Anthrax

BioAgents of Concern Anthrax, Botulism, Smallpox, PlagueTABLE OF CONTENTS

Learning Objectives3

Introduction3

Anthrax as a Biological Weapon11

History of Current Threat13

Epidemiology of Anthrax14

Microbiology

15

Pathogenesis and Clinical Manifestations16

Diagnosis24

Vaccination

26

Therapy28

Infection Control33

Decontamination34

Smallpox as a Biological Weapon47

History and Potential as a Bioweapon47

Epidemiology

48

Microbiology

49

Pathongenesis and Clinical Presentation49

Diagnosis

51

Preexposure Preventive Vaccination

52

Postexposure Therapy53

Postexposure Infection Control54

Hospital Epidemiology and Infection Control55

Vaccine Administration and Complications

56

Decontamination59

Research60

Summary61

Smallpox Update61

Botulism as a Bioterror Weapon81

History of Current Threat81

Microbiology and Virulence Factors

82

Pathogenesis and Clinical Manifestations83

Epidemiology

84

Diagnosis and Differential Diagnosis87

Therapy89

Special Populations90

Prophylaxis91

Decontamination91

Infection Control92

Research Needs92

Plague as a Biological Weapon103

History and Potential as a Bioterrorist Agent103

Epidemiology

104

Microbiology and Virulence Factors

105

Pathogenesis and Clinical Manifestations105

Diagnosis107

Vaccination108

Therapy108

Postexposure Prophylaxis Recommendations112

Infection Control113

Environmental Decontamination114

Appendix125Examination145

Learning Objectives

Upon successful completion of this continuing education module, you will be able to:

Identify and discuss the history, epidemiology, microbiology, pathogenesis, clinical manifestations, diagnosis, treatment and prevention of: Anthrax, Small Pox, Botulism and Plague

Introduction

Bioterrorism has become a common household term ever since anthrax was spread across a wide reach of the nation last fall. Now, it almost appears everyone is involved in serious anti-terrorism campaigns which are not as readily seen as flags attached to cars, homes and clothing.

In the event of another bioterrorist attack, will you as a caregiver be prepared?

RTs and Nurses are in the first line of defense in combating biohazard substances because inhalation is the major pathways for toxic and biological agents to infect humans. The airway is one of the primary routes infectious agents follow to enter the body, and the harm caused by the agent would impact the respiratory system first, so RTs and Nurses need to be alert.

Tom Johnson, MS, RRT, program director of respiratory care and professor at Long Island University in New York, was an officer during the Vietnam era. He trained military personnel about chemical warfare. Thirty years later, he teaches RTs and Nurses about bioterrorism and how they need to be prepared in the event of a biological disaster.

Johnson urges all RTs and Nurses to recognize potential bioterrorist agents. "During the Gulf War, biowarfare became an issue, and I realized I was ignorant and did not know anthrax was already weaponized." Bioterrorism is not a new idea. "We have had the threat of bioterrorism for a long time in history," he said.

Today's need is different. Caregivers need to be prepared and knowledgeable in bioterrorism in order to treat patients in the best manner possible.

Knowledge Is Power In the event of a bioterrorist attack, every second counts, especially when caregivers are trying to determine whether, in fact, a patient has symptoms of a bioterrorist agent. If health care professionals are keen enough to know what symptoms to look for, the impact of a potentially deadly bioterrorist attack can be lessened.

"RTs and nurses are the front line in an attack," Johnson said. If they have a suspicion and knowledge of which tests to run, the treatment can begin. "RTs and Nurses can help in the epidemiological standpoint and help blunt the attack," Johnson said. The key is to be alert in the event a bioterrorist attack happens. "Therapists need to be aware of which drugs to administer by IV and when to begin intubation," he said.

Early detection of an agent allows health care professionals more time to treat the patient and yield a cured patient. "RTs and Nurses need to be very quick thinking and detect early. Also, RTs and Nurses should have strong airway control skills and be very familiar with oxygenation ventilation issues with biological warfare," he said.

The goal is not to make experts of everyone; it's to heighten awareness. "RTs and Nurses can be under-recognized and underutilized, and we have to not only improve our skills but get those skills recognized, maybe within our licensure laws so if we have another disaster, natural or man-made, we can adequately respond as part of the health care team," Johnson said.

September 11 As Americans watched the events surrounding 9/11 unfold on national television, their gasps and sobs could be heard around the country. Little did they know it was just the beginning, a foreshadowing to the anthrax scare.

"Never before has the U.S. become so acutely aware of biological, chemical and radiological threats," said Frank Rando, MS, Ph, CRT, CVT, EMT-P, a certified hazardous materials specialist. Rando is a special adviser on counter-terrorism and public health preparedness and respiratory causality management.

"Respiratory therapists have never received detailed instruction or reading materials on how to handle these types of casualties," said Rando, who became a part of counter-terrorism because he felt RTs and Nurses need to become more aware and oriented about how to medically manage biological, chemical and radiological casualties since they are first-line health care providers. There is a one in 10 chance, he explained, there would be casualties with some degree of respiratory impairment.

Crisis Plans One of the things that would help galvanize hospital staff is to have them prepare response plans and enforce them. Response plans are one key step in advancing a response system to alert staff members and operationalize a plan.

Patrick Libbey, director of Thurston County Public Health and Social Service Department, Olympia, Wash., and the president of the National Association of County and City Health Officials, recognizes the importance of crisis management plans in the event of natural or terrorism events.

"When you have an earthquake or a flood, you have a very set geographic and time-specific event to respond to. Bioterrorism may roll out very differently," he said.

As a result of national campaigns, numerous agencies are creating more concise and structured plans to augment earlier models. Other agencies are creating disaster plans for the first time. All emergency agencies need to be alerted in the event of a disaster. If a hospital activates as a result of an existing condition, it acts in conjunction with the emergency management agency of that jurisdiction, Libbey explained.

Emergency response systems must work cohesively with each other, he added. "If any of the systems are acting independently, that is where the troubles are. They need to work together to make the earliest and most complete intervention," he said.

Crisis drills help prepare individuals involved to have at least a vague idea of what to expect when something does happen. "The more you can think through a scenario, the needs for accessing resources, and who needs to be involved, the better prepared you will be when a situation does occur," Libbey said.

Public Safety September 11 was a wake up call, not only to public safety and law enforcement officers but to the health care establishment as well because the country discovered how vulnerable it is to terrorist attacks and how devastating terrorist attacks can be.

We have become more acutely aware of bioterrorism because of the anthrax mailings, subsequent to the 9/11 attacks. The events of September and beyond have lead health care facilities to revamp and reevaluate their existing disaster response capabilities. Everyone has become leery of planes passing overhead and suspicious looking letters in the mailbox.

"The tricky piece is that many biologic agents can be used, and the initial presenting symptoms are very parallel to other on-going ailments," Johnson said. One of the keys is spotting unusual signs, "to notice if there is something specific in the presenting characteristics of the individual."

Secondly, health care personnel should notice if there is something unusual going on within the community. If there are some out of the ordinary occurring, that merits broader attention, Libbey said. When treating any patient today, clinicians need to be more aware of things they have not thought of before.

"I think it's prudent that RTs and Nurses have a knowledge of this," Johnson said. "We don't all have to be experts in neonatal or geriatrics; we just need to know something about bioterrorism."

Top Five Issues for RTs and Nurses In Bio-Terrorism Attacks

1. Have some familiarity with the top seven biological weapons: anthrax, smallpox, botulism, tularemia, bubonic/pneumonic plague, viral encephalitis, and Staphylococcus enterotoxin B. Therapists need to remembers terrorists get creative and may not use traditional agents.

2. Early warning: The therapist is a part of the early warning