
NURSING IN THE ERA OF
BIOTERRORISM
Definition of Bioterrorism


Premeditated threat or actual use of biological
weapons to produce disease or death in people,
animals, or plants.
Biological weapons: microbes or their toxins.
Biological Weapons
Bioterrorism Overview


Microorganisms or their toxins can be in liquid or
powder form.
Various delivery methods are possible:




aerosol
envelope or package
food or water contamination
Exposure can be isolated to a single area or can be
more widespread.
Bioterrorism
Microorganisms as biologic weapons would
most likely result in illness occurring days to
weeks after attack and would affect persons
dispersed from the site.
Biological Agents:
Types and Characteristics
Bacteria
Viruses
Biological Toxins
CDC Categories

Category A:






easily disseminated OR transmitted person to
person
susceptible population
potential for panic / disruption
requires special action for treatment
high morbidity and mortality
examples: anthrax, smallpox, plague, botulism,
viral hemorrhagic fevers
CDC Categories


Category B:
moderately easy to disseminate



moderate morbidity, low mortality
examples: Q fever, brucellosis, glanders, some
toxins
Category C:



emerging pathogens that could be engineered for
mass dissemination in the future
potential for high morbidity and mortality
examples: hantavirus, tickborne viruses, MDR TB
Isolation Precautions

Standard (“blood and body fluid”):




gloves
mask with face shield
gown
Airborne:

standard plus negative pressure room and N95 mask
(“duckbill mask”)
Creating an Epidemic/Pandemic

How microorganisms spread across a country
USA WNV
Anthrax: Overview
 Gram positive bacillus that forms
spores
 Spores found in soil worldwide
 Humans usually infected by contact
with infected animals or contaminated
animal products
No person-to-person
transmission of inhalation
anthrax
Anthrax: Cutaneous
 Most common form (95%)
 Inoculation of spores in skin
 Incubation: hours to days
 Progression:
1. small papule
2. ulcer surrounded by vesicles
3. painless eschar with edema
 Death:
•
•
untreated – 20%
treated – rare

2.2 KG’S OF ANTHRAX SPRINKLED
FROM A 20TH FLOOR HIGH RISE IN
NEW YORK CITY WOULD KILL / INFECT
OVER 120,000 PEOPLE
Plague: Overview

Yersinia pestis (gram-negative
coccobacillus)

About 10 U.S. cases/yr (SW)

Two major forms

Very contagious via respiratory
droplets
Plague Epidemics
3 major recorded epidemics:
 550, 1350 (Black Death), 1850 (China)

30% - 60% mortality in infected
continents
Plague
 GOOD

NEWS:
future epidemics unlikely due to sanitation,
public health practices, and antibiotics.
 BAD

NEWS:
US and Russia and other countries have
developed techniques to aerosolize plague,
eliminating need for fleas to spread the
infection.
Plague as a Bioweapon


Infected fleas could spread bubonic form
(less likely scenario)
Aerosolized organisms would spread
pneumonic form (more likely scenario)
Plague: Bubonic





Bite from infected flea
Sudden onset flu-like syndrome
Buboes:
 tender, enlarged lymph nodes
(inguinal, axillary, cervical)
Can spread to lungs (hematogenous)
Can also lead to endotoxic septicemic
phase
Plague: Pneumonic

Inhalation of organisms (aerosol)

Incubation: 1-3 days

Sudden onset flu-like syndrome


Pneumonia progresses rapidly to
hypoxemia, cyanosis, hemoptysis
Endotoxin: septic shock with
DIC, ARDS, death
Pneumonic Plague:
Isolation precautions


SECONDARY
TRANSMISSION IS
POSSIBLE - EASILY
USE STANDARD AND
AIRBORNE PRECAUTIONS
Viruses as Bioweapons

Viral Hemorrhagic
Fevers:


Ebola

Lassa

Marburg
Smallpox
Viral Hemorrhagic Fevers

Group of illnesses caused by several RNA
viruses

All can be used as bioweapons

Examples: Ebola, Marburg, Lassa

Mortality can be very high (90% for Ebola)
VHF: Occurrence



Naturally occurring infections can occur via
transmission from infected rodents and arthropods
Readily transmissible from person to person via body
fluids:
 great risk for healthcare workers
VHF very rare in US:

usually travelers to endemic areas
CURRENT OUTBREAK


Current outbreak in Africa (since Dec
2013)
80-89% MORTALITY Usually (this one is
about 60%)
VHF: Pathophysiology

Variable incubation (2-21 days)

Flu-like symptoms with high fever

Increased vascular permeability causes:





hemorrhage in GI tract and mucous membranes
petechial or ecchymotic rash
edema
hypotension
Rapid progression to shock and death
VHF: Treatment





Supportive treatment
IV ribavirin used occasionally for Lassa
fever.
Vaccines under development (FDA
approved experimental use for W African
outbreak)
Postexposure prophylaxis with oral ribavirin
may be useful
Contact and respiratory precautions
necessary
Smallpox

Variola virus

Characteristic skin lesions

About 30% mortality in unvaccinated

Last known natural case: Somalia in 1977
Smallpox as a Bioweapon





Can be aerosolized
Highly contagious
No effective treatment
Vaccination ceased in 70’s
Stable in the environment (contamination for
months)
Smallpox: Pathophysiology





Virus inhaled or deposited on mucous
membranes
Goes to lymph nodes, incubates for 7-17 days
Release into blood causes flu-like symptoms
Rash begins 2-3 days later
Death due to toxemia of viral antigens and
circulating immune complexes
Smallpox: Skin lesions






Macular (flat, red) rash 2-3 days after flu
symptoms
Starts on face, forearms, hands (+ palms and
soles)
Rash evolves synchronously in an area
Evolves into tense vesicles
Scabs form in 7-10 days if patient lives
Infectious until all scabs are shed.
Day 3
Day 5
Day 7
Chickenpox with characteristic
rose-colored macules, papules,
vesicles, pustules, necrotic
pustules, and crusted lesions
occurring simultaneously.
Herpes zoster showing dermatomal
distribution of lesions
Herpes zoster (varicella virus) with
characteristic grouping of vesicles
Smallpox vs. Chickenpox
Smallpox
Chickenpox
Prodrome
yes
minimal or none
Distribution
out to in
in to out
Lesions
Progression
Palms / Soles
painful / deep
synchronous
yes
pruritic / superficial
asynchronous
no
Smallpox vs. Chickenpox
Smallpox: Precautions

Airborne and Contact Isolation

Airborne Isolation:





negative pressure room
anteroom
closed ventilation system
N95 mask (Duckbill mask)
Contact Isolation:

strict use of PPE and handwashing
BIOLOGICAL TOXINS

BOTULINUM – BO-TOX

RICIN

STAPHYLOOCCAL ENTEROTOXIN B (not reviewed)

RICIN
T-2 MYCOTOXINS (not reviewed)
Botulinum Toxin

7 neurotoxins produced by Clostridium botulinum

Among the most toxic substances known

May be found in naturally contaminated food

As a bioweapon, likely to be delivered by aerosol

No person-to-person transmission

Multiple cases without common food source
suggests bioterrorism
Ricin

Potent protein toxin derived from castor beans

Easily produced / Recently found in France

Inhibits protein synthesis

Causes necrotizing airway lesions:



tracheitis
bronchitis and bronchiolitis
interstitial pneumonia with ARDS
Ricin

Inhalation as an aerosol produces severe
respiratory symptoms:


day 1:
cough, fever, dyspnea
day 2-3: pulmonary edema, resp failure, death

Specific serum test is available

No treatment available other than supportive
Chemical Weapons





Nerve agents
Vessicants (blistering agents)
Pulmonary agents
Blood agents (cyanide)
Riot Control agents
Nerve Agents

Most toxic of all the synthetic chemical agents.
Very similar to organophosphate insecticides.
Death within minutes when inhaled or absorbed
through skin.
Developed in WW2 by Germany but not used.
U.S. completed development after WW2.

Examples:





SARIN
Nerve Agents: Effects



Smooth muscle hyper
stimulation
Glandular hyper stimulation
Skeletal muscle hyper
stimulation
Nerve Agents: Effects

Smooth muscle hyper
stimulation:




vomiting and diarrhea
urination
bronchospasm
small pupils (miosis)
Nerve Agents: Effects

Glandular hyper stimulation:




salivation
lacrimation
increased airway secretions
increased GI secretions
Nerve Agents: Effects

Skeletal muscle hyper stimulation at first:


Fasciculations
Later, skeletal muscle exhaustion:

weakness followed by flaccid paralysis
Nerve Agents: Effects
SLUDGE reaction:
 Salivation
 Lacrimation
 Urination
 Defecation
 Generalized twitching
 Emesis
Nerve Agents:
Decontamination

Removal of contaminated clothing
Copious irrigation and washing with soap
and water

BIOSUITS- NO CONTACT WITH AGENT

Sources of
Radioactive Material

High-level sources (plutonium, uranium):



nuclear power plants and weapons sites
high security; more difficult to obtain and handle
Low-level sources (cobalt-60, strontium-90,
cesium-137, americium-241):




hospitals
construction sites
food irradiation plants
smoke detectors
Bombing Frequency


Worldwide, 50% of terrorist attacks are
bombings.
In U.S., over 85% of terrorist attacks are
bombings.