NURSING IN THE ERA OF BIOTERRORISM 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. 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: microbes or their toxins.

Biological Weapons

Bioterrorism Overview Microorganisms or their toxins can be in liquid or powder form. Microorganisms or their toxins can be in liquid or powder form. Various delivery methods are possible: Various delivery methods are possible: aerosol aerosol envelope or package envelope or package food or water contamination food or water contamination Exposure can be isolated to a single area or can be more widespread. 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 BacteriaViruses Biological Toxins

CDC Categories Category A: Category A: easily disseminated OR transmitted person to person easily disseminated OR transmitted person to person susceptible population susceptible population potential for panic / disruption potential for panic / disruption requires special action for treatment requires special action for treatment high morbidity and mortality high morbidity and mortality examples: anthrax, smallpox, plague, botulism, viral hemorrhagic fevers examples: anthrax, smallpox, plague, botulism, viral hemorrhagic fevers

CDC Categories Category B: Category B: moderately easy to disseminate moderately easy to disseminate moderate morbidity, low mortality moderate morbidity, low mortality examples: Q fever, brucellosis, glanders, some toxins examples: Q fever, brucellosis, glanders, some toxins Category C: Category C: emerging pathogens that could be engineered for mass dissemination in the future emerging pathogens that could be engineered for mass dissemination in the future potential for high morbidity and mortality potential for high morbidity and mortality examples: hantavirus, tickborne viruses, MDR TB examples: hantavirus, tickborne viruses, MDR TB

Isolation Precautions Standard (“blood and body fluid”): Standard (“blood and body fluid”): gloves gloves mask with face shield mask with face shield gown gown Airborne: Airborne: standard plus negative pressure room and N95 mask (“duckbill mask”) standard plus negative pressure room and N95 mask (“duckbill mask”)

Creating an Epidemic/Pandemic How microorganisms spread across a country USA WNV How microorganisms spread across a country USA WNV How microorganisms spread across a country USA WNV How microorganisms spread across a country USA WNV

Gram positive bacillus that forms spores Gram positive bacillus that forms spores Spores found in soil worldwide Spores found in soil worldwide Humans usually infected by contact with infected animals or contaminated animal products Humans usually infected by contact with infected animals or contaminated animal products No person-to-person transmission of inhalation anthrax No person-to-person transmission of inhalation anthrax Anthrax: Overview Anthrax: Overview

Anthrax: Cutaneous Most common form (95%) Most common form (95%) Inoculation of spores in skin Inoculation of spores in skin Incubation: hours to days Incubation: hours to days Progression: Progression: 1. small papule 2. ulcer surrounded by vesicles 3. painless eschar with edema Death: Death: untreated – 20% untreated – 20% treated – rare treated – rare

2.2 KG’S OF ANTHRAX SPRINKLED FROM A 20 TH FLOOR HIGH RISE IN NEW YORK CITY WOULD KILL / INFECT OVER 120,000 PEOPLE 2.2 KG’S OF ANTHRAX SPRINKLED FROM A 20 TH FLOOR HIGH RISE IN NEW YORK CITY WOULD KILL / INFECT OVER 120,000 PEOPLE

Plague: Overview Yersinia pestis (gram-negative coccobacillus) Yersinia pestis (gram-negative coccobacillus) About 10 U.S. cases/yr (SW) About 10 U.S. cases/yr (SW) Two major forms Two major forms Very contagious via respiratory droplets Very contagious via respiratory droplets

Plague Epidemics 3 major recorded epidemics: 550, 1350 (Black Death), 1850 (China) 550, 1350 (Black Death), 1850 (China) 30% - 60% mortality in infected continents 30% - 60% mortality in infected continents

Plague GOOD NEWS: GOOD NEWS: future epidemics unlikely due to sanitation, public health practices, and antibiotics. future epidemics unlikely due to sanitation, public health practices, and antibiotics. BAD NEWS: BAD NEWS: US and Russia and other countries have developed techniques to aerosolize plague, eliminating need for fleas to spread the infection. 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) Infected fleas could spread bubonic form (less likely scenario) Aerosolized organisms would spread pneumonic form (more likely scenario) Aerosolized organisms would spread pneumonic form (more likely scenario)

Plague: Bubonic Bite from infected flea Bite from infected flea Sudden onset flu-like syndrome Sudden onset flu-like syndrome Buboes: Buboes: tender, enlarged lymph nodes (inguinal, axillary, cervical) tender, enlarged lymph nodes (inguinal, axillary, cervical) Can spread to lungs (hematogenous) Can spread to lungs (hematogenous) Can also lead to endotoxic septicemic phase Can also lead to endotoxic septicemic phase

Plague: Pneumonic Inhalation of organisms (aerosol) Inhalation of organisms (aerosol) Incubation: 1-3 days Incubation: 1-3 days Sudden onset flu-like syndrome Sudden onset flu-like syndrome Pneumonia progresses rapidly to hypoxemia, cyanosis, hemoptysis Pneumonia progresses rapidly to hypoxemia, cyanosis, hemoptysis Endotoxin: septic shock with DIC, ARDS, death Endotoxin: septic shock with DIC, ARDS, death

Pneumonic Plague: Isolation precautions SECONDARY TRANSMISSION IS POSSIBLE - EASILY SECONDARY TRANSMISSION IS POSSIBLE - EASILY USE STANDARD AND AIRBORNE PRECAUTIONS USE STANDARD AND AIRBORNE PRECAUTIONS

Viruses as Bioweapons Viral Hemorrhagic Fevers: Viral Hemorrhagic Fevers: Ebola Ebola Lassa Lassa Marburg Marburg Smallpox Smallpox

Viral Hemorrhagic Fevers Group of illnesses caused by several RNA viruses Group of illnesses caused by several RNA viruses All can be used as bioweapons All can be used as bioweapons Examples: Ebola, Marburg, Lassa Examples: Ebola, Marburg, Lassa Mortality can be very high (90% for Ebola) Mortality can be very high (90% for Ebola)

VHF: Occurrence Naturally occurring infections can occur via transmission from infected rodents and arthropods Naturally occurring infections can occur via transmission from infected rodents and arthropods Readily transmissible from person to person via body fluids: Readily transmissible from person to person via body fluids: great risk for healthcare workers great risk for healthcare workers VHF very rare in US: VHF very rare in US: usually travelers to endemic areas usually travelers to endemic areas

CURRENT OUTBREAK Current outbreak in Africa (since Dec 2013) Current outbreak in Africa (since Dec 2013) 80-89% MORTALITY Usually (this one is about 60%) 80-89% MORTALITY Usually (this one is about 60%)

VHF: Pathophysiology Variable incubation (2-21 days) Variable incubation (2-21 days) Flu-like symptoms with high fever Flu-like symptoms with high fever Increased vascular permeability causes: Increased vascular permeability causes: hemorrhage in GI tract and mucous membranes hemorrhage in GI tract and mucous membranes petechial or ecchymotic rash petechial or ecchymotic rash edema edema hypotension hypotension Rapid progression to shock and death Rapid progression to shock and death

VHF: Treatment Supportive treatment Supportive treatment IV ribavirin used occasionally for Lassa fever. IV ribavirin used occasionally for Lassa fever. Vaccines under development (FDA approved experimental use for W African outbreak) Vaccines under development (FDA approved experimental use for W African outbreak) Postexposure prophylaxis with oral ribavirin may be useful Postexposure prophylaxis with oral ribavirin may be useful Contact and respiratory precautions necessary Contact and respiratory precautions necessary

Smallpox Variola virus Variola virus Characteristic skin lesions Characteristic skin lesions About 30% mortality in unvaccinated About 30% mortality in unvaccinated Last known natural case: Somalia in 1977 Last known natural case: Somalia in 1977

Smallpox as a Bioweapon Can be aerosolized Can be aerosolized Highly contagious Highly contagious No effective treatment No effective treatment Vaccination ceased in 70’s Vaccination ceased in 70’s Stable in the environment (contamination for months) Stable in the environment (contamination for months)

Smallpox: Pathophysiology Virus inhaled or deposited on mucous membranes Virus inhaled or deposited on mucous membranes Goes to lymph nodes, incubates for 7-17 days Goes to lymph nodes, incubates for 7-17 days Release into blood causes flu-like symptoms Release into blood causes flu-like symptoms Rash begins 2-3 days later Rash begins 2-3 days later Death due to toxemia of viral antigens and circulating immune complexes Death due to toxemia of viral antigens and circulating immune complexes

Smallpox: Skin lesions Macular (flat, red) rash 2-3 days after flu symptoms Macular (flat, red) rash 2-3 days after flu symptoms Starts on face, forearms, hands (+ palms and soles) Starts on face, forearms, hands (+ palms and soles) Rash evolves synchronously in an area Rash evolves synchronously in an area Evolves into tense vesicles Evolves into tense vesicles Scabs form in 7-10 days if patient lives Scabs form in 7-10 days if patient lives Infectious until all scabs are shed. 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 (varicella virus) with characteristic grouping of vesicles Herpes zoster showing dermatomal distribution of lesions

Prodromeyesminimal or none Distribution out to inin to out Lesionspainful / deeppruritic / superficial Progressionsynchronousasynchronous Palms / Solesyesno Smallpox vs. Chickenpox Smallpox Chickenpox

Smallpox vs. Chickenpox

Smallpox: Precautions Airborne and Contact Isolation Airborne and Contact Isolation Airborne Isolation: Airborne Isolation: negative pressure room negative pressure room anteroom anteroom closed ventilation system closed ventilation system N95 mask (Duckbill mask) N95 mask (Duckbill mask) Contact Isolation: Contact Isolation: strict use of PPE and handwashing strict use of PPE and handwashing

BIOLOGICAL TOXINS

BOTULINUM – BO-TOX BOTULINUM – BO-TOX RICIN RICIN STAPHYLOOCCAL ENTEROTOXIN B (not reviewed) STAPHYLOOCCAL ENTEROTOXIN B (not reviewed) T-2 MYCOTOXINS (not reviewed) T-2 MYCOTOXINS (not reviewed) RICIN RICIN

Botulinum Toxin 7 neurotoxins produced by Clostridium botulinum 7 neurotoxins produced by Clostridium botulinum Among the most toxic substances known Among the most toxic substances known May be found in naturally contaminated food May be found in naturally contaminated food As a bioweapon, likely to be delivered by aerosol As a bioweapon, likely to be delivered by aerosol No person-to-person transmission No person-to-person transmission Multiple cases without common food source suggests bioterrorism Multiple cases without common food source suggests bioterrorism

Ricin Potent protein toxin derived from castor beans Potent protein toxin derived from castor beans Easily produced / Recently found in France Easily produced / Recently found in France Inhibits protein synthesis Inhibits protein synthesis Causes necrotizing airway lesions: Causes necrotizing airway lesions: tracheitis tracheitis bronchitis and bronchiolitis bronchitis and bronchiolitis interstitial pneumonia with ARDS interstitial pneumonia with ARDS

Ricin Inhalation as an aerosol produces severe respiratory symptoms: Inhalation as an aerosol produces severe respiratory symptoms: day 1: cough, fever, dyspnea day 1: cough, fever, dyspnea day 2-3: pulmonary edema, resp failure, death day 2-3: pulmonary edema, resp failure, death Specific serum test is available Specific serum test is available No treatment available other than supportive No treatment available other than supportive

Chemical Weapons Nerve agents Nerve agents Vessicants (blistering agents) Vessicants (blistering agents) Pulmonary agents Pulmonary agents Blood agents (cyanide) Blood agents (cyanide) Riot Control agents Riot Control agents

Nerve Agents Most toxic of all the synthetic chemical agents. Most toxic of all the synthetic chemical agents. Very similar to organophosphate insecticides. Very similar to organophosphate insecticides. Death within minutes when inhaled or absorbed through skin. Death within minutes when inhaled or absorbed through skin. Developed in WW2 by Germany but not used. Developed in WW2 by Germany but not used. U.S. completed development after WW2. U.S. completed development after WW2. Examples: Examples: SARIN SARIN

Nerve Agents: Effects Smooth muscle hyper stimulation Smooth muscle hyper stimulation Glandular hyper stimulation Glandular hyper stimulation Skeletal muscle hyper stimulation Skeletal muscle hyper stimulation

Nerve Agents: Effects Smooth muscle hyper stimulation: Smooth muscle hyper stimulation: vomiting and diarrhea vomiting and diarrhea urination urination bronchospasm bronchospasm small pupils (miosis) small pupils (miosis)

Nerve Agents: Effects Glandular hyper stimulation: Glandular hyper stimulation: salivation salivation lacrimation lacrimation increased airway secretions increased airway secretions increased GI secretions increased GI secretions

Nerve Agents: Effects Skeletal muscle hyper stimulation at first: Skeletal muscle hyper stimulation at first: Fasciculations Fasciculations Later, skeletal muscle exhaustion: Later, skeletal muscle exhaustion: weakness followed by flaccid paralysis weakness followed by flaccid paralysis

Nerve Agents: Effects SLUDGE reaction: Salivation Salivation Lacrimation Lacrimation Urination Urination Defecation Defecation Generalized twitching Generalized twitching Emesis Emesis

Nerve Agents: Decontamination Removal of contaminated clothing Removal of contaminated clothing Copious irrigation and washing with soap and water Copious irrigation and washing with soap and water BIOSUITS- NO CONTACT WITH AGENT BIOSUITS- NO CONTACT WITH AGENT

Sources of Radioactive Material High-level sources (plutonium, uranium): High-level sources (plutonium, uranium): nuclear power plants and weapons sites nuclear power plants and weapons sites high security; more difficult to obtain and handle high security; more difficult to obtain and handle Low-level sources (cobalt-60, strontium-90, cesium-137, americium-241): Low-level sources (cobalt-60, strontium-90, cesium-137, americium-241): hospitals hospitals construction sites construction sites food irradiation plants food irradiation plants smoke detectors smoke detectors

Bombing Frequency Worldwide, 50% of terrorist attacks are bombings. Worldwide, 50% of terrorist attacks are bombings. In U.S., over 85% of terrorist attacks are bombings. In U.S., over 85% of terrorist attacks are bombings.