Bioterrorism Attack

December 1, 2001

Bioterrorism Attack
What Infection Control Practitioners Need to Know to Be Prepared
for a Bioterrorism Attack

By Terri Rebmann, RN, MSN, CIC

How do infection control practitioners (ICPs) prepare for a bioterrorism
attack? More specifically, what steps do ICPs need to take to prepare themselves
and their facility or community for the potential threat of a bioterrorism

Following the Sept. 11 attack on the World Trade Center and the Pentagon, the
threat of terrorism has become foremost in Americans' minds. It is only recently
that American citizens have become more aware of the potential threat. Terrorism
has been on the rise in the past few years and there are more terrorist groups
than ever before.1 In addition, many experts now believe that the
goals of some terrorist groups have changed. Traditionally, terrorists wanted
media attention to disseminate their message and a low casualty rate was
critical to maintain sympathy for their cause. Experts now believe that
terrorists are more interested in causing mass casualties as a way to spread
their message, and biological weapons provide a means of accomplishing their

Biological Warfare
There are a number of factors that make biological warfare an effective
weapon: large numbers of people may be exposed, detection may be delayed or even
impossible since the agents are odorless, colorless, and tasteless, and
biological weapons are easy to produce and very inexpensive to generate.3,4
The knowledge needed to obtain and release these agents is easily accessible
through the Internet and experts think that anyone with a degree in basic
microbiology could cultivate the agents; the equipment needed to produce these
agents is also available via the Internet. In addition, biological weapons are
more appealing than traditional weapons because the terrorists can easily
protect themselves from the release by taking chemoprophylaxis and/or vaccines
beforehand and they can escape from the scene prior to the intentional release
being identified.

Domestic, international, and state-sponsored terrorists have all expressed
interest in biological weapons.1 Experts believe that some of these
groups may have offensive biological weapons programs currently underway.
Because of this, the US needs to be prepared for the possibility of a
bioterrorism attack. In the past few years, money has been allocated for
bioterrorism preparedness efforts; however, previous funding for bioterrorism
preparedness initiatives have primarily been provided to traditional first
responders such as fire, police, and emergency medical services personnel. In
the event of a terrorist attack using an explosive device or release of a
chemical agent, this would be appropriate. On the other hand, in the event of a
bioterrorism attack in which the first victims will be encountered in the ER or
family practice clinic, the first responders will be the healthcare and public
health professionals.

There will probably not be an explosion or perhaps any indication that a
biological attack has taken place. Nothing will be suspected until days to weeks
after the event when exposed individuals develop symptoms and seek treatment at
healthcare facilities. It will then require an astute clinician to identify that
something is out of the ordinary and report it to the local health department
and proper authorities.

First Responders
In addition to being the first responders, healthcare and public health
professionals will bear the responsibility of response, notification, and
mitigation. These professionals will carry the burden of responding to and
recovering from the attack. There are many challenges that will face the
healthcare and public health community following a bioterrorism attack.
Healthcare facilities may experience a massive influx of severely ill patients
as well as the "worried well." There will be an imperative need to
quickly identify and treat individuals that require timely post-exposure
prophylaxis, and many staff will be needed to set up distribution centers to
disseminate the appropriate medications. In addition, the healthcare community
may need to handle a large number of bodies of deceased victims with limited
morgue space and staff.

Despite the fact that it will be healthcare and public health's
responsibility to deal with this crisis, healthcare workers (HCWs) have received
minimal education on preparedness for bioterrorism. These healthcare
professionals will be required to perform a variety of functions: diagnosis,
surveillance, isolation, and treatment of the victims. Healthcare professionals
must be familiar with the potential bioterrorism agents and how to appropriately
isolate, treat, and track individuals who will need prompt care in the aftermath
of a biological terrorism incident. As experts in surveillance and epidemiology,
ICPs will play a vital role in the identification of an attack and
implementation of a successful response following a bioterrorism attack. It is
imperative that all ICPs know their role in bioterrorism preparedness and their
facility/community's response plan.

What ICPs Can Do To Be Prepared

Be aware of the risks
According to the FBI, biological agents have become the most frequently
threatened method of attack, accounting for more than half of the weapons of
mass destruction threats in 1998.1 Most experts believe that a
biological attack of some size is likely to happen, but it is impossible to
guess where or when such an attack may occur. The actual risk to any individual
being exposed to a biological weapon is small; however, since the outcome of
such an event is potentially devastating, it is best for all communities to be

Maintain a High Index of Suspicion
Be open to the possibility of a bioterrorism attack occurring in your community.
If you consider the possibility that it could happen, you will be more likely to
quickly identify that an attack has occurred. Furthermore, if you look for the
potential bioterrorism agent diseases, early diagnosis may be made which would
result in a decrease in patient mortality. Many of the potential bioterrorism
agents initially present with non-specific upper respiratory or flu-like
symptoms. Since these diseases are not normally encountered in medical practice,
it will require an astute clinician to identify these agents.

Know Your Baseline
You need to be familiar with your facility/area's baseline of disease in order
to identify that something unusual is happening. Identifying a bioterrorism
attack is similar to spotting an outbreak in your facility; you must be aware of
the normal occurrence of disease in order to identify that there is an increase
or something is out of the ordinary.

Be suspicious of any unusual changes in the patient population, such as an
influx of patients with flu-like illness during non-influenza season, a higher
number of cases of severe respiratory illness or mortality in a previously
healthy population, or an unusual pathogen for your region. Any tight cluster of
cases should be a red flag that bioterrorism is a possible culprit. The
epidemiological curve in most naturally occurring outbreaks has a gradual slope;
a compact cluster of cases implies that the cases may have exposed at the same
time, as would be the case in a bioterrorism event.

Understand the Potential Threats
Be familiar with the likely bioterrorism agents and be able to identify the
signs and symptoms of these diseases. It is imperative to quickly and accurately
diagnose the agent in order to decrease mortality associated with these
diseases. Many of the likely bioterrorism agents are not encountered in routine
clinical practice; clinicians must have a high level of suspicion and the
knowledge needed to identify these diseases. In the event of a release, quickly
identify the organism causing disease or at least narrow the list as rapidly as
possible so that you can provide the correct treatment or prophylaxis. Early
identification of the causative agent is imperative; the survival rate for many
of these diseases depends upon rapid initiation of appropriate antibiotic
therapy. In addition, it is imperative to determine the strain resistance
pattern to ensure that your antibiotic therapy has appropriate coverage.

Carefully and Thoroughly Assess Your Patient(s)
It is critical to identify and document as much information as possible related
to the patient's history and symptoms in order to determine the agent involved
and the possible source of exposure. Some key areas upon which to focus include:
body site affected, route of exposure, severity of illness, timeline (when
exposure occurred/incubation period), onset and progression of symptoms, and
potential date and source of exposure.

Protect Yourself, Your Patients, and Your Community
Follow appropriate infection control practices at all times. Isolate patients
promptly and appropriately; do not discontinue isolation until you are positive
that the patient is no longer contagious. Other things that you can do to
protect yourself and your community include:

  • Take appropriate prophylaxis (including vaccines when indicated)
  • Provide prompt treatment to symptomatic patients
  • Assist in identification of those exposed
  • Assist in dissemination of prophylaxis to asymptomatic exposed individuals

Be Familiar with Your Institution's Disaster Plan
Know what you should expect in the event that your facility implements its
disaster plan. Pay particular attention to our role in the plan. Knowing what to
expect should make implementation smoother.

Form Partnerships With Key Groups
ICPs will not face the consequences of a bioterrorism attack alone; response
and recovery will require coordination between many groups in your facility as
well as within your community and nation. Just a few of the groups with whom
your facility needs to partner include: public health, hospital epidemiologist,
emergency medical services, security, local law enforcement, facilities
engineering, emergency department, local FBI office, CDC, your hospital/facility
administrator, and other local, state, and federal agencies. Having these
partnerships in place before an event takes place will facilitate the response
effort. Everyone should know his or her role in the disaster plan.

In general, decontamination is not an issue in bioterrorism. By the time
patients become symptomatic and present to healthcare institutions days to weeks
after the exposure, the agent will have long been dissipated/destroyed by wind
and sunlight, and patients will most likely have bathed and changed their
clothes. In the event of an announced attack (within 12-24 hours after the
release), exposed individuals should bathe with soap and water and change their
clothing. In some cases, such as a release of smallpox, hard surfaces may need
to be disinfected.

Know the Incident Command System
Many ICPs have never heard of the incident command system (ICS), but it is
the authority/communications system that will be implemented in the event of a
crisis such as a bioterrorism event. ICS consists of basic operating principles
that ensure rapid and appropriate resource management while aiming to continue
routine operating procedures of the organization.2 In other words,
ICS would need to be implemented to mitigate the consequences of a bioterrorism
event, while maintaining as many of the day-to-day duties of the facility as
possible. An ICS consists of the following components: command, planning,
operations, logistics, and finance/administration.2

The primary principles involved in ICS include the following:2

  • Foundation of common terminology
  • Flexible modular organization that allows for expansion and contraction
  • Integrated communications (shared communications plan and standard
    operating procedures)
  • Unity of common (designated leader to which everyone reports)
  • Unified command structure (set of shared objectives and strategies)
  • Manageable span of control (number and list of resources any supervisor
    may control)
  • Designated incident facility (may include a staging area and/or more than
    one facility)
  • Comprehensive resource management

Know How to Access Reliable Information
Make sure that your facility has the information resources it needs before
an incident occurs. In the event of a massive bioterrorism attack, phone and fax
lines, and thus the Internet, may not be accessible. CD-ROMs, textbooks,
pocketcards, or other printed materials need to be on hand in case technology
resources are not available.

Be Flexible
In the event of a massive bioterrorism attack, ICPs may be reassigned to any
number of different areas to assist in mitigation of the disaster. One such area
may include direct patient care areas in order to meet the high demands for
rapid care of new cases and longer-term care for survivors. Be prepared to
assist in whatever capacity your facility or community will need you. Additional
resources may be found on the following Web sites:,, and

The author would like to acknowledge Brooke N. Shadel, PhD, MPH, for her
peer review of this article.

Terri Rebmann, RN, MSN, CIC, is the infectious disease specialist for the
Center for the Study of Bioterrorism and Emerging Infections (CSB&EI) at
Saint Louis University's School of Public Health.

A Word About Air Filtration and Anthrax

High Efficiency Particulate Air (HEPA) filtration can reduce, to some
degree, the airborne concentration of anthrax and other infectious
airborne pathogens in an indoor environment, especially if negative
pressure containment procedures are utilized. When addressing infectious
diseases, healthcare professionals must know how many air changes per hour
are needed and exactly when to use negative pressure to keep the air from
contaminating other areas of the hospital. Engineering controls are used
to prevent the spread and reduce the concentration of infectious droplet
nuclei, and are based primarily on the use of adequate ventilation
systems; these may be supplemented with HEPA filtration and ultraviolet
germicidal irradiation (UVGI) in high-risk areas. For more details, log