Chemical and Biological Terrorism: Current Updates for Nurse Educators

Article excerpt

Anthrax / Brucella / Crimean-Congo hemorrhagic fever virus / Equine morbillivirus Lassa fever virus / isopropylmethylphosphorofluoridate / Variola major virus / Hydrocyanic acid / Halothane / Dengue / Ebola / Plague / SEB / Tularemia / Antimuscarinics / Cholinergics /Tick-borne encephalitis complex viruses / Marburg virus / CS,2-chlorobenzylidenemalononitrile / T-2 Mycotoxin WEE /Venezuelan equine encephalitis virus

ABSTRACT Schools of nursing need to adapt curricula and continuing education programs to provide nursing students, as well as nurses who are currently employed, with the knowledge and skills required to respond to a chemical or biological terrorist attack.This article addresses eight topic areas suitable for a one-semester elective course offering or for incorporation into the existing curriculum as assessment and management lectures: surveillance systems; identification, communication, and response; chemical agents; biological agents; recognizing covert exposure in a population; patient decontamination and mass triage; the availability and safety of therapies; and immunization and prophylactic antibiotics.

RECENT EVENTS HAVE DEMONSTRATED to Americans that terrorism is not something that happens solely on foreign soil. A terrorist attack is no longer a lowprobability event, and our need to prepare an organized, national response to future biological and chemical threats is both pressing and immediate. The national outbreak of anthrax infections that followed the events of September 11, 2001, have heightened the realization that the use of chemical or biologic weapons would have serious implications for the nation's health care workforce. In addition to being overtaxed by serious staffing issues, many nurses (and physicians) currently employed have little knowledge regarding the potential pathogens that could be released, or how to respond to a chemical or biological attack. ALONG WITH HOSPITALS AND HEALTH DEPARTMENTS, SCHOOLS OF NURSING NEED TO ADAPT EXISTING CURRICULA AND CONTINUING EDUCATION PROGRAMS TO PROVIDE NURSING STUDENTS, AS WELL AS NURSES WHO ARE CURRENTLY EMPLOYED, WITH THE KNOWLEDGE AND SKILLS REQUIRED TO PARTICIPATE IN A NATIONAL EMERGENCY RESPONSE.

Background The development, production, and use of biological and chemical weapons are prohibited by international treaties, including the 1925 Geneva Protocol, the 1972 Biological and Toxin Weapons Convention, and the 1993 Chemical Weapons Convention (1). While most countries have subscribed to these treaties, not all have done so. Serious concerns remain that some countries and rogue groups may resort to the use of these weapons.

A comprehensive curriculum for nurses to address chemical and biological warfare should include eight topic areas: Surveillance Systems; Identification, Communication, and Response; Chemical and Biological Agents; Recognizing Covert Exposure in a Population; Patient Decontamination and Mass Triage; the Availability and Safety of Therapies; and Immunization and Prophylactic Antibiotics. Ideally, this material should be taught online, or with PowerPoint presentations with live Internet access.

These topics can be addressed most comprehensively in a one-- semester elective course offering to students. For degree programs where elective credits are limited, these topics can be incorporated into the existing curriculum as additional assessment and management lectures. (See Sidebar 1 for resources.)

Surveillance Systems To differentiate between an impending health care crisis and a hoax, it is imperative that nurses understand the national and international systems of surveillance currently in place. How would a government find out that a deliberate outbreak had taken place?

International System The World Health Organization (WHO) monitors disease outbreaks through the Global Outbreak Alert and Response Network (2). This network, formally launched in April 2000, electronically links the expertise and skills of 72 existing networks from around the world, several of which were uniquely designed to diagnose unusual agents and handle dangerous pathogens. Its purpose is to keep the international community constantly alert to the threat of outbreaks and ready to respond. It has four primary tasks:

1. Systematic disease intelligence and detection The first responsibility of the WHO network is to systematically gather global disease intelligence drawing from a wide range of resources, both formal and informal. Ministries of Health, WHO country offices, government and military centers, and academic institutions all file regular formal reports with the Global Outbreak Alert and Response Network. An informal network scours world communications for rumors of unusual health events.

2. Outbreak verification Preliminary intelligence reports from all sources, both formal and informal, are reviewed and converted into meaningful intelligence by the WHO Outbreak Alert and Response Team, which makes the final determination whether a reported event warrants cause for international concern.

3. Immediate alert A large network of electronically connected WHO member nations, disease experts, health institutions, agencies, and laboratories is kept continually informed of rumored and confirmed outbreaks. The network also maintains and regularly updates an Outbreak Verification List, which provides a detailed status report on all currently verified outbreaks.

4. Rapid response When the Outbreak Alert and Response Team determines that an international response is needed to contain an outbreak, it enlists the help of its partners in the global network. Specific assistance available includes targeted investigations, confirmation of diagnoses, handling of dangerous biohazards (biosafety level IV pathogens), patient care and management, containment, and logistical support in terms of staff and supplies.

Domestic The Centers for Disease Control and Prevention (CDC) maintains a prevention list of restricted agents. (See Table 1.) The CDC operates a large number of infectious disease surveillance systems, most of which are based on voluntary collaboration with state and local health departments. Even the most well recognized of these, the National Notifiable Disease Surveillance System, currently includes many, but not all, of the diseases considered likely to be used in bioterrorism. As with many passive, or voluntary, surveillance systems, it is subject to omissions and long-delayed reports. All disease surveillance systems are dependent on confirmed diagnoses and frequently offer little assistance to the practitioner who is trying to arrive at a diagnosis.

Agent Identification Rapid identification and containment of any suspected chemical or biologic agent is the first priority for all members of the health care team. The U.S. Army Medical Research Institute of Infectious Diseases website lists copies of reports addressing specific agents, their presenting signs and symptoms, laboratory tests, recommended infection control procedures, and known antidotes (3).

Rapid identification of any chemical agent involved in any hazardous material (hazmat) incident is vital to the protection of first responders and emergency medical personnel at local medical facilities as well as to the effective treatment of victims. The detection of a chemical agent at the scene of a terrorist attack will most likely be managed by either the police, fire department, emergency medical services unit, hazmat team, or some combination of the above.

Nurses need to be familiar with the most likely agents to be employed and the consequences of their use (Table 2). Because of their physical properties, chemical agents used in an attack would probably be dispersed in a manner that would involve a vapor hazard in an enclosed space, such as the type of incident seen in Tokyo in March 1995, when Sarin nerve gas was dispersed in the subway system (4).

In the case of many biological agents, the time period between exposure to a pathogen and the onset of symptoms may lag from hours to weeks. Therefore, effective response to a covert terrorist action will depend not on fire and rescue personnel, but on the ability of individual clinicians to identify and accurately diagnose an uncommon disease process.

Chemical Agents Nerve Agents These act by binding to the enzyme acetylcholinesterase, thereby blocking its normal function of breaking down the neurotransmitter acetylcholine following its release at neuronal synapses and neuromuscular junctions throughout the peripheral and central nervous systems. Persons exposed to high concentrations of organophosphorus nerve agents usually develop signs and symptoms within a matter of minutes after exposure. Therefore, initial patient diagnoses and treatment are likely to be based on observations of signs and symptoms by the paramedic or other health care professional at the scene.

Acetylcholine accumulates and overstimulates synapses throughout the brain, nervous system, glands, and skeletal and smooth muscle. Death occurs as a result of respiratory failure (5). The treatment for nerve agents poisoning recommended by the United States military involves the use of three therapeutic drugs, atropine, pralidoxime, and diazepam (3).

Vesicating Agents This category of agents includes "mustard," the name apparently stemming from the compound's smell, taste, and color. At room temperature, sulfur mustard is an oily liquid; at higher temperatures, it becomes the significant vapor hazard "mustard gas." Sulfur mustard was most recently used in the IranIraq conflict, and it is considered the most likely agent to be used on a battlefield (4). It can permeate rubber and is readily absorbed through the skin, eyes, respiratory system, and gastrointestinal tract. It reacts within minutes with components of RNA, DNA, and proteins and interrupts cell functions. Acute effects can be severe and require weeks of care, but mortality, usually from pulmonary insufficency or infection, is rare.

No effective treatment of mustard-damaged skin is currently available. Immediate decontamination of exposed skin is the only means of preventing tissue damage.

Cyanide The cyanide anion, NC-, whether delivered in hydrocyanic acid or in a cyanogen such as cyanide chloride, exerts its toxicity primarily by inhibiting mitochondrial cytochrome oxidase, leading to lactic acidosis, hypoxia, seizures, dysrhymias, and respiratory failure. Death occurs within minutes after inhalation or ingestion of a sizable dose.

One antidote for cyanide poisoning is amyl nitrate, which converts hemoglobin to methemoglobin, which in turn effectively competes for cyanide in the mitochondrial cytochrome oxidase complex. Gastric lavage with activated charcoal should be administered if cyanide is ingested. Cyanide is metabolized faster than other chemical agents. As a result, if the dose administered is small and the victim survives the initial assault, supportive therapy may be sufficient for full recovery in a matter of hours.

Biological Agents The incubation period associated with infectious agents makes responding to an attack from biological agents very different from responding to a chemical attack. According to the WHO experts, anthrax, smallpox, botulism, and plague are the pathogens most likely to be used in the event of a biologic terrorist attack (6) (Sidebar 2). Treatment regimes are based on the CDC categorization of disease and on the specific pathogen involved (Table 3).

Anthrax Anthrax is primarily a disease of herbivorous animals, domesticated as well as wild, and humans usually become infected by contact with infected sheep, goats, cattle, pigs, horses, or contaminated products such as wool. The causative agent is Bacillus anthracis, a bacterium that forms inert spores when exposed to oxygen. These spores are extremely hardy and can live outside a living host for years. Infections begin when spores are inhaled or ingested or enter the body through a wound in the skin. The incubation period from exposure to onset of illness is usually one to seven days but may be up to 60 days (7,8).

Cutaneous infections produce ulceration at the site, along with fever, malaise, and headache. Symptoms of inhalational anthrax include fever, muscle aches, and fatigue that progress rapidly to systemic illness. Mortality is generally low with antibiotic treatment. Untreated, the mortality associated with anthrax rises to almost 100 percent (8-11). Current treatment calls for oral ciproflaxin or doxycylcline as soon as exposure to anthrax spores is suspected, and introducing intravenous ciproflaxin at the earliest signs of infection or disease. Other therapies for shock, volume deficit, and adequate airway may be necessary (12-14).

Smallpox This disease presents a unique risk among the possible biologic weapons in that the secondary contamination risk (person-to-person transmission) is significant (4). Historically, smallpox was an important cause of mortality throughout the world. As a result of aggressive case findings and vaccination programs, it was considered to be eradicated by 1980; the last known cases occurred in 1978.

The causative agent of smallpox is variola, one of a large family of deoxyribonucleic acid (DNA) poxviruses. The variola virus thrives only in human hosts. However, it is highly stable and retains its infectivity for long periods outside the host. Serious concerns persist regarding its use as a biological weapon. American intelligence agents have long suspected that Iraq and North Korea, and possibly other rogue nations, have maintained clandestine stocks of the deadly virus (15).

Individuals who were vaccinated during the smallpox eradication campaign of the 1970s were considered to have immunity for anywhere from three to ten years, with protection diminishing over time. Vaccination is the only proven means of combating an epidemic that could result from the deliberate release of smallpox virus into the population. Antiviral drugs may have a limited role in the management of infected patients; expanding vaccination is the proven means of eradication of the foci of infection.

Botulism This often lethal form of poisoning, most frequently associated with damaged canned goods, is the product of neurotoxins produced by the spore-forming bacterium Clostridium botulinum. The botulinum toxins are the most toxic substances known (4). The exact mechanism by which they affect the body is not known, but whether ingested, inhaled, or injected, the clinical course is similar. Within hours, or up to two days, depending on the dose, dry mouth, difficulty swallowing, and double vision develop. This is followed by progressive weakness culminating in respiratory failure from skeletal muscle paralysis (16).

Plague This disease is well known to be the cause of the Black Death, which devastated much of Europe in the 14th century. The causative agent is Yersinia pesos, a nonsporulating bacillus maintained in nature in fleas. During the Black Death, fleas on rats were the primary vector of transmission. In humans, the bite of an infected flea causes high fever, chills, and headache, along with nausea and vomiting. Within hours, the lymph nodes begin to swell. Left untreated, septicemia develops within days, with an associated mortality rate approaching 35 percent.

Inhalation of Yersinia pesos will result in pneumonic plague presenting as fulminant pneumonia with bloody sputum. Death occurs within hours if treatment is not initiated immediately (within 24 hours) (17).

Recognizing Covert Exposure in a Population In the autumn of 2001, emergency departments in the United States were requested to participate in a system of heightened surveillance to identify clinical syndromes or patterns of illness that might be suggestive of an unusual chemical or biologic exposure. This system is being implemented across the country in conjunction with state and local health departments. Most emergency departments are submitting daily reports that include unusual observations as well as routine data such as the number of patient visits and the number of visits for flulike illness. Assets such as the U.S. Public Health Service National Medical Response Teams (Disaster Medical Response Team, Weapons of Mass Destruction Team, and Disaster Mortuary Team) and the Department of Defense's National Guard Civil Support Teams are also on call and strategically located throughout the nation.

Patient Decontamination and Mass Triage The removal of solid or liquid chemical agents from exposed individuals is the first step in preventing serious injury or death. While the United States has many civilian hazmat teams with basic decontamination plans in place, they vary widely, and few are trained for mass decontamination. In the event of an attack, the burden will fall to hospitals for mass decontamination. Few hospitals have formal decontamination facilities, nor are staff trained to handle mass casualties of a chemical or biologic nature.

A Disaster Preparedness and Bioterrorism course for nurses should include the following:

* Development of a plan for mass triage of casualties.

* The benefit versus risk of removing patient clothing.

* Optimal types of decontamination.

* Showering time to remove chemical agents.

Methods of assessing whether the patient is "clean."

* Risk assessment of contamination of health care providers. This material can be covered in a one-day seminar or integrated into an emergency or acute care patient management series of lectures.

Availability and Safety of Therapies Treatment depends on the particular pathogen or chemical identified as the source of the outbreak. Both WHO and the CDC have recommended strategies to contain natural or deliberate disease and chemical events. WHO has standard operating procedures for treating and containing outbreaks of all known infectious diseases (18,19). In some cases, isolation of patients, containment of infection, and the provision of accurate public information constitute the most effective strategy.

Immunization and Prophylactic Antibiotics The recent outbreak of anthrax and concern about other potential terrorist attacks raise questions about the use of prophylactic antibiotics and immunization (13). Neither anthrax nor smallpox vaccine is currently available to the public in the United States (20). Research investigating the efficacy of the use of a diluted smallpox vaccine is currently being conducted. The recommendations for vaccine against smallpox may change pending the results of this investigation.

The CDC strongly recommends against prescribing prophylactic antibiotics in the absence of any surveillance or laboratory evidence of a communicable disease risk in the community. In the event a risk is identified, local health departments would be charged with immediately notifying the health care community and providing detailed recommendations on the diagnosis, treatment, and preventive measures for the specific biologic agent. The CDC currently maintains a National Pharmaceutical Stockpile of appropriate antibiotics and vaccines that can be delivered within 12 hours.

The inappropriate use of antibiotics can result in serious adverse side effects and in increased antibiotic resistance among the microorganisms causing common bacterial infections. In addition, stockpiling by individuals will result in inappropriate self-medication, incomplete course of antibiotics, the use of expired medications, and the depletion of national supplies for medically indicated uses (14). Nurses need to be able to explain these issues to their patients and encourage physicians and nurse practitioners not to prescribe antibiotics for the purpose of patient or group stockpiling. Naturally occurring infectious diseases, and childhood diseases in particular, continue to require routine vaccinations.

Conclusion The threat of chemical and biological terrorism, coupled with the world events of September 2001, has caused the many disciplines responsible for the health and welfare of the public to evaluate their ability to respond adequately to an international use of a weapon of mass destruction. The national health care community - including public health agencies, emergency medical services, hospitals, and health care providers - would bear the brunt of the consequences of a chemical or biological attack.

The leadership and faculty of our nation's schools of nursing must ensure that graduates are adequately prepared with the knowledge and skill sets needed to function effectively in the event of such a terrorist attack. The increased probability of this type of warfare mandates integration of this knowledge into existing curricula at all levels, and warrants the development of continuing education programs to update nurses already practicing in the community.

[Sidebar]

Sidebar 1. RESOURCES AND WEBSITES

[Sidebar]

The second updated edition of Health Aspects of Biological and Chemical Weapons: Report of a WHO Group of Consultants was released in December 2001. It is a standard guide to help countries prepare for emergencies caused by the deliberate use of chemical weapons and I I possible biological weapons. Other helpful contacts for bioterrorism preparedness resources are:

* Centers for Disease Control and Prevention Emergency Hotline: 770/488-7100 or http://www.bt.cdc.gov (official federal site for health professionals to reference when providing information to the public or updating protocols)

* Domestic Preparedness Hotline: 800/368-6498 or http://www.cbhelp@sbccom.apgea.army.mil

[Sidebar]

* National Domestic Preparedness Office: 202/324-9025 or http://www.ndpo.gov

* U.S. Public Health Service Office of Emergency Preparedness: 800/USA-NDMS or http://www.ndms.dhhs.gov

* National Pharmaceutical Stockpile Program Emergency Hotline: 770/488-7516

* Johns Hopkins Center for Civilian Biodefense Studies: http://www.hopkins-biodefense.org/index.html

* Clinical Guidelines on Bioterrorism, National Guidelines on Bioterrorism, National Guidelines Clearinghouse: http://www.guidelines.gov/static/bio.asp?view=bio

[Sidebar]

Sidebar 2.

[Sidebar]

Centers for Disease Control and Prevention

Public Health Emergency Preparedness and Response: Biological Diseases/Agents

[Sidebar]

CATEGORY A DISEASES/AGENTS

[Sidebar]

The U.S. public health system and primary health care providers must be prepared to address varied biological agents, including pathogens that are rarely seen in the United States. High-priority agents include organisms that pose a risk to national security because they can be easily disseminated or transmitted from person to person; cause high mortality and have the potential for major public health impact; might cause public panic and social disruption; and require special action for public health

[Sidebar]

preparedness.

Anthrax (Bacillus anthracis)

Botulism (Clostridium botulinum toxin)

Plague (Yersinia pestis)

Smallpox (Variola major)

Tularemia (Francisella tularensis)

Viral hemorrhagic fevers

[Sidebar]

CATEGORY B DISEASES/AGENTS

[Sidebar]

Second highest priority agents include those that are moderately easy to disseminate; cause moderate morbidity and low mortality; and require specific enhancements of CDC's diagnostic capacity and enhanced

[Sidebar]

disease surveillance.

[Sidebar]

Brucellosis (Brucella species)

Epsilon toxin of Clostridium perfringens

Glanders (Burkholderia mallei)

Q fever (Coxiella burnetti)

Ricin toxin from Ricinus communis (castor beans)

Staphylococcus enterotoxin B

[Sidebar]

CATEGORY C DISEASES/AGENTS

[Sidebar]

Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of availability; ease of production and dissemination; and potential for high morbidity

[Sidebar]

and mortality and major health impact.

Hantaviruses

Multidrug-resistant tuberculosis

Nipah virus

Tick-borne encephalitis viruses

Tick-borne hemorrhagic fever viruses

Yellow fever

Keywords Biological Weapons - Chemical Weapons - Terrorism Nursing Curriculum - Nursing Education, Continuing

[Reference]

References

[Reference]

1. World Health Organization. (2001). Health aspects of biological and chemical weapons: Report of a WHO group of consultants (2nd ed.). Geneva, Switzerland:Author.

2. World Health Organization. (2001). Responding to the deliberate use of biological agents and chemicals as weapons [On-line].Available: http://www.who.int/emc/deliberate-epi.html

[Reference]

3. U.S.Army Medical Research Institute of Infectious Diseases. (2001). Agents, presenting signs and symptoms, laboratory tests, recommended infection control procedures, and known anti dotes [On-line].Available http:/www.usamriid.army.mil/ education/bluebook.html

4. Institute of Medicine and National Research Council. (1999). Chemical and biological terrorism: Research and development to improve civilian medical response. Washington DC: National Academy Press [On-line]. Available: http://www.nap.edu

[Reference]

5. Grob, D., & Harvey, A. M. (1953). The effects and treatment of nerve gas poisoning. American journal of Medicine, 14, 52-63.

6.World Health Organization. (2001). Frequently asked questions regarding the deliberate use of biological agents and chemicals as weapons [Online].Available http://www.who.int/emc/questions.htm)

7. Franz, D. R.Jahrling, R B., Friedlander, A. M., McClain D. J., Hoover, D. L., Byrne W R., Pavin J.A., Christopher, G.W, & Eitzen, E. M, (1997). Clinical recognition and management of

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patients exposed to biological warfare agents. Journal of the American Medical Association 278, 399-411.

[Reference]

8. Moran, G. J. (1999). Update on emerging infections from the Centers for Disease Control and Prevention. Bioterrorism alleging use of anthrax and interim guidelines for management - United States, 1998. Annals of Emergency Medicine, 34(2), 229-232.

9. Friedlander, A. M. (2000). Anthrax: Clinical features, pathogenesis, and potential biological warfare threat. Current Clinical Topics in Infectious Diseases, 20, 335-349.

[Reference]

10. Dixon,T C., Meselson, M., Guillemin, J., & Hanna, PC. (1999). Medical progress: Anthrax. New England Journal of Medicine, 341, 815-826. 11. Centers for Disease Control and Prevention. (2002). Public health emergency preparedness and response. Anthrax information [On-line]. Available: http://www.bt.cdc.gov/Agent/ Anthrax/AnthraxGen.asp

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12. Inglesby TV., Henderson, D.A., Bartlett, J. G., Ascher, M. S., Eitzen E., & Friedlander, A. M.

( 1999). Anthrax as a biological weapon: Medical and public health management.Working Group on Civilian Biodefense.JAMA, 281, 1735-- 1745.

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13. Jernigan, J. J., Stephens, D. S., Ashford, D.A., Omenaca, C., Martin S.,Topiel, M. S., & Galbraith, M. (2001). Bioterrorism-related inhalational anthrax:The first 10 cases reported in the United States. Emerging Infectious Diseases, 7(6).

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14. Centers for Disease Control and Prevention. (2002). Public health emergency preparedness and response. Biological diseases/agents listing [On-line].Available: http://www.bt.cdc.gov/Agent/Agentlist.asp

[Reference]

15. Purdum,T. S., & Mitchell,A. (2001, October 21).A nation challenged.The disease: Drills predicted gaps in preparedness seen in the anthrax response. The New York Times, Section I B, p. 7.

16. Middlebrook, J. L., & Franz, D. R. (1997). Botulinum toxins. In F. R. Sidell, E.T.Takafuli, & D. R. Franz (Eds.). Textbook of military medicine. Part 1,Warfare, weaponry, and the casualty. Medical aspects of biological warfare (pp. 655-- 676).Washington, DO Office of the Surgeon General, U.S. Department of the Army.

[Reference]

17. McGovern,TW, & Friedlander,A. M. (1997). Plague. In F R. Sidell, E.T Takafuli, & D. R. Franz (Eds.). Textbook of military medicine.

Part I, Warfare, weaponry, and the casualty: Medical aspects of biological warfare (pp. 479-- 502).Washington, DC: Office of the Surgeon General, U.S. Department of the Army. 18.World Health Organization Group of Consultants. ( 1970). Health aspects of chemical and biological weapons. Geneva, Switzerland: Author.

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19.World Health Organization Group of Consultants (2001). Updated report: Health aspects of chemical and biological weapons. Geneva, Switzerland: Author.

20.Advisory Committee on Immunization Practices. (2000). Use of anthrax vaccine in the United States. MMWR, Morbidity & Mortality Weekly Report 49 RR- 15: 1 -20.

[Author Affiliation]

About the Author Tener Goodwin Veenema, PhD, MPH, CPNP, is an assistant professor, Center for High-Risk Children and Youth, School of Nursing, University of Rochester Medical Center, Rochester, New York.

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