Bioterrorism & Nursing Responses

1. Bioterrorism & Nursing Responses Nursing 454 Dr. Schoolmeesters Queens University of Charlotte 2010 Dawn Hall R.N., Caroline Cate R.N., & Christy Olloh R.N.

2. Bioterrorism • Terrorism is defined in the United States Code, Title 18, section 2331(18 USC 2331) as “Violent acts or acts dangerous to human life that…appear to be intended: • To intimidate or coerce a civilian population; • To influence the policy of a government by intimidation or coercion; or • To affect the conduct of a government by assassination or kidnapping.

3. BIOTERRORISM ACT • The events of Sept. 11, 2001, reinforced the need to enhance the security of the United States. Congress responded by passing the Public Health Security & Bioterrorism Preparedness & Response Act of 2002 (the Bioterrorism Act), which President Bush signed into law June 12, 2002.

4. BioterrorismBiological weapons/agents • Are living microorganisms such as bacteria, viruses, fungi, that can kill or incapacitate. • Classified as category A, B, or C in descending order of priority.

5. Category A • Poses the greatest risk • Easily disseminated person to person • High mortality rates • Potential for major public health impact • Require special action for public health preparedness

6. Category A Agents/Diseases • Anthrax • Botulism • Plague • Smallpox • Tularemia • Viral Hemorrhagic Fever (e.g., Ebola, Marburg) • Arenaviruses (e.g., Lassa, Machupo)

7. Category B agents/diseases • Second highest priority agents include those that are moderately easy to disseminate • Result in moderate morbidity rates & low mortality rates • Require specific enhancements of center for disease control diagnostic capacity & enhanced disease surveillance

8. Category B • Brucellosis(brucella species) • Epsilon toxin of clostridium perfringens • food safety threats(Salmonella species, e- coli , shigella) • Glanders(burkholderia mallei) Melioidosis (burkholderia pseudomallei) • Psittacosis (chlamydia psittaci)

9. Category B Agents/Diseases Continued • Q fever (coxiella burnetii) • Ricin -from ricinus communis (castor beans) • Staphylococcal enterotoxin b • Typhus fever (rickettsia prowazekii) • Viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis]) • Water safety threats (e.g., Vibrio cholerae)

10. Category C • Third highest priority agents • Emerging pathogens that could be engineered for mass dissemination • Ease of fabrication & distribution • Potential for high morbidity & mortality rates, major health impact • Nipah virus & hantavirus

11. Bioterrorism • Health care facilities may be the initial site of recognition & response to bioterrorist activity. • Each facility is required to have a readiness plan with all internal & external departments to contact.

12. Response to bioterrorism agents: • Internal reporting requirements (within a facility): • Infection control personnel • Epidemiologist (local & state) • Administration (health care facility & health department) • Office of public affairs in the health facility

13. Response to bioterrorism agents: • External contacts (outside of facility) • Local health department- Mecklenburg County- 704-336-4700 • State Health Department-919-707-5000 • FBI-Charlotte-704-177-9200 • CDC- N.C. 800-232-4636 • Local police -911 • EMS- 911

14. Containment of Bioterrorism Agents • Isolation Practices- standard precautions • Patient placement – routine if isolated, grouping if large scale • Patient transport –only essential movement • Cleaning, sterilization of environment using standard precautions

15. Containment Continued: • Discharge management – patient must be noninfectious. • Home care if possible with education on barriers, hand washing, waste management, cleaning & disinfection

16. Interventions • Hand washing • Vaccinations • Rapid recognition ,isolation with appropriate precautions • Secondary prevention -include post exposure prophylaxis , medical screening, surveillance to identify & treat people • Education of personnel

17. Interventions • “In addition to improving implementation of known interventions, basic & applied research is needed in a variety of areas to assess and/or improve the efficacy of potential preventive measures & to improve the evidence base for public health recommendations .” (http://www.cdc.gov/niosh/docs/2009-139/pdfs/2009-139.pdf)

18. Nursing Roles in Disaster Preparedness: • Increased funding for Bioterrorism Hospital Preparedness Program from the Health Resources and Services Administration (HRSA) is needed • Educate individuals for personal preparedness • Nurse managers must plan & participate in disaster preparedness exercises

19. NURSING Roles in Disaster Preparedness: • Provide volunteer support efforts • Practice stringent adherence to infection control practices • Increased bioterrorism training for Nurses is required • Early infectious disease detection & surveillance • Respond to individual & community mental health aspects of terrorism

20. Post-Mortem Care • Notification of Pathology • Provide instructions to funeral director

21. Recognizing Category A Agents • Anthrax • Plague • Smallpox • Botulism • Tularemia • Viral Hemorrhagic Fever (e.g., Ebola, Marburg) • Arenaviruses (e.g., Lassa, Machupo)

22. Anthrax • Acute infectious disease caused by bacillus anthracis

23. Anthrax Modes of transmission • Inhalation of spores • Skin contact • Ingestion of contaminated food

24. Anthrax Cutaneous signs & symptoms • Local skin involvement with direct contact • Commonly seen on head, forearms, or hands • Localized itching followed by popular lesion that turns vescular within 2-6 days – develops into depressed black eschar Prognosis • Good if treated with Ciprofloxacin, Doxyclin or Levofloaxcin

25. ANTHRAX may also be transmitted via ingestion Gastrointestinal signs & symptoms • Abdominal pain, nausea, vomiting, fever • Bloody diarrhea, hematemesis • Positive culture after 2-3 days • Prognosis- poor If progression to toxemia & sepsis

26. Anthrax may also be inhaled • Person-to-person transmission of inhalation disease does not occur.

27. ANTHRAX Pulmonary signs & symptoms • Flu-like symptoms that may briefly improve 2 to 4 days after initial symptoms • Abrupt onset of respiratory failure • Hemodynamic collapse • Thoracic edema

28. ANTHRAX Pulmonary signs & symptoms: • Positive blood culture in 2-3 days of illness • Widened mediastinum on x-ray • Positive blood culture in 2-3 days of illness • Prognosis: Good if treated early- High mortality rate if treated after respiratory onset

29. Anthrax Incubation period • Pulmonary: 2-60 days • Cutaneous: 1-7 days • Gastrointestinal: 1-7 days

30. Anthrax Transmission • Anthrax is not airborne person to person. • Direct contact with infectious skin lesions can transmit infection.

31. Anthrax Prevention • Vaccine available-limited quantities.

32. Plague • Plague is an acute bacterial disease caused by Yesinia Pestis.

33. Plague Mode of Transmission • Plague normally transmitted from an infected flea

34. Plague Mode of Transmission • Can be aerosol-probable use in bioterrorism

35. Plague Incubation period • Flea bite – 2-8 days • Aerosol – 1-3 days

36. Plague Prognosis Good if treated with Tetracycline, Ciprofloxacin, Streptomycin or Gentamicin early

37. Plague Signs & Symptoms • Fever • Cough • Chest pain • Hemoptysis • Watery sputum • Bronchopneumonia on xray

38. Viral Agents • Small Pox Virus

39. Viral Agents • Smallpox is an acute viral illness caused by the variola virus. • Mode of transmission - airborne: droplets

40. Smallpox Signs & symptoms • Flu like symptoms-fever, myalgia • Skin lesions • appear quickly progressing from macules to papules to vesicles • Rash • scabs over in 1-2 weeks • occurs in all areas at once, not in crops

41. Smallpox

42. Smallpox Incubation period • From 7 to17 days, average is 12 days • Contagious when rash is apparent & remains infectious until scabs separate (approx. 3 weeks)

43. Smallpox Prognosis • Vaccine available & effective post-exposure • Passive immunization is also available in the form of vaccina- immune-globulin (Vig) • Smallpox has a high mortality rate.

44. Toxins Botulism • Potent neurotoxin caused by an anaerobic bacillus- clostridium botulinum.

45. Botulism Transmission • Contaminated food • Inhalation

46. Botulism Signs & symptoms • Gastrointestinal symptoms • Drooping eyelids • Weakened jaw clench • Difficulty swallowing or speaking • Blurred vision • Respiratory distress

47. Botulism Incubation period • Food borne botulism – 12-36 hours after ingestion • Inhalation botulism – 24-72 hours after exposure

48. Botulism Prevention: • Vaccine available • Botulism cannot be transmitted person to person

49. Tularemia • Serious illness - occurs naturally in the U.S. • Cause- bacterium francisella • Tularensis found in animals (especially rodents, rabbits, & hares). Symptoms • Sudden fever • Chills • Headaches • Diarrhea • Muscle aches • Joint pain • Dry cough • Progressive weakness • Chest pain, • Bloody sputum dyspnea

50. Tularemia as a bioterrorism weapon • Francisella tularensis is very infectious. A small number (10-50 or so organisms) can cause disease. • Airborne exposure • Severe respiratory illness, including life-threatening pneumonia & systemic infection