Bioterrorism Attack


Bioterrorism Attack
What Infection Control Practitioners Need to Know to Be Preparedfor a Bioterrorism Attack

By Terri Rebmann, RN, MSN, CIC

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

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

Biological Warfare
There are a number of factors that make biological warfare an effectiveweapon: large numbers of people may be exposed, detection may be delayed or evenimpossible since the agents are odorless, colorless, and tasteless, andbiological weapons are easy to produce and very inexpensive to generate.3,4The knowledge needed to obtain and release these agents is easily accessiblethrough the Internet and experts think that anyone with a degree in basicmicrobiology could cultivate the agents; the equipment needed to produce theseagents is also available via the Internet. In addition, biological weapons aremore appealing than traditional weapons because the terrorists can easilyprotect themselves from the release by taking chemoprophylaxis and/or vaccinesbeforehand and they can escape from the scene prior to the intentional releasebeing identified.

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

There will probably not be an explosion or perhaps any indication that abiological attack has taken place. Nothing will be suspected until days to weeksafter the event when exposed individuals develop symptoms and seek treatment athealthcare facilities. It will then require an astute clinician to identify thatsomething is out of the ordinary and report it to the local health departmentand proper authorities.

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

Despite the fact that it will be healthcare and public health'sresponsibility to deal with this crisis, healthcare workers (HCWs) have receivedminimal education on preparedness for bioterrorism. These healthcareprofessionals will be required to perform a variety of functions: diagnosis,surveillance, isolation, and treatment of the victims. Healthcare professionalsmust be familiar with the potential bioterrorism agents and how to appropriatelyisolate, treat, and track individuals who will need prompt care in the aftermathof a biological terrorism incident. As experts in surveillance and epidemiology,ICPs will play a vital role in the identification of an attack andimplementation of a successful response following a bioterrorism attack. It isimperative that all ICPs know their role in bioterrorism preparedness and theirfacility/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 frequentlythreatened method of attack, accounting for more than half of the weapons ofmass destruction threats in 1998.1 Most experts believe that abiological attack of some size is likely to happen, but it is impossible toguess where or when such an attack may occur. The actual risk to any individualbeing exposed to a biological weapon is small; however, since the outcome ofsuch an event is potentially devastating, it is best for all communities to beprepared.

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 toquickly identify that an attack has occurred. Furthermore, if you look for thepotential bioterrorism agent diseases, early diagnosis may be made which wouldresult in a decrease in patient mortality. Many of the potential bioterrorismagents initially present with non-specific upper respiratory or flu-likesymptoms. 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 orderto identify that something unusual is happening. Identifying a bioterrorismattack is similar to spotting an outbreak in your facility; you must be aware ofthe normal occurrence of disease in order to identify that there is an increaseor something is out of the ordinary.

Be suspicious of any unusual changes in the patient population, such as aninflux of patients with flu-like illness during non-influenza season, a highernumber of cases of severe respiratory illness or mortality in a previouslyhealthy population, or an unusual pathogen for your region. Any tight cluster ofcases should be a red flag that bioterrorism is a possible culprit. Theepidemiological curve in most naturally occurring outbreaks has a gradual slope;a compact cluster of cases implies that the cases may have exposed at the sametime, 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 thesigns and symptoms of these diseases. It is imperative to quickly and accuratelydiagnose the agent in order to decrease mortality associated with thesediseases. Many of the likely bioterrorism agents are not encountered in routineclinical practice; clinicians must have a high level of suspicion and theknowledge needed to identify these diseases. In the event of a release, quicklyidentify the organism causing disease or at least narrow the list as rapidly aspossible so that you can provide the correct treatment or prophylaxis. Earlyidentification of the causative agent is imperative; the survival rate for manyof these diseases depends upon rapid initiation of appropriate antibiotictherapy. In addition, it is imperative to determine the strain resistancepattern 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 relatedto the patient's history and symptoms in order to determine the agent involvedand the possible source of exposure. Some key areas upon which to focus include:body site affected, route of exposure, severity of illness, timeline (whenexposure occurred/incubation period), onset and progression of symptoms, andpotential date and source of exposure.

Protect Yourself, Your Patients, and Your Community
Follow appropriate infection control practices at all times. Isolate patientspromptly and appropriately; do not discontinue isolation until you are positivethat the patient is no longer contagious. Other things that you can do toprotect 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 itsdisaster plan. Pay particular attention to our role in the plan. Knowing what toexpect should make implementation smoother.

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

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

Know the Incident Command System
Many ICPs have never heard of the incident command system (ICS), but it isthe authority/communications system that will be implemented in the event of acrisis such as a bioterrorism event. ICS consists of basic operating principlesthat ensure rapid and appropriate resource management while aiming to continueroutine operating procedures of the organization.2 In other words,ICS would need to be implemented to mitigate the consequences of a bioterrorismevent, while maintaining as many of the day-to-day duties of the facility aspossible. 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 beforean incident occurs. In the event of a massive bioterrorism attack, phone and faxlines, and thus the Internet, may not be accessible. CD-ROMs, textbooks,pocketcards, or other printed materials need to be on hand in case technologyresources are not available.

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

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

Terri Rebmann, RN, MSN, CIC, is the infectious disease specialist for theCenter for the Study of Bioterrorism and Emerging Infections (CSB&EI) atSaint 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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