Overview of Bioterrorism
This course has been awarded two (2.0) contact hours.

This course expires on November 12, 2014.
Copyright © 2008 by RN.com. All Rights Reserved. Reproduction and distribution of these materials are prohibited without the express written authorization of RN.com.

First Published: Updated:

November 12, 2008 Nov 12, 2011

IMPORTANT INFORMATION RN.com strives to keeps its content fair and unbiased. The author has no conflicts of interest to disclose. The planners of the educational activity have no conflicts of interest to disclose. (Conflict of Interest Definition: Circumstances create a conflict of interest when an individual has an opportunity to affect Education content about products or services of a commercial interest with which he/she has a financial relationship.) There is no commercial support being used for this course. Participants are advised that the accredited status of RN.com does not imply endorsement by the provider or ANCC of any products/therapeutics mentioned in this course. The information in the course is for educational purposes only. There is no “off label” usage of drugs or products discussed in this course.

Acknowledgements
RN.com acknowledges the valuable contributions of…
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…The Centers for Disease Control (CDC) (www.cdc.gov), the key government agency responsible for disseminating knowledge about various biological agents. …U.S. Medical Research Institute of Infectious Diseases (USAMRRID). USAMRRID spearheads efforts to protect service members from biological threats. Its efforts are well known and utilized by the civilian population. USAMRRID is located at Fort Detrick, Maryland. …Nadine Salmon, RN, BSN, IBCLC is the Clinical content Specialist for RN.com. Nadine earned her BSN from the University of the Witwatersrand, Johannesburg, South Africa. She worked as a midwife in Labor and Delivery, an RN in Postpartum units and Antenatal units, before moving to the United Kingdom, where she worked as a Medical Surgical Nurse. After coming to the US in 1997, Nadine worked in obstetrics and became a Board Certified Lactation Consultant. Nadine was the Clinical Pre Placement Manager for the International Nurse Staffing division before joining RN.com. When not writing courses and other educational materials, Nadine is currently pursuing her master’s degree in Nursing Leadership. …Karen Siroky, RN, MSN, course coordinator of Overview of Bioterrorism. Karen is the Senior Director of Education for RN.com. Karen received her B.S.N. from the University of Arizona and her MSN from San Diego State University. Her nursing experience includes ICU, transplant coordination, recruitment, quality improvement, information and education. She has previously published articles on Quality Improvement and Cardiac Transplantation.

Purpose and Objectives
Define the signs, symptoms, and modes of transmission of the most likely biological warfare agents. 1. Identify how to report a potential bioterrorist attack. 2. Describe how decontamination can occur. 3. Describe how treatment locations and personnel are managed. 4. Describe how treatment supplies are obtained. After successful completion of this course, you will be able to: The purpose of this course is to provide the learner with information needed to prepare for and respond to a bioterrorism attack.

Introduction
Bioterrorism is a national security issue. Numerous state and federal agencies are dedicated to prevention, reporting and management of any potential terrorist act, including bioterrorism. Federal, state, and local agencies are working together to define plans and run mock drills that will assist in a response to a biological terrorist attack.

What is Bioterrorism?
Terrorism is the use of force or violence against persons or property in violation of the criminal laws of the United States for purposes of intimidation, coercion, or ransom. Terrorists often use threats to create fear among the public, to try to convince citizens that their government is powerless to prevent terrorism, and to get immediate publicity for their causes. The Federal Bureau of Investigation (FBI) categorizes terrorism in the United States as one of two
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types: Domestic terrorism or international terrorism. Domestic terrorism involves groups or individuals whose terrorist activities are directed at elements of our government or population without foreign direction. International terrorism involves groups or individuals whose terrorist activities are foreign-based and/or directed by countries or groups outside the United States or whose activities transcend national boundaries. Bioterrorism is the employment of bacteria, viruses, or other biological toxins to intimidate societies or governments. This is usually for political or ideological reasons.

Biological and Chemical Weapons
Biological agents are infectious microbes or toxins used to produce illness or death in people, animals, or plants in order to intimidate or coerce a government or civilian population. Biological agents can be dispersed as aerosols or airborne particles. Terrorists may use biological agents to contaminate food or water because they are extremely difficult to detect. Chemical agents kill or incapacitate people, destroy livestock, or ravage crops. Some chemical agents are odorless and tasteless and are difficult to detect. They can have an immediate effect (a few seconds to a few minutes) or a delayed effect (several hours to several days). Biological and chemical weapons have been used primarily to terrorize an unprotected civilian population and not as a weapon of war. This is because of fear of retaliation and the likelihood that the agent would contaminate the battlefield for a long period of time. The Persian Gulf War in 1991 and other confrontations in the Middle East were causes for concern in the United States regarding the possibility of chemical or biological warfare. While no incidents occurred, there remains a concern that such weapons could be involved in an accident or be used by terrorists.

Preparation for Potential Attack of Bioterrorism
Local or interjurisdictional emergency management agencies create and keep current a plan of disaster mitigation, preparedness, response, and recovery. Responsibilities of various persons and agencies must be clearly outlined. The Federal Emergency Management Agency (FEMA), part of Department of Homeland Security (DHS), oversees the federal emergency management efforts.

Clues to a Biologic Warfare (BW) or Terrorist Attack
The U.S Army Medical Research Institute of Infectious Diseases (USAMRIID) located at Fort Derick, Maryland lists the following as epidemiological clues to a possible biologic related terrorist attack: • • • • • • The presence of a large epidemic with a similar disease or syndrome, especially in a discrete population Many cases of unexplained diseases or deaths More severe disease than is usually expected for a specific pathogen or failure to respond to standard therapy Unusual routes of exposure for a pathogen, such as the inhalation route for diseases that normally occur through other exposures A disease that is unusual for a given geographic area or transmission season Disease normally transmitted by a vector that is not present in the local area

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•

Multiple simultaneous or serial epidemics of different diseases in the same population

Clues to a Biologic Warfare (BW) or Terrorist Attack
Additional clues to an attack include the following: • • • • • • •
•

A single case of disease by an uncommon agent (smallpox, some viral hemorrhagic fevers) A disease that is unusual for an age group Unusual strains or variants of organisms or antimicrobial resistance patterns different from those circulating Similar genetic type among agents isolated from distinct sources at different times or locations Higher attack rates in those exposed in certain areas, such as inside a building if released indoors, or lower rates in those inside a sealed building if released outside Disease outbreaks of the same illness occurring in noncontiguous areas A disease outbreak with zoonotic (a disease that can be transmitted from animals to humans) impact Intelligence of a potential attack, claims by a terrorist or aggressor of a release, and discovery of munitions or tampering (USAMRIID, 2011).

Agents of Bioterrorism
Potential agents of bioterrorism are classified into 3 categories. This course details those diseases in Category A or high priority agents. Category A, or high-priority agents include organisms that pose a risk to national security because they: • • • • Can be easily disseminated or transmitted from person to person. Result in high mortality rates and have the potential for major public health impact. Might cause public panic and social disruption. Require special action for public health preparedness.

For each agent this course presents an overview, symptoms, treatments, vaccines, and decontamination issues. At the end of this section there is a discussion on decontamination in general. U.S Army Medical Research Institute of Infectious Diseases (USAMRIID) www.usamriid.army.mil/education, located at Fort Detrick, MD is the source of the critical information on the Category A potential agents of bioterrorism.

Anthrax Outbreak of 2001
After the World Trade Center bombings of September 2001, anthrax was sent through the mail to several different sites. From October to November 20, 2001, 22 cases of anthrax were diagnosed. Eleven were inhalational and eleven were cutaneous. Five cases were fatal. Nine of the eleven inhalational cases involved either postal or non postal workers who handled mail. Four letters containing anthrax spores were known to have been mailed. The initial group of letters was mailed to the media, the second group to government leaders. These outbreaks shut down media outlets and governmental buildings and agencies for days, as well as the postal service centers that served these
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buildings. This outbreak of anthrax and clear case of bioterrorism initiated the development of policies to manage other possible bioterrorist attacks.

Anthrax
Overview Bacillus anthracis, the causative agent of Anthrax, is a gram-positive, sporulating rod. The spores are the usual infective form. Anthrax is primarily a zoonotic disease of herbivores, with cattle, sheep, goats, and horses being the usual domesticated animal hosts. Other animals may be infected. Humans generally contract the disease when handling contaminated hair, wool, hides, flesh, blood, and excreta of infected animals, and from manufactured products such as bone meal. Infection is introduced through scratches or abrasions of the skin, wounds, inhalation of spores, eating insufficiently cooked infected meat, or by being bitten by fleas. The primary concern for intentional infection by this organism is through inhalation after aerosol dissemination of spores. All human populations are susceptible. The spores are very stable and may remain viable for many years in soil and water. They resist sunlight for varying periods. Signs and Symptoms Incubation period is generally 1–6 days. Fever, malaise, fatigue, cough, and mild chest discomfort progresses to severe respiratory distress with dyspnea, diaphoresis, stridor, cyanosis, and shock. Death typically occurs within 24–36 hours after onset of severe symptoms. Contagious?

NO!

Anthrax
Diagnosis Physical findings are non-specific. A widened mediastinum may be seen on CXR in later stages of illness. The organism is detectable by Gram stain of the blood and by blood culture late in the course of illness. Treatment Less effective after symptoms begin. High dose antibiotic treatment with penicillin, ciprofloxacin, or doxycycline and supportive therapy are standard. Prophylaxis Oral ciprofloxacin (Cipro) or doxycycline (Vibramycin) is used for known or imminent exposure. An FDA vaccine is available, and is given at various intervals followed by annual boosters. Anthrax vaccine is made from a strain of the anthrax bacteria that cannot cause anthrax infection. This vaccine does not contain mercury, penicillin, fetal tissue, eggs,or pork. The licensed schedule for anthrax vaccine is 0-4 weeks, 6-12-18 months, plus annual boosters. In 2008, the FDA approved a change in the vaccination series by removing the 2 week dose and asserting the safety and effectiveness of the new 5 dose regimen. This is a change from the originally licensed 6 dose
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regimen. Isolation and Decontamination Standard precautions are used. After an invasive procedure or autopsy, instruments and area used are disinfected with a sporicidal agent (hypochlorite).

Plague: Overview
Yersinia pestis is a rod-shaped, non-motile, non-sporulating, gram-negative bacterium. It causes plague, a zoonotic disease of rodents (e.g., rats, mice, ground squirrels). Fleas that live on the rodents can transmit the bacteria to humans, who then suffer from the bubonic form of plague. The bubonic form may progress to the septicemic and/or pneumonic forms. Pneumonic plague is the predominant form after a purposeful aerosol dissemination. All human populations are susceptible. Recovery from the disease is followed by temporary immunity. The organism remains viable in water, moist soil, and grains for several weeks. At near freezing temperatures, it will remain alive from months to years but is killed by 15 minutes of exposure to 55°C. It also remains viable for some time in dry sputum, flea feces, and buried bodies but is killed within several hours of exposure to sunlight. Contagious?

YES!
Plague: Symptomology & Diagnosis
Signs and Symptoms Pneumonic plague begins after an incubation period of 1–6 days, with high fever, chills, headache, malaise, followed by cough (often with hemoptysis), progressing rapidly to dyspnea, stridor, cyanosis, and death. Gastrointestinal symptoms are often present. Death results from respiratory failure, circulatory collapse, and a bleeding diathesis. Bubonic plague, featuring high fever, malaise, and painful lymph nodes (buboes) may progress spontaneously to the septicemic form (septic shock, thrombosis, DIC) or to the pneumonic form. Diagnosis Suspect plague if large numbers of previously healthy individuals develop fulminant Gram negative pneumonia, especially if hemoptysis is present. Presumptive diagnosis can be made by Gram, Wright, Giemsa, or Wayson stain of blood, sputum, CSF, or lymph node aspirates. Definitive diagnosis requires culture of the organism from those sites. Immunodiagnosis is also helpful.

Plague: Management & Prevention
Treatment Early administration of antibiotics is critical, as pneumonic plague is fatal if therapy is delayed. Effective antibiotics include: streptomycin, gentamicin (Garamycin), ciprofloxacin (Cipro), or
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doxycycline (Vibramycin). Chloramphenicol (Chloromycetin) is used for for plague meningitis. Prophylaxis For exposed but asymptomatic persons or for a patient with suspected pneumonic plague, doxycycline (Vibramycin) is given. Alternative antibiotics include ciprofloxacin (Cipro), tetracycline, or chloramphenicol (Chloromycetin). No vaccine is currently available for plague prophylaxis. Isolation and Decontamination Use Standard Precautions for bubonic plague and Respiratory Droplet Precautions for suspected pneumonic plague. Y. pestis can survive for varying periods, but is susceptible to heat, disinfectants, and exposure to sunlight. Soap and water are effective decontaminants. Take measures to prevent local disease cycles if vectors (fleas) and reservoirs (rodents) are present.

Tularemia: Overview & Symptomology
Overview Francisella tularensis, the causative agent of tularemia, is a small, aerobic non-motile, gram-negative cocco-bacillus. Tularemia (also known as rabbit fever and deer fly fever) is a zoonotic disease that humans typically acquire after skin or mucous membrane contact with tissues or body fluids of infected animals, or from bites of infected ticks, deerflies, or mosquitoes. Less commonly, inhalation of contaminated dusts or ingestion of contaminated foods or water may produce clinical disease. Respiratory exposure by aerosol would typically cause typhoidal or pneumonic tularemia. F. tularensis can remain viable for weeks in water, soil, carcasses, hides, and for years in frozen rabbit meat. It is resistant for months to temperatures of freezing and below. It is easily killed by heat and disinfectants. Signs and Symptoms Ulceroglandular tularemia presents with a local ulcer and regional lymphadenopathy, fever, chills, headache, and malaise. Typhoidal tularemia presents with fever, headache, malaise, substernal discomfort, prostration, weight loss, and a non-productive cough. Contagious?

NO!
Tularemia: Diagnosis, Management & Prevention
Diagnosis Physical findings are usually non-specific. Chest x-ray may reveal a pneumonic process, mediastinal lymphadenopathy, or pleural effusion. Routine culture is possible but difficult. The diagnosis can be established retrospectively by serology. Treatment Administration of antibiotics (streptomycin or gentamicin [Garamycin]) with early treatment is very effective.
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Prophylaxis A live, attenuated vaccine is available as an investigational new drug. It is administered once by scarification. A two-week course of tetracycline is effective as prophylaxis when given after exposure. Isolation and Decontamination Standard Precautions for healthcare workers. Organisms are relatively easy to render harmless by mild heat (55 degrees Celsius for 10 minutes) and standard disinfectants.

Botulinum: Overview
The botulinum toxins are a group of seven related neurotoxins produced by the spore-forming bacillus Clostridium botulinum and two other Clostridia species. These toxins are the most potent neurotoxins known; paradoxically, they have been used therapeutically to treat spastic conditions (strabismus, blepharospasm, torticollis, tetanus) and cosmetically to treat wrinkles. The spores are ubiquitous; they germinate into vegetative bacteria that produce toxins during anaerobic incubation. Industrial-scale fermentation can produce large quantities of toxin for use as a BW agent. There are three epidemiologic forms of naturally occurring botulism: Food borne, infantile, and wound. Botulinum could be delivered by aerosol or used to contaminate food or water supplies. When inhaled, these toxins produce a clinical picture very similar to food borne intoxication, although the time to onset of paralytic symptoms after inhalation may actually be longer than for food borne cases, and may vary by type and dose of toxin. The clinical syndrome produced by these toxins is known as "botulism." Contagious?

NO!
Botulinum
Signs and Symptoms Symptoms usually begins with cranial nerve palsies, including ptosis, blurred vision, diplopia, dry mouth and throat, dysphagia, and dysphonia. This is followed by symmetrical descending flaccid paralysis, with generalized weakness and progression to respiratory failure. Symptoms can begin 12–36 hours after inhalation, but may take several days after low level exposure. Diagnosis Diagnosis is primarily a clinical one. Biowarfare attack are suspected if multiple persons present with progressive descending flaccid paralysis. Lab confirmation can be obtained by bioassay (mouse neutralization) of the patient’s serum. Other helpful labs include: ELISA or ECL for antigen in environmental samples, PCR for bacterial DNA in environmental samples, or nerve conduction studies and electromyography.

Botulinum: Management & Prevention
Treatment
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Early administration of trivalent licensed antitoxin or heptavalent antitoxin (IND product) may prevent or decrease progression to respiratory failure and hasten recovery. Intubation and ventilatory assistance for respiratory failure. Tracheostomy may be required. Prophylaxis Pentavalent toxoid vaccine (types A, B, C, D, and E) is available as an IND product for those at high risk of exposure.

Isolation and Decontamination Standard Precautions for healthcare workers. Toxin is not dermally active and secondary aerosols are not a hazard from patients. Decontaminate with soap and water. Botulinum toxin is inactivated by sunlight within 1–3 hours. Heat (80OC for 30 min., 100OC for several minutes) and chlorine (>99.7% inactivation by 3 mg/L FAC in 20 min.) also destroy the toxin.

Viral Toxins
Viral agents may also be used as agents of bioterrorism. The viral agents that are considered as Category A agents are: • • Smallpox Viral Hemorrhagic Fevers

Viral Hemorrhagic fevers includes several key diseases from diverse toxins, but are grouped together for discussion as they have the potential to be aerosolized.

Smallpox: Overview & Symptomology
Overview Smallpox is caused by the virus variola, which occurs in at least two strains, variola major and the milder disease, variola minor. Despite the global eradication of smallpox and continued availability of a vaccine, the potential weaponization of variola continues to pose a military threat. This threat can be attributed to the aerosol infectivity of the virus, the relative ease of large-scale production, and an increasingly smallpox-naive population. The fully developed cutaneous eruption of smallpox is unique, but earlier stages of the rash can be mistaken for varicella (Chicken pox). Secondary spread of infection can occur from the time of onset of the rash until scabs have separated. Quarantine with respiratory isolation should be applied to secondary contacts for 17 days post-exposure. Vaccinia vaccination and vaccinia immune globulin each possess some efficacy in post-exposure prophylaxis. Contagious?

YES!
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Signs and Symptoms Clinical manifestations begin acutely with malaise, fever, rigors, vomiting, headache, and backache. 2–3 days later lesions appear which quickly progress from macules to papules, and eventually to pustular vesicles. They are more abundant on the extremities and face, and develop synchronously.

Smallpox: Diagnosis, Management & Prevention
Diagnosis Neither electron nor light microscopy are capable of discriminating variola from vaccinia, monkeypox, or cowpox. The new PCR diagnostic techniques may be more accurate in discriminating between variola and other similar viruses.. Treatment There is no effective drug therapy, and treatment remains supportive. Prophylaxis Immediate vaccination or revaccination for anyone exposed. Isolation and Decontamination Droplet and Airborne Precautions for a minimum of 17 days following exposure for all contacts. Patients are considered infectious until all scabs separate. Quarantine of asymptomatic contacts for 17 days is the desired preventative measure. If this cannot be enforced, an alternative is to require contacts to check their temperatures daily. Any fever above 38° C (101° F) up to 17 days following exposure to a confirmed case would suggest smallpox. The person is immediately isolated, until smallpox is either confirmed or ruled out.

Viral Hemorrhagic Fevers: An Overview & Symptomology
The viral hemorrhagic fevers are a diverse group of illnesses caused by RNA viruses from four viral families. The Arenaviridae include the etiologic agents of Argentine, Bolivian, and Venezuelan hemorrhagic fevers, and Lassa fever. The Bunyaviridae include the members of the Hantavirus genus, the Congo-Crimean hemorrhagic fever virus from the Nairovirus genus, and the Rift Valley fever virus from the Phlebovirus genus; the Filoviridae include Ebola and Marburg viruses; and the Flaviviridae include dengue and yellow fever viruses. These viruses are spread in a variety of ways; some may be transmitted to humans through a respiratory portal of entry. Although evidence for weaponization does not exist for many of these viruses, they are included in this handbook because of their potential for aerosol dissemination or weaponization, or likelihood for confusion with similar agents that might be weaponized.

Contagious?

YES!
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Signs and Symptoms VHFs are febrile illnesses which can feature flushing of the face and chest, petechiae, bleeding, edema, hypotension, and shock. Malaise, myalgias, headache, vomiting, and diarrhea may occur in any of the hemorrhagic fevers.

Viral Hemorrhagic Fevers: Diagnosis, Management & Prevention
Diagnosis Definitive diagnosis rests on specific virologic techniques. Significant numbers of military personnel with a hemorrhagic fever syndrome should suggest the diagnosis of a viral hemorrhagic fever. Treatment Intensive supportive care may be required. Antiviral therapy with ribavirin (Virazole) may be useful . Convalescent plasma may be effective in Argentine hemorrhagic fever, available only as IND (Investigational New Drug) under protocol. Prophylaxis The only licensed VHF vaccine is yellow fever vaccine. Prophylactic ribavirin (Virazole) may be effective for Lassa fever, Rift Valley fever, Crimean-Congo Hemorrhagic Fever (CCHF), and possibly Hemorrhagic Fever with Renal Syndrome (HFRS); it is only available as IND under protocol.

Viral Hemorrhagic Fevers: Isolation & Decontamination
Contact isolation, with the addition of a surgical mask and eye protection for those coming within three feet of the patient, is indicated for suspected or proven Lassa fever, CCHF, or filovirus infections. Respiratory protection should be upgraded to airborne isolation, including the use of a fit-tested HEPA filtered respirator, a battery powered air purifying respirator, or a positive pressure supplied air respirator, if patients with the above conditions have prominent cough, vomiting, diarrhea, or hemorrhage. Decontamination is accomplished with hypochlorite or phenolic disinfectants.

Decontamination Overview
Contamination is the introduction of an infectious agent on a body surface, food or water, or other inanimate objects. Decontamination involves either disinfection or sterilization to reduce microorganisms to an acceptable level on contaminated articles, thus rendering them suitable for use. Disinfection is the selective reduction of undesirable microbes to a level below that required for transmission. Sterilization is the killing of all organisms. Decontamination methods have always played an important role in the control of infectious diseases. However, we are often unable use the most efficient means of rendering microbes harmless (e.g., toxic chemical sterilization), as these methods may injure people and damage materials which are to be decontaminated. BW agents can be decontaminated by mechanical, chemical and physical methods.
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Mechanical Decontamination
Mechanical decontamination involves measures to remove but not necessarily neutralize an agent. An example is the filtering of drinking water to remove certain water-borne pathogens or in a BW context, the use of an air filter to remove aerosolized anthrax spores, or water to wash agent from the skin.

Physical Decontamination
Agents can be rendered harmless through such physical means as heat and radiation. To render agents completely harmless, sterilize with dry heat for two hours at 160 degrees centigrade. If autoclaving with steam at 121 degrees centigrade and 1 atmosphere of overpressure (15 pounds per square inch), the time may be reduced to 20 minutes, depending on volume. Solar ultraviolet (UV) radiation has a disinfectant effect, often in combination with drying. This is effective in certain environmental conditions but hard to standardize for practical usage for decontamination purposes.

Chemical Decontamination
Chemical decontamination renders BW agents harmless by the use of disinfectants that are usually in the form of a liquid, gas, or aerosol. Some disinfectants are harmful to humans, animals, the environment, and materials.

Skin Treatment after Exposure
Skin exposure to a suspected BW aerosol should be immediately treated by soap and water decontamination. Careful washing with soap and water removes nearly all of the agent from the skin surface. Hypochlorite solution or other disinfectants are reserved for gross contamination (i.e. following the spill of solid or liquid agent from a munition directly onto the skin). In the absence of chemical or gross biological contamination, these will confer no additional benefit, may be caustic, and may predispose to colonization and resistant superinfection by reducing the normal skin flora. Grossly contaminated skin surfaces should be washed with a 0.5% sodium hypochlorite solution, if available, with a contact time of 10 to 15 minutes.

Hypochlorite
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Hypochorite is found in common bleach. Standard "Clorox" bleach is 5.25.% sodium hypochlorite. The amount of sodium hypochlorite in other bleaches ranges from 3-6%. Hypochlorite solutions must NOT be used in: • Open body cavity wounds, as it may lead to the formation of adhesions. • Brain and spinal cord injuries. However, this solution may be instilled into non-cavity wounds and then removed by suction to an appropriate disposal container. Within about five minutes, this contaminated solution will be neutralized and nonhazardous. Subsequent irrigation with saline or other surgical solutions should be performed. Prevent the chlorine solution from being sprayed into the eyes, as corneal opacities may result. For decontamination of fabric clothing or equipment, a 5% hypochlorite solution should be used. For decontamination of equipment, a contact time of 30 minutes prior to normal cleaning is required. This is corrosive to most metals and injurious to most fabrics, so rinse thoroughly and oil metal surfaces after completion.

Environmental Decontamination
The health hazards posed by environmental contamination by biological agents differ from those posed by persistent or volatile chemical agents. Many aerosolized agents are eventually inactivated by solar ultraviolet light. Little, if any, environmental residues would occur. Possible exceptions include residue near the dissemination line, or in the immediate area surrounding a point-source munition. Agents deposited on the soil would be subject to degradation by environmental stressors, and competing soil microflora. Studies suggest that secondary reaerosolization would be difficult, and would probably not pose a human health hazard. Rooms in fixed spaces are best decontaminated with gases or liquids in aerosol form (e.g., formaldehyde). This is usually combined with surface disinfectants to ensure complete decontamination (U.S Army Medical Research Institute of Infectious Diseases, 2005).

Reporting Possible Bioterrorism Acts
You can report possible acts of bioterrorism in any number of ways. • • • • • • Contact your state or local health department Regional Poison Control Centers: 1-800-222-1222 Coordinating Office for Terrorism Preparedness and Emergency Response: 404-639-7405 Bioterrorism Preparedness and Response Program: 404-639-0385 National Center for Environmental Health and Agency for Toxic Substances and Disease Registry: 770-488-7100 Call 911

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Acquisition of Treatment Related Supplies
The SNS (Strategic National Supply) is a national repository of antibiotics, antidotes, antitoxins, life-support medications, IVs, airway maintenance supplies, and medical/surgical items. SNS is activated to provide appropriate treatment supplies as quickly as possible. During a national emergency, state, local, and private stocks of medical materiel will be depleted quickly. State and local first responders and health officials can use the SNS to bolster their response to a national emergency, with a 12-hour Push Package, VMI, or a combination of both, depending on the situation. The SNS is not a first response tool. The SNS first lines of support are the immediate response "12-hour Push Packages." These include items designed to provide rapid delivery of a broad spectrum of assets in the early hours of an an ill defined threat. These Push Packages are strategically positioned in secure warehouses. They can be deployed within within 12 hours of the federal decision to deploy SNS assets.

Acquisition of Treatment Related Supplies
If additional pharmaceuticals and/or medical supplies are required, follow-on Vendor Managed Inventory (VMI) supplies arrive within 24 to 36 hours. If the agent is well defined, VMI can be tailored to provide pharmaceuticals, supplies and/or products specific to the suspected or confirmed agent(s). In this case, the VMI could act as the first option for immediate response from the SNS DHS will transfer authority for the SNS materiel to the state and local authorities once it arrives at the designated receiving and storage site. State and local authorities will then begin the breakdown of the 12-hour Push Package for distribution. SNS members will remain on site in order to assist and advise state and local officials in putting the SNS assets to prompt, and effective use.

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When and How is the SNS Deployed?
The decision to deploy SNS assets may be based on evidence showing the overt release of an agent that might adversely affect public health. It is more likely, however, that subtle indicators, such as unusual morbidity and/or mortality identified through the nation’s disease outbreak surveillance and epidemiology network, will alert health officials to the possibility (and confirmation) of a biological or chemical incident or a national emergency. To receive SNS assets, the affected state’s governor’s office will directly request the deployment of the SNS assets from the Centers for Disease Control and Prevention (CDC), or the Department of Homeland Security (DHS). DHS, CDC, and other federal officials will evaluate the situation and determine a prompt course of action.

Facility Organized Response Plan
Facilities across the country have developed and tested their organized response plan to emergencies, including bioterrorism. The keys to each plan are generally the same: 1. Mitigation: The planning process that takes place prior to any event to lessen the impact from an event. 2. Preparedness: Activities taken to prepare for response including interagency and/or interfacility contracts that would assist in the management of an event. 3. Response: The actual activities that take place that follow the preparedness plan. 4. Recovery: Activities that take place once the key event has passed to begin to work through the process to move “back to normal” (Texas Department of Public Safety, Division of Emergency Management, 2011).

Facility Organized Response Plan
Your facility plan will most likely include the following sections that will assist healthcare providers in an emergency response situation. Areas included are generally the following: • • A Hospital Incident Command Center Training and Education

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• • • • • • • • •

Decontamination of Patient and Environment Evidence Collection Preparing for a Large Influx of Patients Managing the Psychological Aspects of Bioterrorism The Media Role of Laboratory, Pharmacy, other support services Discharge Planning Post Mortem Care Concept of Emergency Management Planning

Facility Organized Response Plan
Your facility plan will discuss each of these in detail. In this course we will briefly outline 3 areas: • • • Evidence Collection Laboratory Support Post Mortem Care

(Decontamination and Pharmacy issues were discussed in the sections on “Decontamination” and the Strategic National Supply ) These are examples of how plans might work. Your facility may have a different plan. Always defer to your facility plan.

Evidence Collection
Although patient care is the paramount mission of the hospital, it is possible that evidence may need to be collected for law enforcement agencies. In general, the hospital Infection Control Department would be the key persons involved in developing this policy and in making certain it is carried out. Lines of authority, evidence chain of custody, management of patient clothing, and valuables are all issues that should be addressed in the policy.

Laboratory Support
Laboratories at different facilities have different levels of capability for identifying and managing agents that may be used in bioterrorism. Depending on the facility type, certain specimens will need to be sent to a laboratory within the state, or even a federal laboratory for identification of specimens. Specific policies need to outline this process.

Post Mortem Care
Hospitals work with the local government agencies and public health services to determine what action to take if the number of deceased persons exceeds the capacity of the hospital morgue.
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Additionally, the public health department will be responsible for determining if the local facility does the autopsy, or if it is handled in a different fashion. Policies outlining the correct contact persons and management of this process will be in place.

Patient Care Planning
Patient care planning issues are different for every patient and this includes patients who enter a facility after exposure to a bioterrorism agent. However, there are some key components that are similar based on the pathogen the patient is exposed to: • • • • • Isolation Precautions (level of precautions; other special isolation needs). Patient Placement- (private room; room with patients with similar symptoms; airflow/filter issues). Patient Transport Issues (in room only; transport with mask; unlimited movement). Cleaning and Disinfection of Equipment (type of cleaning; equipment / linen reuse; medical waste disposal; cleaning and disinfection at home). Post Mortem Care (Type of precautions, mask, disinfectants).

Community Education
Healthcare professionals are ideally positioned to act as community educators regarding bioterrorism prevention and preparedness, and can educate the public in disaster preparation to help people deal more effectively with acts of bioterrorism or other disasters if and when they occur (CDC, 2011). The Centers for Disease Control and Prevention (CDC) and the American Red Cross have joined forces to provide step by step guidance the public can follow in preparing for a disaster or act of terrorism. These organizations recommend that the public: 1. Get a Kit: Gather Emergency Supplies 2. Make a plan: Develop a Family Disaster Plan 3. Stay Informed: Learn how to shelter in place, understand quarantine and isolation and maintain a healthy state of mind. The CDC also provides a template for use in communicating with the public within the first minutes after a suspected terrorism incident when little is known (See Appendix 2).

Resources
Knowing what resources to use is key in the event of a biological attack. The following list of resources is one that provides both federal and state specific information on bioterrorism, response, and treatment issues.
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Centers for Disease Control (www.cdc.gov). The central federal government agency with information about infectious diseases Department of Homeland Security (www.dhs.gov). The federal agency tasked with making sure the nation is secure. Federal Emergency Management Agency (www.fema.gov). The federal agency within DHS whose responsibility is emergency response at the federal level to all types of emergencies, including bioterrorist attacks. U.S Army Medical Research Institute of Infectious Diseases (USAMRIID) (www.usamriid.army.mil/education). A key source of critical information on various potential biological weapons.

Conclusion
Bioterrorism attacks have occurred both inside and outside of the U.S. In the past several years, federal, state and local agencies, along with healthcare facilities, have outlined plans that help prepare for the possibility of an attack. Through these coordinated plans, a quicker and more effective response can be undertaken. Information in this course is meant to be general and is current at the time of publication. Due to the nature of bioterrorism, as well as changing guidelines, you are always directed to follow your facility policies and procedures when dealing with a possible bioterrorism attack.

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