NURSING IN THE ERA OF BIOTERRORISM

1.
NURSING IN THE ERA OF BIOTERRORISM
Accurate information is the best defense against panic and confusion in the event of a crisis.
3. Definition of Bioterrorism
Premeditated threat or actual use of biological weapons to produce disease or death in people, animals, or plants. Biological weapons: microbes or their toxins.
4. Biological Weapons
5. Bioterrorism Overview
Microorganisms or their toxins can be in liquid or powder form. Various delivery methods are possible: aerosol envelope or package food or water contamination Exposure can be isolated to a single area or can be more widespread.
6. 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.
7. Biological Agents:Types and Characteristics
Bacteria Viruses Biological Toxins BIOLOGICAL AGENTS Critical biologic agents fall into three types; Bacteria, viruses, and toxins. Each of these groups possesses it�s own unique characteristics and challenges in diagnosis, treatment and prevention of secondary transmission. BIOLOGICAL AGENTS Critical biologic agents fall into three types; Bacteria, viruses, and toxins. Each of these groups possesses it�s own unique characteristics and challenges in diagnosis, treatment and prevention of secondary transmission.
8. CDC Categories
Category A: easily disseminated OR transmitted person to person susceptible population potential for panic / disruption requires special action for treatment high morbidity and mortality examples: anthrax, smallpox, plague, botulism, viral hemorrhagic fevers
9. CDC Categories
Category B: moderately easy to disseminate moderate morbidity, low mortality examples: Q fever, brucellosis, glanders, some toxins Category C: emerging pathogens that could be engineered for mass dissemination in the future potential for high morbidity and mortality examples: hantavirus, tickborne viruses, MDR TB
10. Isolation Precautions
Standard (�blood and body fluid�): gloves mask with face shield gown Airborne: standard plus negative pressure room and N95 mask (�duckbill mask�) Treatment of botulism involves the use of antitoxin in conjunction with supportive care. CDC maintains the national botulism anti-toxin supply. A physician diagnosing a case of botulism and wishing to treat the patient with anti-toxin must contact the CDC through their state health department (609-392-2020). This way public health officials are alerted immediately about potential cases of botulism. Penicillin can also be used for wound or infant botulism to kill organism that is producing toxin. **These treatments are not generally recommended for pregnant women and children. Their use in a specific clinical setting must be decided upon the basis of their risk versus the benefit to the patient. Treatment of botulism involves the use of antitoxin in conjunction with supportive care. CDC maintains the national botulism anti-toxin supply. A physician diagnosing a case of botulism and wishing to treat the patient with anti-toxin must contact the CDC through their state health department (609-392-2020). This way public health officials are alerted immediately about potential cases of botulism. Penicillin can also be used for wound or infant botulism to kill organism that is producing toxin. **These treatments are not generally recommended for pregnant women and children. Their use in a specific clinical setting must be decided upon the basis of their risk versus the benefit to the patient.
11.
HANDWASHING
12. Gram positive bacillus that forms spores Spores found in soil worldwide Humans usually infected by contact with infected animals or contaminated animal products No person-to-person transmission of inhalation anthrax
Anthrax: Overview While B. Anthracis is an organism that is found in soil throughout the world, Anthrax is not a common disease � Only 4 reported human cases were identified in the U.S. between 1983 and 2000. When humans are infected it is normally via contact with contaminated animals or animal products. The inhalational form of anthrax (very rare) is usually found in persons exposed to aerosolized spores when working with contaminated hides. There is no person- to- person transmission of inhalational anthrax.While B. Anthracis is an organism that is found in soil throughout the world, Anthrax is not a common disease � Only 4 reported human cases were identified in the U.S. between 1983 and 2000. When humans are infected it is normally via contact with contaminated animals or animal products. The inhalational form of anthrax (very rare) is usually found in persons exposed to aerosolized spores when working with contaminated hides. There is no person- to- person transmission of inhalational anthrax.
13. Anthrax: Cutaneous
Most common form (95%) Inoculation of spores in skin Incubation: hours to days Progression: 1. small papule 2. ulcer surrounded by vesicles 3. painless eschar with edema Death: untreated � 20% treated � rare Cutaneous anthrax is the most common naturally occurring form of B. anthracis infection. Cutaneous anthrax is contracted when spores are inoculated under skin where there is a break such as a cut, there is no infection of intact skin. Cutaneaous anthrax results in a painless non pyogenic ulcer with surrounding edema. Death occurs in approximately 20% of untreated cases but is very rare if treated with antibiotics. (Picture of eschar with surrounding edema)Cutaneous anthrax is the most common naturally occurring form of B. anthracis infection. Cutaneous anthrax is contracted when spores are inoculated under skin where there is a break such as a cut, there is no infection of intact skin. Cutaneaous anthrax results in a painless non pyogenic ulcer with surrounding edema. Death occurs in approximately 20% of untreated cases but is very rare if treated with antibiotics. (Picture of eschar with surrounding edema)
15.
19. Anthrax: Gastrointestinal
Ingestion of contaminated meat Fever, vomiting, bloody diarrhea Intestinal eschar similar to cutaneous anthrax lesion Progression to general toxemia Mortality 50% despite treatment Gastrointestinal anthrax is very rare and results from ingesting contaminated meat. Diagnosis is difficult and the disease can result in high mortality despite treatment. Symptoms include acute gastroenteritis, bloody diarrhea, and an intestinal eschar similar to a cutaneous anthrax lesion. [Picture of intestinal lesion from GI anthrax] Gastrointestinal anthrax is very rare and results from ingesting contaminated meat. Diagnosis is difficult and the disease can result in high mortality despite treatment. Symptoms include acute gastroenteritis, bloody diarrhea, and an intestinal eschar similar to a cutaneous anthrax lesion. [Picture of intestinal lesion from GI anthrax]
20. Anthrax Testing
Nasal Swab: A tool for epidemiology, not diagnosis Limitations: positive test indicates exposure, not infection false positives have been seen (positive test does not prove infection) false negatives (negative test does not rule out anthrax infection) Treatment of botulism involves the use of antitoxin in conjunction with supportive care. CDC maintains the national botulism anti-toxin supply. A physician diagnosing a case of botulism and wishing to treat the patient with anti-toxin must contact the CDC through their state health department (609-392-2020). This way public health officials are alerted immediately about potential cases of botulism. Penicillin can also be used for wound or infant botulism to kill organism that is producing toxin. **These treatments are not generally recommended for pregnant women and children. Their use in a specific clinical setting must be decided upon the basis of their risk versus the benefit to the patient. Treatment of botulism involves the use of antitoxin in conjunction with supportive care. CDC maintains the national botulism anti-toxin supply. A physician diagnosing a case of botulism and wishing to treat the patient with anti-toxin must contact the CDC through their state health department (609-392-2020). This way public health officials are alerted immediately about potential cases of botulism. Penicillin can also be used for wound or infant botulism to kill organism that is producing toxin. **These treatments are not generally recommended for pregnant women and children. Their use in a specific clinical setting must be decided upon the basis of their risk versus the benefit to the patient.
Nasal Swab: A tool for epidemiology, not diagnosis Limitations: positive test indicates exposure, not infection false positives have been seen (positive test does not prove infection) false negatives (negative test does not rule out anthrax infection) Serologic tests: Available at special labs but not used for routine screening Treatment of botulism involves the use of antitoxin in conjunction with supportive care. CDC maintains the national botulism anti-toxin supply. A physician diagnosing a case of botulism and wishing to treat the patient with anti-toxin must contact the CDC through their state health department (609-392-2020). This way public health officials are alerted immediately about potential cases of botulism. Penicillin can also be used for wound or infant botulism to kill organism that is producing toxin. **These treatments are not generally recommended for pregnant women and children. Their use in a specific clinical setting must be decided upon the basis of their risk versus the benefit to the patient. Treatment of botulism involves the use of antitoxin in conjunction with supportive care. CDC maintains the national botulism anti-toxin supply. A physician diagnosing a case of botulism and wishing to treat the patient with anti-toxin must contact the CDC through their state health department (609-392-2020). This way public health officials are alerted immediately about potential cases of botulism. Penicillin can also be used for wound or infant botulism to kill organism that is producing toxin. **These treatments are not generally recommended for pregnant women and children. Their use in a specific clinical setting must be decided upon the basis of their risk versus the benefit to the patient.
Nasal Swab: A tool for epidemiology, not diagnosis Limitations: positive test indicates exposure, not infection false positives have been seen negative test does not rule out anthrax infection Serologic tests: Available at special labs but not used for routine screening Blood cultures: Probably best test for symptomatic individual at risk Treatment of botulism involves the use of antitoxin in conjunction with supportive care. CDC maintains the national botulism anti-toxin supply. A physician diagnosing a case of botulism and wishing to treat the patient with anti-toxin must contact the CDC through their state health department (609-392-2020). This way public health officials are alerted immediately about potential cases of botulism. Penicillin can also be used for wound or infant botulism to kill organism that is producing toxin. **These treatments are not generally recommended for pregnant women and children. Their use in a specific clinical setting must be decided upon the basis of their risk versus the benefit to the patient. Treatment of botulism involves the use of antitoxin in conjunction with supportive care. CDC maintains the national botulism anti-toxin supply. A physician diagnosing a case of botulism and wishing to treat the patient with anti-toxin must contact the CDC through their state health department (609-392-2020). This way public health officials are alerted immediately about potential cases of botulism. Penicillin can also be used for wound or infant botulism to kill organism that is producing toxin. **These treatments are not generally recommended for pregnant women and children. Their use in a specific clinical setting must be decided upon the basis of their risk versus the benefit to the patient.
23. ANTHRAX: Treatment
Inhalation anthrax or cutaneous anthrax with systemic involvement: ciprofloxacin (400mg, IV, q12h) or doxycycline (100 mg, IV, q12h) combine with one of the following: rifampin, vancomycin, penicillin, ampicillin, clindamycin, clarithromycin Treat for 60 days Early treatment is essential in treating anthrax as antibiotics will kill the organism but do not affect the toxin already released. Antibiotics used to treat anthrax are Penicillin, Doxycycline, or Ciprofloxacin. If the patient survives the initial illness, antibiotic therapy may be needed for as long as 30 to 60 days depending on the form of anthrax and/or vaccine use. It is important that health care providers use antibiotic susceptibility testing to help guide therapy. Health care workers should use standard precautions when caring for patients infected with inhalational anthrax. Quarantine is not required as anthrax is not spread person to person.Early treatment is essential in treating anthrax as antibiotics will kill the organism but do not affect the toxin already released. Antibiotics used to treat anthrax are Penicillin, Doxycycline, or Ciprofloxacin. If the patient survives the initial illness, antibiotic therapy may be needed for as long as 30 to 60 days depending on the form of anthrax and/or vaccine use. It is important that health care providers use antibiotic susceptibility testing to help guide therapy. Health care workers should use standard precautions when caring for patients infected with inhalational anthrax. Quarantine is not required as anthrax is not spread person to person.
24. Anthrax: Other Treatment
Uncomplicated cutaneous anthrax: Cipro (500 mg, po, bid) or doxycycline (100 mg, po, bid) Prophylaxis for exposure: Cipro (500 mg, po, bid) or doxycycline (100 mg, po, bid) Children or breastfeeding mothers: amoxicillin Levoquin- adults 18 and older Treat for 60 days Early treatment is essential in treating anthrax as antibiotics will kill the organism but do not affect the toxin already released. Antibiotics used to treat anthrax are Penicillin, Doxycycline, or Ciprofloxacin. If the patient survives the initial illness, antibiotic therapy may be needed for as long as 30 to 60 days depending on the form of anthrax and/or vaccine use. It is important that health care providers use antibiotic susceptibility testing to help guide therapy. Health care workers should use standard precautions when caring for patients infected with inhalational anthrax. Quarantine is not required as anthrax is not spread person to person.Early treatment is essential in treating anthrax as antibiotics will kill the organism but do not affect the toxin already released. Antibiotics used to treat anthrax are Penicillin, Doxycycline, or Ciprofloxacin. If the patient survives the initial illness, antibiotic therapy may be needed for as long as 30 to 60 days depending on the form of anthrax and/or vaccine use. It is important that health care providers use antibiotic susceptibility testing to help guide therapy. Health care workers should use standard precautions when caring for patients infected with inhalational anthrax. Quarantine is not required as anthrax is not spread person to person.
25.
2.2 KG�S OF ANTHRAX SPRINKLED FROM A 20TH FLOOR HIGH RISE IN NEW YORK CITY WOULD KILL / INFECT OVER 120,000 PEOPLE
26. Plague: Overview
Yersinia pestis (gram-negative coccobacillus) About 10 U.S. cases/yr (SW) Two major forms Very contagious via respiratory droplets Plague is one of the few bioterrorist disease threats that occurs naturally in the United States. There are approximately 15-20 cases a year in the United States with most of those occurring in the southwest portion of the county. A case of Plague has never been reported in New Jersey. Of the cases that do occur in the US, Bubonic is the most common form with only 1-2 cases a pneumonic plague occurring each year. Yersinia Pestis, the causative agent of plague, is usually transmitted to humans by fleas from other mammalian hosts. [Picture is Giemsa stain of Y. pestis] Plague is one of the few bioterrorist disease threats that occurs naturally in the United States. There are approximately 15-20 cases a year in the United States with most of those occurring in the southwest portion of the county. A case of Plague has never been reported in New Jersey. Of the cases that do occur in the US, Bubonic is the most common form with only 1-2 cases a pneumonic plague occurring each year. Yersinia Pestis, the causative agent of plague, is usually transmitted to humans by fleas from other mammalian hosts. [Picture is Giemsa stain of Y. pestis]
27. Plague Epidemics
3 major recorded epidemics: 550, 1350 (Black Death), 1850 (China) 30% - 60% mortality in infected continents
28. Plague
GOOD NEWS: future epidemics unlikely due to sanitation, public health practices, and antibiotics. BAD NEWS: US and Russia and other countries have developed techniques to aerosolize plague, eliminating need for fleas to spread the infection.
29. Plague as a Bioweapon
Infected fleas could spread bubonic form (less likely scenario) Aerosolized organisms would spread pneumonic form (more likely scenario)
30. Plague: Bubonic
Bite from infected flea Sudden onset flu-like syndrome Buboes: tender, enlarged lymph nodes (inguinal, axillary, cervical) Can spread to lungs (hematogenous) Can also lead to endotoxic septicemic phase Symptoms of bubonic plague typically develop 2 to 8 days after being bitten by an infected flea. These include fever, chills, weakness, and tender lymph nodes. Bubonic plague results in regional lymphadenitis which is most commonly found in the inguinal, axillary or cervical regions. Bubonic plague is also indicated by cutaneous findings that may include papules, vesicles or pustules at the inoculation site. [Picture of swollen lymph nodes or buboes]Symptoms of bubonic plague typically develop 2 to 8 days after being bitten by an infected flea. These include fever, chills, weakness, and tender lymph nodes. Bubonic plague results in regional lymphadenitis which is most commonly found in the inguinal, axillary or cervical regions. Bubonic plague is also indicated by cutaneous findings that may include papules, vesicles or pustules at the inoculation site. [Picture of swollen lymph nodes or buboes]
31. Plague: Pneumonic
Inhalation of organisms (aerosol) Incubation: 1-3 days Sudden onset flu-like syndrome Pneumonia progresses rapidly to hypoxemia, cyanosis, hemoptysis Endotoxin: septic shock with DIC, ARDS, death Pneumonic plague is rare, usually only 1-2 cases/year in US, and is characterized by a rapid onset of symptoms including high fever and hemoptysis.The disease progresses rapidly and will result in death from respiratory collapse/sepsis if not treated early.Pneumonic plague is rare, usually only 1-2 cases/year in US, and is characterized by a rapid onset of symptoms including high fever and hemoptysis.The disease progresses rapidly and will result in death from respiratory collapse/sepsis if not treated early.
32. Plague Disease Complex
Inhalational of plague organisms Flu-like Syndrome Sudden onset 2 -3 days Pneumonic plague presents within 2 to 3 days of aerosol inhalation of bacilli (from biological weapon agent dissemination source or from respiratory droplets from another infected patient). There is a sudden onset of fever, chills, and an influenza-like syndrome followed within 24 hours by the onset of a fulminant pneumonia with hepatocellular damage and systemic toxicity. Coagulation abnormalities are common and severe ecchymosis may occur (�black death�). Oropharangeal primary infections may progress to fulminant pneumonia following endeobronchial aspiration of plague bacilli. This fulminant pneumonia is rapidly followed by systemic toxicity, respiratory failure, and circulatory collapse. Six percent of pneumonia cases have an accompanying meningitis.Pneumonic plague presents within 2 to 3 days of aerosol inhalation of bacilli (from biological weapon agent dissemination source or from respiratory droplets from another infected patient). There is a sudden onset of fever, chills, and an influenza-like syndrome followed within 24 hours by the onset of a fulminant pneumonia with hepatocellular damage and systemic toxicity. Coagulation abnormalities are common and severe ecchymosis may occur (�black death�). Oropharangeal primary infections may progress to fulminant pneumonia following endeobronchial aspiration of plague bacilli. This fulminant pneumonia is rapidly followed by systemic toxicity, respiratory failure, and circulatory collapse. Six percent of pneumonia cases have an accompanying meningitis.
Fulminant Pneumonia Flu-like Syndrome Sudden onset productive cough bilateral infiltrates cyanosis 2 -3 days 24 hrs Inhalational of plague organisms Pneumonic plague presents within 2 to 3 days of aerosol inhalation of bacilli (from biological weapon agent dissemination source or from respiratory droplets from another infected patient). There is a sudden onset of fever, chills, and an influenza-like syndrome followed within 24 hours by the onset of a fulminant pneumonia with hepatocellular damage and systemic toxicity. Coagulation abnormalities are common and severe ecchymosis may occur (�black death�). Oropharangeal primary infections may progress to fulminant pneumonia following endobronchial aspiration of plague bacilli. This fulminant pneumonia is rapidly followed by systemic toxicity, respiratory failure, and circulatory collapse. Six percent of pneumonia cases have an accompanying meningitis.Pneumonic plague presents within 2 to 3 days of aerosol inhalation of bacilli (from biological weapon agent dissemination source or from respiratory droplets from another infected patient). There is a sudden onset of fever, chills, and an influenza-like syndrome followed within 24 hours by the onset of a fulminant pneumonia with hepatocellular damage and systemic toxicity. Coagulation abnormalities are common and severe ecchymosis may occur (�black death�). Oropharangeal primary infections may progress to fulminant pneumonia following endobronchial aspiration of plague bacilli. This fulminant pneumonia is rapidly followed by systemic toxicity, respiratory failure, and circulatory collapse. Six percent of pneumonia cases have an accompanying meningitis.
ARDS DIC Fulminant Pneumonia Flu-like Syndrome Sudden onset 2 -3 days 24 hrs Inhalational of plague organisms Pneumonic plague presents within 2 to 3 days of aerosol inhalation of bacilli (from biological weapon agent dissemination source or from respiratory droplets from another infected patient). There is a sudden onset of fever, chills, and an influenza-like syndrome followed within 24 hours by the onset of a fulminant pneumonia with hepatocellular damage and systemic toxicity. Coagulation abnormalities are common and severe ecchymosis may occur (�black death�). Oropharangeal primary infections may progress to fulminant pneumonia following endobronchial aspiration of plague bacilli. This fulminant pneumonia is rapidly followed by systemic toxicity, respiratory failure, and circulatory collapse. Six percent of pneumonia cases have an accompanying meningitis.Pneumonic plague presents within 2 to 3 days of aerosol inhalation of bacilli (from biological weapon agent dissemination source or from respiratory droplets from another infected patient). There is a sudden onset of fever, chills, and an influenza-like syndrome followed within 24 hours by the onset of a fulminant pneumonia with hepatocellular damage and systemic toxicity. Coagulation abnormalities are common and severe ecchymosis may occur (�black death�). Oropharangeal primary infections may progress to fulminant pneumonia following endobronchial aspiration of plague bacilli. This fulminant pneumonia is rapidly followed by systemic toxicity, respiratory failure, and circulatory collapse. Six percent of pneumonia cases have an accompanying meningitis.
ARDS DIC Fulminant Pneumonia Flu-like Syndrome Sudden onset 2 -3 days 24 hrs Inhalational of plague organisms Endotoxemia Respiratory failure Circulatory collapse Pneumonic plague presents within 2 to 3 days of aerosol inhalation of bacilli (from biological weapon agent dissemination source or from respiratory droplets from another infected patient). There is a sudden onset of fever, chills, and an influenza-like syndrome followed within 24 hours by the onset of a fulminant pneumonia with hepatocellular damage and systemic toxicity. Coagulation abnormalities are common and severe ecchymosis may occur (�black death�). Oropharangeal primary infections may progress to fulminant pneumonia following endeobronchial aspiration of plague bacilli. This fulminant pneumonia is rapidly followed by systemic toxicity, respiratory failure, and circulatory collapse. Six percent of pneumonia cases have an accompanying meningitis.Pneumonic plague presents within 2 to 3 days of aerosol inhalation of bacilli (from biological weapon agent dissemination source or from respiratory droplets from another infected patient). There is a sudden onset of fever, chills, and an influenza-like syndrome followed within 24 hours by the onset of a fulminant pneumonia with hepatocellular damage and systemic toxicity. Coagulation abnormalities are common and severe ecchymosis may occur (�black death�). Oropharangeal primary infections may progress to fulminant pneumonia following endeobronchial aspiration of plague bacilli. This fulminant pneumonia is rapidly followed by systemic toxicity, respiratory failure, and circulatory collapse. Six percent of pneumonia cases have an accompanying meningitis.
ARDS DIC Fulminant Pneumonia Flu-like Syndrome Sudden onset 2 -3 days 24 hrs Inhalational of plague organisms Endotoxemia Respiratory failure Circulatory collapse Pneumonic plague presents within 2 to 3 days of aerosol inhalation of bacilli (from biological weapon agent dissemination source or from respiratory droplets from another infected patient). There is a sudden onset of fever, chills, and an influenza-like syndrome followed within 24 hours by the onset of a fulminant pneumonia with hepatocellular damage and systemic toxicity. Coagulation abnormalities are common and severe ecchymosis may occur (�black death�). Oropharangeal primary infections may progress to fulminant pneumonia following endeobronchial aspiration of plague bacilli. This fulminant pneumonia is rapidly followed by systemic toxicity, respiratory failure, and circulatory collapse. Six percent of pneumonia cases have an accompanying meningitis.Pneumonic plague presents within 2 to 3 days of aerosol inhalation of bacilli (from biological weapon agent dissemination source or from respiratory droplets from another infected patient). There is a sudden onset of fever, chills, and an influenza-like syndrome followed within 24 hours by the onset of a fulminant pneumonia with hepatocellular damage and systemic toxicity. Coagulation abnormalities are common and severe ecchymosis may occur (�black death�). Oropharangeal primary infections may progress to fulminant pneumonia following endeobronchial aspiration of plague bacilli. This fulminant pneumonia is rapidly followed by systemic toxicity, respiratory failure, and circulatory collapse. Six percent of pneumonia cases have an accompanying meningitis.
37. Pneumonic Plague:Isolation precautions
SECONDARY TRANSMISSION IS POSSIBLE - EASILY USE STANDARD AND AIRBORNE PRECAUTIONS Pneumonic plague may be highly communicable under appropriate climate conditions. For patients with confirmed pneumonic plague, droplet precautions are required until sputum cultures are negative. This category of personal protection requires a surgical mask and suggests a private room. However, patients may be cohorted or, if necessary, placed in a room where they are separated by several feet. Accidental exposures to health care workers are managed by giving post-exposure tetracycline or doxycycline therapy for a minimum of 7 days. Vaccine is ineffective against aerosol exposures to plague.Pneumonic plague may be highly communicable under appropriate climate conditions. For patients with confirmed pneumonic plague, droplet precautions are required until sputum cultures are negative. This category of personal protection requires a surgical mask and suggests a private room. However, patients may be cohorted or, if necessary, placed in a room where they are separated by several feet. Accidental exposures to health care workers are managed by giving post-exposure tetracycline or doxycycline therapy for a minimum of 7 days. Vaccine is ineffective against aerosol exposures to plague.
38. Management / Prophylaxis
Antibiotic therapy IV amino glycoside and IV doxycycline Ciprofloxacin Antibiotic resistant strains exist Supportive measures Prophylaxis for respiratory droplet exposure: oral doxycycline or oral ciprofloxacin for 7-10 days vaccine - no longer manufactured in U.S. Early antibiotic therapy of plague patients is imperative. Streptomycin and Gentamicin are considered the drugs of choice but supplies could be quickly exhausted in a mass casualty incident. Alternative choices include doxycycline, ciprofloxicin, and chloramphenicol. In addition to antibiotic therapy, many patients will also require advanced medical supportive therapy. Patients with pneumonic plague should be considered infectious until 1) minimum of 48 hours after the initiation of appropriate antibiotic treatment with patient showing a favorable clinical response, i.e. no fever or 2) until one sputum culture is negative (at least 48 hours after start of therapy). * These treatments are not generally recommended for pregnant women and children. Their use in a specific clinical setting must be decided upon the basis of their risk versus the benefit to the patient. Early antibiotic therapy of plague patients is imperative. Streptomycin and Gentamicin are considered the drugs of choice but supplies could be quickly exhausted in a mass casualty incident. Alternative choices include doxycycline, ciprofloxicin, and chloramphenicol. In addition to antibiotic therapy, many patients will also require advanced medical supportive therapy. Patients with pneumonic plague should be considered infectious until 1) minimum of 48 hours after the initiation of appropriate antibiotic treatment with patient showing a favorable clinical response, i.e. no fever or 2) until one sputum culture is negative (at least 48 hours after start of therapy). * These treatments are not generally recommended for pregnant women and children. Their use in a specific clinical setting must be decided upon the basis of their risk versus the benefit to the patient.
39. Plague:Diagnostic Tests
No widely available rapid tests Gram stain of body fluids or lymph node aspirate may reveal gram-negative organisms Blood cultures should be positive within 2 days. Confirmatory testing via government labs (antigen detection, immunoassays, and PCR)
40. Viruses as Bioweapons
Viral Hemorrhagic Fevers: Ebola Lassa Marburg Smallpox Certain viruses have characteristics that would make them particularly well suited for use as biological agents. These include smallpox and several of the viral hemorrhagic fever (VHF) viruses. Certain viruses have characteristics that would make them particularly well suited for use as biological agents. These include smallpox and several of the viral hemorrhagic fever (VHF) viruses.
41. Viral Hemorrhagic Fevers
Group of illnesses caused by several RNA viruses All can be used as bioweapons Examples: Ebola, Marburg, Lassa Mortality can be very high (90% for Ebola)
42. VHF: Occurrence
Naturally occurring infections can occur via transmission from infected rodents and arthropods Readily transmissible from person to person via body fluids: great risk for healthcare workers VHF very rare in US: usually travelers to endemic areas
43. CURRENT OUTBREAK
Current outbreak in Africa 80-89% MORTALITY
44. VHF: Pathophysiology
Variable incubation (2-21 days) Flu-like symptoms with high fever Increased vascular permeability causes: hemorrhage in GI tract and mucous membranes petechial or ecchymotic rash edema hypotension Rapid progression to shock and death
45. VHF: Lab Testing
No widely available rapid tests Government labs can provide nucleic acid assays Routine labs reveal clotting abnormalities: elevated PT and PTT, decreased platelets
46. VHF: Treatment
Supportive treatment IV ribavirin used occasionally for Lassa fever. Vaccines under development Postexposure prophylaxis with oral ribavirin may be useful Contact and respiratory precautions necessary
47. Smallpox
Variola virus Characteristic skin lesions About 30% mortality in unvaccinated Last known natural case: Somalia in 1977
49. Smallpox as a Bioweapon
Can be aerosolized Highly contagious No effective treatment Vaccination ceased in 70�s Stable in the environment (contamination for months)
50. Smallpox: Pathophysiology
Virus inhaled or deposited on mucous membranes Goes to lymph nodes, incubates for 7-17 days Release into blood causes flu-like symptoms Rash begins 2-3 days later Death due to toxemia of viral antigens and circulating immune complexes
51. Smallpox: Skin lesions
Macular (flat, red) rash 2-3 days after flu symptoms Starts on face, forearms, hands (+ palms and soles) Rash evolves synchronously in an area Evolves into tense vesicles Scabs form in 7-10 days if patient lives 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
58. Prodrome yes minimal or none
Smallpox vs. Chickenpox Smallpox Chickenpox If today�s physician were to encounter a patient with early symptoms of smallpox infection, the most likely differential diagnosis would be chickenpox. The most identifiable difference between smallpox and chickenpox is distribution and progression of rash. It is also important to note that chickenpox would be much less likely to present in an adult patient. Distribution: Smallpox: Centrifugal - starts centrally moves outward Chickenpox: centripetal - starts peripheral, moves central If today�s physician were to encounter a patient with early symptoms of smallpox infection, the most likely differential diagnosis would be chickenpox. The most identifiable difference between smallpox and chickenpox is distribution and progression of rash. It is also important to note that chickenpox would be much less likely to present in an adult patient. Distribution: Smallpox: Centrifugal - starts centrally moves outward Chickenpox: centripetal - starts peripheral, moves central
59. Prodrome yes minimal or none Distribution out to in in to out
60. Prodrome yes minimal or none Distribution out to in in to out Lesions painful / deep pruritic / superficial Progression synchronous asynchronous Palms / Soles yes no
61. Smallpox vs. Chickenpox
The lesions of chickenpox develop as a series of "crops" over several days and are very superficial. Papules, vesicles, pustules, and scabs can be seen adjacent to each other. The trunk is usually more affected than the face or extremities. The lesions of chickenpox develop as a series of "crops" over several days and are very superficial. Papules, vesicles, pustules, and scabs can be seen adjacent to each other. The trunk is usually more affected than the face or extremities.
62. Smallpox: Diagnosis
CLINICAL PRESENTATION AND PATIENT HISTORY IS THE KEY TO DIAGNOSIS No widely available rapid test Electron microscopy to confirm presence of variola virus particles
63. Smallpox:Treatment and Prophylaxis
No effective treatment Animal trials with cidofovir are promising Vaccinia immune globulin may be useful Vaccination within 3-4 days of ALL potential contacts may prevent or lessen disease
64. Smallpox: Precautions
Airborne and Contact Isolation Airborne Isolation: negative pressure room anteroom closed ventilation system N95 mask (Duckbill mask) Contact Isolation: strict use of PPE and handwashing
65. Smallpox: Precautions
Patients may be cohorted Laundry kept separate and in Red Bag Limit number of personnel in contact Mask patient if in-hospital transport Contacts placed under 18 day fever surveillance (>100.5 reportable)
66. Smallpox Vaccine
Vaccination in U.S. ended in 1972 except military personnel Not known if previous vaccination is protective now Not a benign vaccine: side effects and fatalities Possibly MANY deaths if given to all in US THERE IS A THOUGHT THAT PEOPLE THAT HAD VACCINE MANY YEARS AGO MAY NEED LESS OF A DOSETHERE IS A THOUGHT THAT PEOPLE THAT HAD VACCINE MANY YEARS AGO MAY NEED LESS OF A DOSE
Vaccine is for vaccinia, a closely related and more benign virus Vaccine contraindicated in some, unless exposure has occurred: Immunosuppressed (hiv / cancer/transplant patients chronic steroid usage (eyedrops) eczema or chronic exfoliative skin disorders pregnancy age under 18 CARDIAC DISEASE- Mi�s / Myopathy / Angina
Virus sheds from vaccine site for up to 6 weeks Shedding can infect household contacts with vaccinia Some serious vaccine reactions: encephalitis, severe vaccinia, anaphylaxis, Stevens-Johnson Auto-inoculation of orifices can occur
69. AUTO-INNOCULATION
70.
74. NEW JERSEY CLINICS
NORTHWEST- Sussex/Passaic/Warren/Morris St Joe�s and ID Associates NORTHEAST- Bergen/Essex/Hudson Hackensack / UMDNJ- Newark CENTRALEAST- Middlesex/Union/Monmouth/Ocean Raritan Bay Medical Center
75.
CENTRALWEST- Somerset/Mercer/ Hunterdon Hunterdon Hospital South- Camden/Burlington/Atlantic/Salem Our Lady of Lourdes and Shore Hospitals
76. VACCINATION REPORT
HEALTH CARE WORKERS NEW JERSEY- 619 NYC- 138 PENNSYLVANIA- 67 NEVADA � 0 MINNESOTA- 1439 TENNESSEE- 2407
77. VACCINATORS
NEW JERSEY - 50
78.
FEDERAL VACCINATION PROGRAM IS NOW ON �HOLD�
79. BIOLOGICAL TOXINS
80.
BOTULINUM � BO-TOX RICIN STAPHYLOOCCAL ENTEROTOXIN B (not reviewed) T-2 MYCOTOXINS (not reviewed) RICIN A large variety of lethal biological toxins exist. The agents that will be discussed in this section are those which were found to have the necessary manufactured stability and effectiveness to effect a large area coverage attack and cause mass casualties. These toxins include Botulinum Toxin A, Ricin, and the incapacitating agent Staphlococcal Enterotoxin B (SEB). These toxins produce disease effects by different mechanisms. Botulinum Toxin acts to block nerve conduction, while Ricin is a potent cytotoxin which inhibits normal protein synthesis in mammalian cells. A large variety of lethal biological toxins exist. The agents that will be discussed in this section are those which were found to have the necessary manufactured stability and effectiveness to effect a large area coverage attack and cause mass casualties. These toxins include Botulinum Toxin A, Ricin, and the incapacitating agent Staphlococcal Enterotoxin B (SEB). These toxins produce disease effects by different mechanisms. Botulinum Toxin acts to block nerve conduction, while Ricin is a potent cytotoxin which inhibits normal protein synthesis in mammalian cells.
81. Botulinum Toxin
7 neurotoxins produced by Clostridium botulinum Among the most toxic substances known May be found in naturally contaminated food As a bioweapon, likely to be delivered by aerosol No person-to-person transmission Multiple cases without common food source suggests bioterrorism
82. Botulinum Toxin:Mechanism of Action
Site: neuromuscular junction (pre-synaptic) Action: binds at acetylcholine release sites to prevent release Effect: muscle weakness (skeletal and cranial nerve distribution) Does not cross the blood-brain barrier: patients remain alert and afebrile
83. Botulinum Toxin:Clinical Findings
Botulism onset: about 1-3 days Cranial nerve palsies early: Eye: blurred vision, photophobia, diplopia, ptosis Throat: dysarthria, dysphagia Skeletal muscle weakness later: symmetrical, descending, progressive abrupt respiratory failure
84. Botulinum Toxin:Differential Diagnosis
Differential Diagnosis: tetanus, myasthenia gravis, Guillain-Barre Botulism differentiated by: more cranial nerve involvement facial muscles more involved than below neck lack of sensory changes
85. Botulinum Toxin: Lab
Laboratory testing: generally not helpful detection of toxin in serum is possible
86. Botulinum Toxin: Treatment
Do not wait for lab confirmation Administer antitoxin: available from CDC but very limited supplies only binds to circulating toxin to prevent progression will not reverse symptoms already present anaphylaxis and serum sickness may result do not prophylax exposed but asymptomatic patients Respiratory support necessary Recovery takes weeks to months
87. RICIN

88. Ricin
Potent protein toxin derived from castor beans Easily produced / Recently found in France Inhibits protein synthesis Causes necrotizing airway lesions: tracheitis bronchitis and bronchiolitis interstitial pneumonia with ARDS
89. Ricin
Inhalation as an aerosol produces severe respiratory symptoms: day 1: cough, fever, dyspnea day 2-3: pulmonary edema, resp failure, death Specific serum test is available No treatment available other than supportive
90. Chemical Weapons
91. Chemical Weapons
Nerve agents Vessicants (blistering agents) Pulmonary agents Blood agents (cyanide) Riot Control agents
92. Nerve Agents
Most toxic of all the synthetic chemical agents. Very similar to organophosphate insecticides. Death within minutes when inhaled or absorbed through skin. Developed in WW2 by Germany but not used. U.S. completed development after WW2. Examples: SARIN
93. Nerve Agents: Effects
Smooth muscle hyper stimulation Glandular hyper stimulation Skeletal muscle hyper stimulation
Smooth muscle hyper stimulation: vomiting and diarrhea urination bronchospasm small pupils (miosis)
Glandular hyper stimulation: salivation lacrimation increased airway secretions increased GI secretions
Skeletal muscle hyper stimulation at first: Fasciculations Later, skeletal muscle exhaustion: weakness followed by flaccid paralysis
SLUDGE reaction: Salivation Lacrimation Urination Defecation Generalized twitching Emesis
98. Nerve Agents:Decontamination
Removal of contaminated clothing Copious irrigation and washing with soap and water BIOSUITS- NO CONTACT WITH AGENT
Mark 1 Nerve Agent Antidote Kit ATROPINE PROTOPAM VALIUM
100. Sources ofRadioactive Material
High-level sources (plutonium, uranium): nuclear power plants and weapons sites high security; more difficult to obtain and handle Low-level sources (cobalt-60, strontium-90, cesium-137, americium-241): hospitals construction sites food irradiation plants smoke detectors
101. Key Point: Avoidance
Avoidance prevents or minimizes effects: TIME: decrease time near source of radiation DISTANCE: increase distance from source SHIELDING: increase barriers between you and source
102. Decontamination
Spray light water mist on clothes to decrease radioactive dust Remove clothes (up to 90% decrease in radioactivity exposure) Washing skin and hair with soapy water
103. Treatment
Potassium Iodide: may prevent thyroid cancer after radiation exposure NJ dispensed it to those who live within 10 mi. of nuclear plant blocks thyroid uptake of radioactive iodine
104. Treatment
Depends on specific radioactive substance and mode of exposure (inhaled, ingested, skin). Call Poison Control if available. Meticulously clean contaminated wounds. For ingestions, lavage, laxatives, and ion-exchange resins may be indicated.
105. Bombing Frequency
Worldwide, 50% of terrorist attacks are bombings. In U.S., over 85% of terrorist attacks are bombings.
Dramatic, low risk, draw attention Few skills needed Can execute attack remotely Large groups not required Components readily available Forensic evidence difficult to identify, collect and assemble Why Use Explosives?
107. BOMB COOKBOOK
HUNDREDS OF SITES ON INTERNET BOOKS- �Bombs for Dummies� Most supplies available in home depot and garden shops
108. �Dirty Bombs�
A type of radiological dispersion device. Combines conventional explosives with radioactive materials in the form of powder or pellets. Disperses radioactive material. Causes fear and contaminates land and buildings for prolonged periods.
109. �Dirty Bombs�
Dangers of dirty bombs: if low-level radioactive sources used, primary danger is blast itself gauging degree of radioactive contamination due to fallout is difficult most probable sources would not provide enough radiation to cause acute radiation sickness environmental contamination
110.
REMEMBER- REPORT ANY SUSPICIOUS ILLNESSES CLUSTERING OF CASES UNUSUAL NUMBERS OF PATIENTS WITH SAME COMPLAINTS
111.
SUSPECTED BIOLOGICAL INCIDENTS- REPORTABLE: FOLLOW HANDOUT 1- LOCAL AND / OR STATE DOH 2- LOCAL / STATE POLICE / FBI 3- BIOTERRORISM TASK FORCE 4- CDC � FEDERAL TASK FORCE- ETC

NURSING IN THE ERA OF BIOTERRORISM

NURSING IN THE ERA OF BIOTERRORISM

Presentation Transcript

Agents of Bioterrorism

BIOTERRORISM

Bioterrorism

Bioterrorism

Bioterrorism

Bioterrorism:

GIS in a context of Bioterrorism

Bioterrorism

Bioterrorism & Nursing Responses

Menacing Microbes: The Threat of Bioterrorism

BIOTERRORISM

Bioterrorism

Bioterrorism

BIOTERRORISM

BIOTERRORISM

BIOTERRORISM:

BIOTERRORISM

In the era of ALMA

Bioterrorism

Bioterrorism

BIOTERRORISM

Bioterrorism

NURSING IN THE ERA OF BIOTERRORISM