterrorist attack with this microorganism would most likely be airborne, causing a pneumonic plague.

The clinical manifestations would include fever, cough, chest pain, coughing blood, and a confirmed chest x-ray for pneumonia. Plague is usually transmitted by infected rodents, but aerosolized droplets are a mode of transmission. Incubation time is about 2-8 days. The incubation period for pneumonic plague is much shorter, 1-3 days because of pulmonary exposure. Mortality rate is 100% if not treated within 12-24 hours.

There is a vaccination for bubonic plague, but here is no vaccine effective for pneumonic plague. The bubonic vaccine is not available in the US. No vaccine exists for any other types of plague.

Ricin Poisoning

 

Another real concern in biological bioterrorism is the spread of ricin. Ricin is a stable toxin made from the mash that remains from castor beans for oil. Castor oil was once used as a laxative, but is now mainly used as an industrial lubricant and for manufacturing leather products.

The concern with bioterrorism is that it can be sprayed over the US and is a toxic, potent nerve gas. It is deadly and is transmitted by inhalation, ingestion, or injection of the poison. Respiratory symptoms will develop in as few as three hours.

 

Bioterrorism preparedness

 

With only a very few exceptions, most hospitals and healthcare facilities are not equipped to handle the mass destruction of a bioterrorist attack. There simply are not enough rooms, decontamination equipment, or protection suits available to safeguard the spread of disease throughout the hospital. The healthcare system would be saturated with hundreds of victims.

 

In response to the public outcry for the government to “do something”, antibiotics have been stockpiled, vaccines are being produced in mass quantities for mass inoculations, and government money is pouring into research projects ranging from early warning systems, to longer term research on antidotes.

 

Be prepared. One can never be really prepared for a bioterrorist attack, as an attack would most likely happen without any warning. There are ways in which you can reduce the risks of an attack.

Stay alert, especially in public places. Report any packages or bags left unattended or anyone acting suspiciously. Know the location of emergency exits. Never accept a package from a stranger.

 

A lot of uncertainty comes with the threat of a terrorist attack. Being aware is a big step toward feeling in control.

Hospital and healthcare providers must communicate with the appropriate internal and external personnel, including community agencies when confronted with an actual or potential bioterrorist attack or threat. Most facilities now have a plan in place to deal with bioterrorism. Find out what your plan is in the place you work.

 

Bioterrorism outbreaks are an element of surprise, generally unannounced. Detection becomes increasingly important for accurate assessment of unusual disease clusters or symptoms. Physician’s are then faced with the challenge of working with the symptoms and ruling out potential agents one by one.

 

Death toll will undoubtly be high, and a frantic hysteria will definitely be among us.

Although the likelihood of biological attack is unknown, significant preparation is underway by America. Many believe America is vulnerable. Many people have purchased equipment for protection against bioterrorism attack. Without prior knowledge of an attack, healthcare workers are also vulnerable and prone to fear. Many diseases caused by weaponized biological agents present with symptoms that can be misleading as a natural occurrence, rather than an act of terrorism. Hospital emergency rooms need to be very alert to large numbers of people presenting for treatment with similar signs and symptoms. Closely monitoring and observing these disease patterns may help save lives. Public education is also essential. Public information can help to minimize the spread of chemical contamination or infectious diseases caused by people fleeing from an area of panic.

 

As the United States prepares to deal with bioterrorism, the CDC recommends that nurses and healthcare providers monitor the CDC website for the latest news in bioterrorism information. www.bt.cdc.gov

The CDC’s plan includes public health communication systems, an infrastructure comprised of local, state and federal agencies. These systems are in place to rapidly respond to a threat to our nation. A large scale attack of a virus, aerosolized agent, nerve gas or other chemical agent would be overwhelming. Preparation plans are essential in the pre-planning stages to be ready and informed.

 

CDC is the first line of defense in the federal response to bioterrorism. Established in 1946 to combat malaria, typhus and other infectious diseases, the agency now has over 8,500 employees. The CDC headquarters is located in Atlanta, Ga. The bioterrorism Emergency Number at the CDC is 770-488-7100.

 

 

References:

Most of this article was comprised from the CDC website information for public access.
www.bt.cdc.gov

 

BIOPORT (Producers of anthrax vaccine) 517-327-1500

 

CDC, Biological and Chemical terrorism, Strategic planning workshop April, 2000

 

Federal Emergency Management Agency
www.fema.gov

 

Center for Disease Information
Washington, DC
202-332-0600

 

Chemical and Biological Arms Control
www.cbaci.org

Homeland Health
www.homelandhealth.com

Bioterrorism Preparedness

2 contact hours

Course # 105

Author: Monica Oram, RN, BSN

 

This course is intended for the reader to be able to achieve the following objectives:

  1. Understand the role of healthcare workers in preparing for bioterrorism activity

  2. Understand what bioterrorism is

  3. Identify five biological agents to be concerned about

  4. How to be prepared and stay alert

  5. What to do if an attack takes place

 

 

What is bioterrorism?

 

Bioterrorism is best described as the intentional release of harmful bacteria, viruses or germs, (called agents) released into the air or environment. Bioterrorism, like all forms of terrorism, aims to injure or kill people, cause panic or fear, and disrupt daily routines. Bioterrorism is different from other forms of terrorism in the aspect that unlike other attacks, a biological attack could take days or weeks to notice. By that time, many people may have been infected.

 

Many people have stated, “It is not a question of IF it can happen, it is a question of WHEN it will happen.” Biological weapons are the oldest form of the nuclear, biological, and chemical triad of weapons of mass destruction. Any organism or toxin found in nature that can be used to kill, incapacitate, or impede an adversary can be used as a biological weapon.

 

Bioterrorism is the use of a biological weapon against a living organism. The act of bioterrorism can range from hoaxes to an individual’s use of a biological agents in an attempt to produce mass destruction. One can not know when an act of bioterrorism can take place, but we can learn how to become prepared to handle such a situation.

 

On September 11, 2001, America became devastated and our security was shattered, perhaps forever, when foreign terrorists hijacked domestic airliners and crashed into the World Trade Center in New York City and the Pentagon in Arlington, Virginia. America was barely able to absorb the tragedy of the World Trade Center disaster, when Anthrax slowly invaded the most unlikely place: The United States Postal System. At the height of the anthrax scare, the United States postal service was receiving as many as 500 hoaxes or reports of incidents related to Anthrax every day. As a result, the use of weapons of mass destruction as a hoax is now considered a felony.

On September 25th,2001 the World Health Organization issued a statement that warned government agencies to strengthen their capacity to respond to attacks by chemical or biological weapons and to prepare for the possibility of attacks. Biological weapons are easy to acquire, manufacture, and use. A small amount can kill hundreds of thousands of people without harm to property. They are easy to conceal, transport, and disseminate.

Since the tragedy of 9/11, everyday vocabulary has included bioterrorism, emergency preparedness, weapons of mass destruction, and other words that reflect the recent acts of terror, fear about the future, and the role that further terrorist acts may play. Fears are reinforced every day as the mass media continues to explore and report new threats that are emerging, by observing increased security measures and armed guards at airports, and even opening the mail.

 

 

Three main forms of biological warfare were used before the twentieth century. Enemy food and water supplies were contaminated, Microorganisms and toxins were placed in the weapons systems, and fabrics were biologically inoculated with disease such as smallpox and shipped to major businesses and corporations for distribution to the communities.

 

The threat of bioterrorism today, is not much different from the attacks and actions conducted by terrorists for decades. Some research of documented terrorist activity using biological warfare has even dated back to as far as

1763! In this case, one of the earliest examples of bioterrorism in North America was the distribution of smallpox infected blankets at Fort Pitt. (Now known as Pittsburgh, Pa.) to start an epidemic among Chief Pontiac’s forces in 1763.

 

The difference of now compared to then, is that nuclear and biological warfare has become much more advanced and sophisticated over time with advancing technology.

 

 

Bioterrorism is definitely unpredictable in nature. The possibility of biological or chemical terrorism should not be ignored because the consequences of being unprepared will definitely have a devastating impact on America. Bioterrorism has been a part of the world for a very long time.

 

Definition of Key Terms

 

Emergency- refers to an extraordinary event or situation that requires existing community resources for rapid response.

 

Disaster- refers to an event or situation of a larger magnitude and of greater duration than an emergency. A disaster takes a toll on human basic needs such as water, food, sanitation, and shelter.

 

Natural disaster- defined by the World Health Organization as “ecological disruptions or threats that exceed the adjustment capacity of the affected community” They are natural disasters that are acts of nature, such as hurricane, flood, and earthquakes.

 

Man made disasters- events or situations that are caused by humans. Examples are environmental contamination of water, commercial waste, war and the events and acts of terrorism.

 

Weapons of mass destruction- includes biological, chemical, nuclear, or explosive material/devices and any combination of these, that can widely and rapidly adversely affect human life.

 

Some Documented Acts Of Terrorism

  • In 1945, an anthrax outbreak in Iran resulted in the death of approximately one million sheep.

  • In 1979, the former Soviet Union accidentally released an aerosolized form of anthrax spores from a military facility. The release caused approximately 79 cases of infectious inhalation of Anthrax. The death toll was 68.

  • Between 1979 and 1985, more than 10,000 humans have contracted anthrax exposure around the world.

  • As recently as 1995, the release of sarin ( a nerve gas) was released into a Tokyo subway. This terrorist attack killed 12 victims. The same terrorist group was linked to releasing anthrax and botulism in an aerosolized form throughout Tokyo.

  • In October 2001, evidence of bioterrorism hit Florida when a man was positively confirmed to have Anthrax in his cerebrospinal fluid. The autopsy indicated that the cause of death was inhalation of Anthrax.

  • Additional cases of Anthrax inhalation have been found in New Jersey, and the Nation’s capital in Washington, DC.

 

These cases, and others have prompted a need for public awareness. It has prompted a need for community education and a need to educate healthcare professionals about such bioterrorist disasters.

 

Biological Agents

 

Biological agents include, but are not limited to Anthrax, Smallpox, Botulism, Tularemia, and plagues.

 

Quick overview of each

Anthrax- Anthrax spores may be spread by direct skin contact or through the air. Some symptoms of cutaneous (skin) exposure include itching and boils. Symptoms of inhalation of Anthrax may be similar to the flu, but without congestion. Anthrax is not contagious.

 

Smallpox- Smallpox could be spread through the air. The first symptoms usually include a high fever, fatigue and body aches. These are usually followed by a rash, about 2-3 days later. This rash is generally most noticeable on the face, legs and arms. Smallpox is contagious and victims need to be isolated.

 

Botulism- Botulism may be spread through the air or by contaminated food. Symptoms include trouble seeing, breathing and swallowing. Botulism is not contagious.

 

Tularemia- Tularemia is spread through the air. Symptoms are similar to the flu. It is not known to be contagious.

 

Plague- The plague can be spread by infected fleas on rodents, or through the air. Symptoms include trouble seeing, breathing, or swallowing.

The plague is contagious.

Federal, state and local health-care and law enforcement agencies are forming plans to deal with these and other agents.

 

Anthrax

 

What is Anthrax?

Anthrax is an acute infectious disease caused by a bacterium called Bacillus anthracis. Anthrax most commonly occurs in livestock, but is known to infect humans as well. Anthrax is most common in agricultural regions where it occurs in animals. Although anthrax can be found globally, it is more often a risk in countries with less standardized and effective public health programs. Areas currently listed as high risk include South and Central America, Southern and Eastern Europe, Asia, Africa, the Caribbean, and the Middle East.

 

When Anthrax affects humans, it is usually due to an occupational exposure to infected animals. Workers who are exposed to dead animals and animal products (industrial anthrax) from other countries where anthrax is more common may become infected with B. Anthracis. Anthrax in animals rarely occurs in the United States and human anthrax is also rare, though there is a widespread concern due to bioterrorism. Anthrax spores can survive in soil for years and are resistant to extreme environmental conditions and can remain viable for decades, making it an excellent choice as an effective weapon.

 

How Anthrax is transmitted

Anthrax infection can occur in three forms.

  1. Inhalation ( pulmonary)

  2. Cutaneous ( skin)

  3. Gastrointestinal

 

Since anthrax can live in the soil for decades, animals become infected by grazing in contaminated pastures. Humans can become infected with Anthrax by handling infected animals or by inhaling anthrax spores from contaminated animals or animal products. Anthrax can also be spread by eating undercooked meat of infected animals.

 

Pulmonary anthrax is associated with bioterrorism exposure to aerosolized spores. Mortality is high despite antibiotic treatment if this type of anthrax is not treated before the onset of respiratory symptoms. Many will not be treated until symptoms appear, therefore making it very deadly.

 

A biological attack of anthrax would most likely occur with anthrax spores by aerosol delivery. Aerosol delivery is the most effective way to achieve extensive population exposure.

 

Cutaneous exposure can include handling of contaminated wool hides or hair in textile industries. This has become known as “wool handler’s disease” Cutaneous anthrax is not usually fatal if treated with antibiotics in a timely manner.

 

Gastrointestinal anthrax is usually fatal after it has progressed to toxemia and sepsis. Most commonly it is transmitted by ingestion of contaminated meat.

 

Common symptoms associated with Anthrax exposure

 

Inhalation Anthrax ( pulmonary) Initial symptoms may resemble the common cold. Inhalation anthrax can incubate for 2-60 days after pulmonary exposure. After several days, the symptoms progress to severe breathing problems and shock. Inhalation anthrax usually results in death in 1-2 days after onset of acute symptoms, if antibiotics are not initiated soon after exposure. This is a problem, because when the symptoms start to appear, it is to late for effective treatment. Symptoms begin with a non-specific type of flu like symptoms, with a brief interim of improvement. Approximately 2-4 days after initial symptoms, acute symptoms develop such as abrupt onset of respiratory failure, which is fatal 1-2 days after these symptoms arise.

 

Cutaneous anthrax (skin exposure) presents as localized itching, which resembles an insect bite. followed by papular lesions that blister and turn into painless ulcers, usually 1-3 cm in diameter within 2-6 days, then it turns into a depressed black eschar. Most anthrax skin exposure infections occur when the bacterium enters a cut or abrasion on the skin. Though absorption is also a way of transmission through the pores of the skin.

Death can be prevented with appropriate antibiotic therapy.

The incubation time for cutaneous anthrax exposure is 1-7 days for symptoms to arise.

 

Gastrointestinal anthrax 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. This type of anthrax exposure usually results in death after symptoms of toxemia and sepsis become prominent. The incubation period for gastrointestinal anthrax exposure is 1-7 days for symptoms to present.

 

Direct person to person contact of anthrax most likely does not occur. It is spread by inhalation, direct skin contact or ingestion of anthrax spores.

Transmission of cutaneous anthrax is possible but considered unlikely. Standard precautions should be implemented and open wounds should be covered with dressings.

 

Anthrax is diagnosed by isolating B. anthracis from the blood, skin lesions, or respiratory secretions or by measuring specific antibodies in the blood of suspected cases.

 

Treatment and Prevention

The treatment of choice includes the use of antibiotic Ciprofloxin.

Treatment needs to be done by prophylaxis management of cipro 500mg twice a day and continued until anthrax exposure is ruled out. If exposure is confirmed, then it needs to continue for about 8 more weeks. Other antibiotics used include levofloxacin, and ofloxicin.

 

The cell free anthrax vaccine should be given after a confirmed exposure to anthrax. Three doses of this vaccine are required, followed by three more and an annual booster to maintain immunity.

The first dose is administered immediately after confirming diagnosis. The second dose is given again in two weeks, and finally at four weeks the third dose is given. Then the person is given an injection at 6, 12, and 18 months following exposure. Then an annual booster thereafter.

There is currently only one vaccine for humans licensed in the United States. Because anthrax is considered to be a potential agent to be used in bioterrorism attack, the Department of Defense recently announced that it will begin vaccination of US Military personnel. Among civilians it will not be given unless exposure is confirmed. Though, the federal officials are recommending vaccinations for first responders and postal workers. The vaccine is said to be 95% effective in protecting against cutaneous anthrax exposure. It is not clearly known of percentage rate of effectiveness in regards to gastrointestinal and inhalation exposure to anthrax.

The Bioport Company in Michigan is currently the only manufacturer of the anthrax vaccine. There is only short supply of the vaccine available.

 

Smallpox

 

Smallpox is an acute viral illness caused by the variola virus. Smallpox is a bioterrorism threat due to its potential to cause severe morbidity in a non-immune population and because it can be transmitted via airborne route. A single case is considered a public health emergency.

 

Smallpox was declared eradicated in 1970. Now there is national concern that smallpox will hit the US again through acts of bioterrorism. The US stopped civilian vaccination in 1972. Now vaccinations may be a necessity. Smallpox can be easily manufactured in large quantities.

It is estimated that the current supply of smallpox vaccines is limited, but it is estimated that there are between 7.5 and 18 million doses of the vaccine in the CDC repository and 20 million doses stored at the World Health Organization. Federal officials have been negotiating with private drug companies to produce up to 300 million more doses by the end of 2004.

 

The variola virus is essentially a disease of tissue destruction. Viral particles are inhaled into the lungs. Patients are infectious 3-6 days after the appearance of fever. Patients may present with malaise, fatigue, fever, vomit, headache and backache. 2-3 days later, lesions appear which quickly evolve into macules to papules to pustular vesicles. The rash typically begins on the face and extremities, remaining abundant in these areas.

Smallpox can be transmitted widely by air and direct contact with the lesions. Patients are considered infectious if they are sneezing, coughing, or have a rash or lesions.

 

One confirmed case is considered to be a national emergency and a public health concern. Public health officials are to be notified immediately. The person should be isolated in a negative air pressure isolation room for at least 3 weeks, or until all lesions and scabs have separated from one another.

 

Those vaccinated prior to 1972 should be aware that the vaccine is estimated to be protective for a period of 10 years.

This will mean that even though some Americans were vaccinated for smallpox in the past, they will need to be revaccinated if smallpox becomes an epidemic. The vaccine is not currently available to civilians in the US. The CDC can obtain the vaccine when it is necessary.

 

Botulism

Foodborne botulism is a serious paralytic illness caused by a nerve toxin produced by the bacterium Clostridium Botulinum. It is caused by eating foods that contain the botulism toxin. This toxin may not give a bad taste or odor to foods. In humans, a characteristic flaccid paralysis occurs when the botulinem toxin inhibits the release of acetylcholine. Botulism is produced in spores that are present worldwide in soil and marine sediment. The most common form is food borne botulism, but there is an airborne type that also exists. Both forms may be a method of bioterrorism attack.

 

The symptoms include severe flu like symptoms, diarrhea, vomit, the patient may have no fever, they may experience respiratory problems due to paralysis of respiratory muscles.

 

It is predicted that if a bioterrorist attack happens by way of botulism, it will be aerosolized over livestock feed. For example, a dust cropping airplane could spread botulism through the air with the intention of contaminating the food source of grazing animals. After eating the meat, humans would become infected with the microorganism. The incubation time after aerosolization would be approximately 12-36 hours after ingestion. 24 - 72 hours after exposure, neurological symptoms will begin to appear.

 

Botulism is not transmitted from person to person.

 

Inhalation Botulism in the event of a bioterrorist attack would be substantially a major problem because the botulism toxin through inhalation is 15,000 times more toxic than nerve agents.

 

A vaccine is in the experimental stages at this point. It was developed by the Department of Defense. It is only available on an investigational basis. The vaccination should be given at the onset of exposure, again in two weeks, and then at four weeks after exposure. Routine immunization is not recommended unless exposure is confirmed.

 

Tularemia

 

The fear and concern with tularemia is that it can become an epidemic of bioterrorism attack by being spread and dumped from the air onto American soil. It will then infect humans and animals. Many wild animals will become infected. ( rabbits, squirrels, muskrats, beavers, deer, rodents, and the like) Tularemia is not spread from person to person, but it is spread from inoculation of the skin or mucous membranes with blood or tissue while handling or skinning a hunted animal, from fluids in infected fleas or ticks, or being bitten by infected fleas and ticks.

 

Symptoms include sudden high fever, chills, headaches, muscle aches, joint pain, dry cough, progressive weakness and then pneumonia. Symptoms usually appear in 3-5 days after exposure.

 

A vaccine is under review by the FDA, but none is currently available in the United States.

 

Plagues

 

Plague is most commonly transmitted by infected fleas, resulting in lymphatic and blood infections. Such as bubonic plague and septicemia plague)

 

A bioterrorist attack with this microorganism would most likely be airborne, causing a pneumonic plague.

The clinical manifestations would include fever, cough, chest pain, coughing blood, and a confirmed chest x-ray for pneumonia. Plague is usually transmitted by infected rodents, but aerosolized droplets are a mode of transmission. Incubation time is about 2-8 days. The incubation period for pneumonic plague is much shorter, 1-3 days because of pulmonary exposure. Mortality rate is 100% if not treated within 12-24 hours.

There is a vaccination for bubonic plague, but here is no vaccine effective for pneumonic plague. The bubonic vaccine is not available in the US. No vaccine exists for any other types of plague.

Ricin Poisoning

 

Another real concern in biological bioterrorism is the spread of ricin. Ricin is a stable toxin made from the mash that remains from castor beans for oil. Castor oil was once used as a laxative, but is now mainly used as an industrial lubricant and for manufacturing leather products.

The concern with bioterrorism is that it can be sprayed over the US and is a toxic, potent nerve gas. It is deadly and is transmitted by inhalation, ingestion, or injection of the poison. Respiratory symptoms will develop in as few as three hours.

 

Bioterrorism preparedness

 

With only a very few exceptions, most hospitals and healthcare facilities are not equipped to handle the mass destruction of a bioterrorist attack. There simply are not enough rooms, decontamination equipment, or protection suits available to safeguard the spread of disease throughout the hospital. The healthcare system would be saturated with hundreds of victims.

 

In response to the public outcry for the government to “do something”, antibiotics have been stockpiled, vaccines are being produced in mass quantities for mass inoculations, and government money is pouring into research projects ranging from early warning systems, to longer term research on antidotes.

 

Be prepared. One can never be really prepared for a bioterrorist attack, as an attack would most likely happen without any warning. There are ways in which you can reduce the risks of an attack.

Stay alert, especially in public places. Report any packages or bags left unattended or anyone acting suspiciously. Know the location of emergency exits. Never accept a package from a stranger.

 

A lot of uncertainty comes with the threat of a terrorist attack. Being aware is a big step toward feeling in control.

Hospital and healthcare providers must communicate with the appropriate internal and external personnel, including community agencies when confronted with an actual or potential bioterrorist attack or threat. Most facilities now have a plan in place to deal with bioterrorism. Find out what your plan is in the place you work.

 

Bioterrorism outbreaks are an element of surprise, generally unannounced. Detection becomes increasingly important for accurate assessment of unusual disease clusters or symptoms. Physician’s are then faced with the challenge of working with the symptoms and ruling out potential agents one by one.

 

Death toll will undoubtly be high, and a frantic hysteria will definitely be among us.

Although the likelihood of biological attack is unknown, significant preparation is underway by America. Many believe America is vulnerable. Many people have purchased equipment for protection against bioterrorism attack. Without prior knowledge of an attack, healthcare workers are also vulnerable and prone to fear. Many diseases caused by weaponized biological agents present with symptoms that can be misleading as a natural occurrence, rather than an act of terrorism. Hospital emergency rooms need to be very alert to large numbers of people presenting for treatment with similar signs and symptoms. Closely monitoring and observing these disease patterns may help save lives. Public education is also essential. Public information can help to minimize the spread of chemical contamination or infectious diseases caused by people fleeing from an area of panic.

 

As the United States prepares to deal with bioterrorism, the CDC recommends that nurses and healthcare providers monitor the CDC website for the latest news in bioterrorism information. www.bt.cdc.gov

The CDC’s plan includes public health communication systems, an infrastructure comprised of local, state and federal agencies. These systems are in place to rapidly respond to a threat to our nation. A large scale attack of a virus, aerosolized agent, nerve gas or other chemical agent would be overwhelming. Preparation plans are essential in the pre-planning stages to be ready and informed.

 

CDC is the first line of defense in the federal response to bioterrorism. Established in 1946 to combat malaria, typhus and other infectious diseases, the agency now has over 8,500 employees. The CDC headquarters is located in Atlanta, Ga. The bioterrorism Emergency Number at the CDC is 770-488-7100.

 

 

References:

Most of this article was comprised from the CDC website information for public access.
www.bt.cdc.gov

 

BIOPORT (Producers of anthrax vaccine) 517-327-1500

 

CDC, Biological and Chemical terrorism, Strategic planning workshop April, 2000

 

Federal Emergency Management Agency
www.fema.gov

 

Center for Disease Information
Washington, DC
202-332-0600

 

Chemical and Biological Arms Control
www.cbaci.org

Homeland Health
www.homelandhealth.com