Bioterrorism Attack

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 attack?

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 mission.

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 prepared.

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 onto

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