Bioterorism—are you ready for the silent killer? - Home Study Program

Kristina Stillsmoking

The article "Bioterrorism--Are you ready for the silent killer?" is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education.

A minimum score of 70% on the multiple-choice examination is necessary to earn 2 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Sept 30, 2005.

Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to

AORN Customer Service
c/o Home Study Program
2170 S Parker Rd, Suite 300
Denver, CO 80231-5711

or fax the information with a credit card number to (303) 750-3212.

BEHAVIORAL OBJECTIVES

After reading and studying the article on bioterrorism, the nurse will be able to

(1) define bioterrorism,

(2) describe our historical reaction to bioterrorist attacks,

(3) discuss the routes of exposure for the major biological agents of greatest concern, and

(4) describe correct management of a biological crisis.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

Bioterrorism can be defined as the use of a microorganism to kill or harm an enemy or a population of people, food, or livestock by whatever means necessary to demoralize, intimidate, or conquer. (1) A bioterrorism attack is an insidious and often unnoticed event, so health care workers need to be alert to its characteristics. Bioterrorism attacks in the United States no longer are a matter of if; they are a matter of when. Recent events have determined that the "when" is happening now, but being educated about bioterrorism can help alleviate the impact of a crisis.

Dennis O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, believes that more health care workers must be trained to become familiar with pathogens that may be used during bioterrorism attacks, aware of the symptoms they produce, and alert to the possibility of their use? The United States is not unprepared for bioterrorism, but US health care workers could be better prepared than they are today. Health care in the United States is entering an era when caregivers need to reexamine policies on emergency preparedness.

The recent attacks on the World Trade Center and the Pentagon, as well as the anthrax threats that followed, transformed US citizens' perceptions of how safe they are and left them confused and frightened. Perioperative nurses, as the keepers of asepsis, need to become more involved in helping those around them understand the nature of bioterrorism and how to prevent the spread of disease if an attack should occur. The Centers for Disease Control and Prevention (CDC) has emphasized that the health care profession needs to be prepared for this eventuality.

Many perioperative nurses have heard or read reports about what the different microbes that could be involved in a bioterrorism attack can do. Some have buried their heads in the sand and others are afraid of what these biological agents can do, but early intervention and statements by technical experts (eg, perioperatiye nurses) and political leaders can help defuse public feelings of confusion and fear and lead citizens to appropriate behaviors. Perioperative nurses provide a composed facade every day as they work to calm and protect surgical patients. They know what havoc fear and confusion can play in a surgical patient's recovery and survival. In addition, perioperative nurses represent a nursing specialty that constantly is looked upon by the world as providing the gold standard of asepsis. To provide patients and their family members with appropriate information, however, perioperative nurses need to understand the mechanics of bioterrorism, its history, and the delivery and routes of exposure of biological agents. By understanding the disease process, treatments available, and how to counter the impact of exposure, caregivers can avert panic and confusion.

THE HISTORY OF BIOTERRORISM

The history of biological warfare is varied. For example, the ancient Romans contaminated the water supplies of their enemies, and in 1346, the Tartars catapulted bodies infected with bubonic plague over the walls of the besieged city of Kaffa. (3) In the eighteenth century, British officials sent smallpox-contaminated blankets to Native Americans in the hopes of lessening their numbers. (4) During the 1930s and 1940s, military organizations in Japan, Great Britain, Germany, and the Soviet Union developed the technology to produce weapons of mass destruction, and they conducted a variety of experiments on humans and animals. During the 1940s and up until the 1970s, the United States also developed weapons of mass destruction to counter the Japanese, British, German, and Soviet development. The United States began developing vaccines, personal protective equipment (PPE), decontamination procedures, and antibiotics for use in counterterrorism.

In the early 1970s, countries with biological weapons realized that controls were needed over this type of weapons development. In 1972, at the Convention on the Prohibition of the Development, Production, and Stockpiling of Bacteriological (Biological) and Toxin Weapons and on Their Destruction, a treaty banning the development, production, and stockpiling of biological weapons not required for peacetime, was introduced. As of June 2000, 144 countries had signed the treaty. (5) Although several rogue nations continue to produce biological weapons, the recent focus on biological warfare threats has turned to terrorist groups. For example, in 1984, the Rajneeshee religious cult laced several restaurant salad bars in Dalles, Ore, and Wasco County, Ore, with Salmonella. In 1995, members of the Aum Shinrikyo cult released Sarin gas into the Japanese subway. (6)

The twenty-first century brought us the horrific attacks on the World Trade Center and Pentagon on Sept 11, 2001, followed a few weeks later by letters filled with anthrax spores that were sent to members of the US government, key television news reporters, and a publishing company. Luckily, what could have been a major disaster was averted by a Florida physician's quick recognition of the anthrax virus.

REACTION TO THE THREAT

In recent months, the US government has undertaken even more research and development on counterterrorism measures, vaccines, disaster preparedness, and public awareness. The government has created the National Pharmaceutical Stockpile Program at eight sites around the country, with four more being requested. (7) These stored push packs of bulk antibiotics can be delivered in less than 12 hours from the time of request. Additional equipment and personnel may accompany this shipment to prepare inventory for distribution. Additionally, millions of dollars are being poured into homeland safety measures, and emergency medical system, fire, police, and public health departments around the country have been trained as first responders to recognize and contain a biological incident.

The CDC and other governmental agencies are working overtime to prepare and educate the public. State laboratories are being updated, and staff members are being trained in the identification of weapons of mass destruction. Millions of dollars have been pledged to preparedness, research, development, testing, and production of anthrax and smallpox vaccines, as well as adjunct antibiotics.

The ability to weaken an enemy, provoke terror and fear, demoralize, paralyze large populations, and overwhelm medical resources are the major goals of bioterrorism. Once described as the "poor man's atomic bomb," this method of terrorism is relatively easy to produce behind closed doors using very inexpensive supplies. (8) Creating a biological agent can be as simple as manufacturing beer and less dangerous than refining heroin. In addition, for many of these agents, transportation to the target is simple because the amount needed to achieve an overwhelming effect is small and easily concealed. Some researchers believe that affecting one square kilometer of land would cost

* $2,000 if using a conventional weapon,

* $800 if using a nuclear weapon,

* $200 if using a gas-containing weapon, but

* only $1 if using a biological weapon. (9) Conventional weapons are costly to maintain and produce, but a small, simple, and hidden laboratory can produce biological agents easily and cheaply. It has been only within the past several years that the loophole for anyone to obtain sample biological agents for research and development was closed by the US government.

ROUTES OF EXPOSURE

Inhalation through aerosolization is the most effective method for spreading biological agents because it is the most rapid method, which is why chemical spraying aircraft were grounded after the attacks on the World Trade Center and the Pentagon. Absorption through open cuts or breaks in the skin, ingestion from contaminated foods due to undercooking, infection via naturally occurring methods, or deliberate inoculation are other means of exposure.

Each microorganism has unique characteristics that can make it difficult to use as a weapon. Some do not like sunlight or heat, and others have to be a certain size to enter the lungs in large enough numbers to be effective. In addition, the agent may only affect older adult or immunocompromised hosts. It takes approximately 8,000 to 10,000 1-mm to 5-mm spores of a biological agent to enter a person's respiratory tract and be consumed by macrophages. (10) If the microbes attach to dust particles, it is difficult for the agent to enter the blood stream. Larger sized microbes are more likely to produce a cutaneous exposure. In the host, these microbes are moved to the lymph system where they respond to the new host environment and begin actively reproducing, which generates toxins.

There still is a lot of speculation as to the real nature of biological agent microbes because they have the ability to act in unexpected ways, which makes the solution to the puzzle even more wearisome. The initial difficulty is determining whether there has been an overt attack with a biological weapon or whether it is a naturally occurring epidemic. Following Sept 11,2001, many peoples' panicky response to any sort of powdery substance taxed local public health department systems. Commonsense was replaced by fear and panic. For example, one local public health department received a call from a woman who had just picked up her child from a daycare center and the child had a white powdery substance on her clothing. Common sense would indicate that the substance possibly was baby powder from a diaper change.

Caregivers should not ignore powdery residues, however. They should wash their hands, remove their clothes carefully, and clean them as described below. Some local officials have issued guidelines for 911 operators to triage calls and collaborated on newspaper articles to help educate the public. Public health departments can instruct concerned citizens to call special telephone numbers for information or to speak with a public health department official. A physician education sheet also helps physicians answer patient questions and address concerns.

BIOLOGICAL AGENTS AS WEAPONS

There are four category A agents of major concern that officials have identified as potential agents for a bioterrorism attack. These include

* anthrax (ie, Bacillus anthracis),

* smallpox (ie, variola major),

* plague (ie, Yersiniapestis), and

* botulism (ie, Clostridium botulinum toxin). (11)

There are other category A agents of interest, but they are not the major focus of public education at this time.

Anthrax (ie, Bacillus anthracis). Anthrax is highly lethal if it is not diagnosed and treated within 24 to 36 hours of onset of severe symptoms. Incubation generally occurs within one to six days, but it has been found to appear 60 days postexposure in test animals. Bacillus anthracis is a grampositive spore-forming rod that has been known to survive in the soil for more than 100 years, and it exists worldwide. Anthrax also is known as the wool sorter's disease because it exists naturally in infected sheep, cattle, and horses. The flu-like symptoms indicative of anthrax may include high fever, fatigue, cough, malaise, and mild chest discomfort progressing to respiratory distress, cyanosis, diaphoresis, dyspnea, stridor, and shock. (12) A nonspecific physical finding late in the illness is a widened mediastinum as seen on a chest x-ray. Additionally, a gram stain of blood and blood culture detects the bacillus. Patients should receive high dose antibiotic treatment with ciprofloxacin or doxycycline before the onset of symptoms. Use of dual antibiotics is recommended to control the ensuing possibility of meningitis. The same treatment is used with the onset of symptoms, although it has limited effectiveness. In addition, the same supportive measures are used.

A vaccine for anthrax does exist but only limited quantities are available, so its use is limited to military purposes. The vaccination process includes six injections given during the course of one year with an annual booster. Prophylaxis in cases when exposure is known and verified includes oral ciprofloxacin or doxycycline, although several antibiotics with similar abilities are being investigated currently.

As an agent of bioterrorism, the method of exposure to anthrax would be airborne or via contact with inanimate objects (eg, mail, wool). Standard precautions for health care workers should be practiced when caring for patients infected with anthrax because no person-to-person transmission has been documented. Any areas or instruments needing cleaning should be disinfected with a sporicidal agent (eg, phenol, hypochlorite).

Smallpox (ie, variola major). The smallpox variola virus has a 70% survivability rate with an incubation period of seven to 10 days. Patients with smallpox may experience flu-like symptoms, including fever, vomiting, headache, rigors, backache, and malaise. Within two to three days, lesions appear that progress quickly from macules to papules and eventually pustular vesicles. These lesions develop synchronously and are more abundant over the extremities and face. They are unlike chickenpox, which develops first on the trunk of the body and is seen in various stages of development. (13)

No current technology is capable of discriminating variola from vaccinia (ie, the acute infectious disease caused by smallpox vaccination). There is no effective chemical therapy at present, and treatment remains supportive in nature. In the past, vaccination was the choice for prevention, but smallpox vaccinations were stopped in 1977 because the disease was eradicated in the United States. It has been speculated, however, that those who were vaccinated before 1977 no longer have immunity. (14) In addition, there is a limited amount of the vaccine in existence, but research and development are underway to produce much more during the next two years.

As an agent of bioterrorism, the method of exposure to smallpox would be airborne or via direct contact. When a patient is suspected of having smallpox, airborne and droplet precautions should be followed for a minimum of 17 days after exposure for all contacts with the infected person. Patients are considered contagious and should remain in quarantine until all scabs separate. If quarantine is impractical, asymptomatic contacts must check their temperature daily. Any fever above 38[degrees] C (101[degrees] F) during 17 days postexposure would suggest development of smallpox. Quarantine and isolate the patient until the diagnosis is confirmed, ruled out, or scabs separate.

Plague (ie, Yersinia pestis). Both pneumonic plague and bubonic plague are caused by the same organism (ie, Yersinia pestis). Pneumonic plague is highly lethal with an incubation period of one to six days if left untreated. A gram-negative bacillus usually is transmitted from infected fleas to rodents to people. The flu-like symptoms, including high fever, headache, chills, and malaise followed by a cough with hemoptysis (ie, blood stained sputum), will progress rapidly to dyspnea, stridor, cyanosis, and death. Bubonic plague symptoms are very similar, exhibiting the development of painful lymph nodes (ie, buboes) and progressing to septic shock, thrombosis, disseminated intravascular coagulation, or pneumonic form. (15)

Pneumonic or bubonic plague should be suspected when large groups of previously healthy individuals develop fulminate gram-negative pneumonia with hemoptysis. Gram's, Wright's, Wayson's, or Giemsa's stain of blood, sputum, cerebrospinal fluid, or lymph node aspirates can result in a presumptive diagnosis. No vaccine currently is available for pneumonic or bubonic plague. Early treatment with antibiotics, however, is critical within one day of onset of symptoms. Antibiotics of choice might include ciprofloxacin, doxycycline, gentamycin, or streptomycin. Chloramphenicol is the medication of choice for plague meningitis. Asymptomatic people exposed to plague aerosol or people with suspected pneumonic plague may be given antibiotics for the duration of the risk of exposure plus one week.

As an agent of bioterrorism, the method of plague exposure would be airborne. Caregivers should use standard precautions and respiratory droplet precautions for suspected cases of plague. Plague organisms are susceptible to heat, disinfectants, and exposure to sunlight, so the use of soap and water is effective for decontamination. Take measures to prevent cycling of the disease by decreasing flea and rodent reservoirs.

Botulism (ie, Clostridium botulinum toxin). The clostridium botulinum microbe is 70% lethal without respiratory support and has an incubation period of 24 to 73 hours when aerosolized or 12 to 36 hours when ingested. Death can occur within 24 to 72 hours, or respiratory support may be needed for months. An anaerobic, this gram-positive bacillus produces a neurotoxin, which inhibits the release of acetylcholine, resulting in flaccid paralysis. (16)

Botulism begins with cranial nerve palsies, including ptosis, blurred vision, diplopia, dry mouth and throat, dysphagia, and dysphonia. Onset of symmetrical descending flaccid paralysis, with generalized weakness and progression to respiratory failure, follows. Symptoms usually are apparent 12 to 36 hours after inhalation, although low doses of toxin exposure may delay symptoms.

Diagnosis is made primarily through clinical signs. Multiple, simultaneous casualties with progressive descending flaccid paralysis should heighten suspicion. A bioassay of the patient's serum, a enzyme-linked immunosorbent assay or electro-chemiluminescence for antigen, and a polymerase chain reaction (ie, bacterial DNA) in environmental samples or nerve conduction studies would help confirm the diagnosis.

Administration of trivalent licensed antitoxin or heptavalent botulinum may prevent or decrease a patient's progression to respiratory failure and hasten recovery. Respiratory support and a possible tracheostomy may be required. People at high risk to exposure may need the pentavalent toxoid vaccine (ie, serotypes A, B, D, E, F).

As an agent of bioterrorism, the method of exposure to botulism would be through food consumption or inhalation. Health care workers should use standard precautions when working with patients infected with botulism. There is no person-to-person transmission, so the skin acts as natural barrier. Soap and water can be used for decontamination. Sunlight will inactivate the toxin within one to three hours. Heat (ie, 80[degrees] C [176[degrees] F] for 30 min, 100[degrees] C [212[degrees] F] for several minutes) and chlorine (ie, > 99.7% inactivation by 3 mg per L in 20 minutes) also will destroy the toxin.

VACCINES

Vaccines have been available for many years for anthrax and smallpox, but they exist in very small quantities. The Biological and Toxins Weapons Convention of 1972 mandated that the last of the smallpox stockpiles from Russia and the United States be destroyed in June 1999; however, with tensions building around suspected weapons of mass destruction build up, the mandate was not carried out. Recently, the US government has been working on several avenues of research and development of a new smallpox vaccine to be readied as soon as possible. One British firm has accelerated its production of the smallpox vaccine, and the first 40 million doses could be ready by mid to late 2002. (17) The anthrax vaccine also is in limited supply, but the only US producer of the vaccine is working diligently to increase the supply. At present, full-scale vaccination of the population is being evaluated. With accelerated production of these vaccines, the question of who will be vaccinated first becomes a significant political and ethical issue.

HEALTH ASSESSMENT

Obtaining certain information from a suspected exposed patient allows caregivers to be better prepared to understand the possibility of an escalating crisis situation and treat the patient quickly. Nurses need to be aware of the heightened possibility of a biological threat, whether it is natural or planned, so an epidemic can be recognized early and possibly averted. If a patient has a suspicious diagnosis, the facility's infection control officer and local public health department should be alerted immediately for consultation and direction. Perioperative nurses should be alert to the following items when doing preadmission paperwork.

* Possibility of exposure--Has the patient experienced any suspicious smells, powders, funny tasting foods, or unusual cloudiness not related to cigarette smoke during a public event? Has the patient recently traveled to another state or outside the country?

* Allergies--Does the patient have medical allergies that might manifest as symptoms that could confuse the diagnosis of the presenting complaint? This information will aid in determining chemical therapy to be used during treatment.

* Medical examination--Does the patient present with any unusual lesions or pustules on his or her trunk or extremities? How long has the patient had them? Is the patient having difficulty breathing and why? Does the patient exhibit any flaccid paralysis, and has he or she coughed up bloody sputum? What was the patient's general health condition before this visit?

* Past medical history--Have past visits outside the country affected the patient's health? Does the patient have a history of immunocompromise disease?

* Laboratory findings--Do the laboratory tests and findings show the need for further follow-up to differential diagnose from possible exposure history?

STEPS TO TREATMENT

As in the treatment of any compromised patient, management of the airway, breathing, and circulation should be instituted immediately, along with standards for decontamination and treatment of a creditable exposure. Airway adjuncts should be implemented depending on assessment of the patient's symptoms or complaints. Breathing support should be initiated via endotracheal intubation and ventilator support or nasal/mask oxygen. The patient's circulation should be supported through chemical therapy, fluid challenge, or chest compressions. Decontamination should be completed as deemed necessary by the presenting history and physical evidence and should include clothing. Usually the facility's infection control officer and the public health department will be involved at this level too. Caregivers should follow their hospital disaster preparedness policies and procedures. Medications and chemical therapy will be determined by the presenting history, physical complaints, differential laboratory and imaging diagnosis, and the patient's past history. It may take several hours to several days to make a solid diagnosis due to the confusion of presenting signs and symptoms that are similar to everyday flu.

MANAGING A BIOLOGICAL CRISIS

Nurses can protect themselves by being aware of their surroundings and washing their hands well after touching public items. In addition, they should watch for suspicious clouds or sprays and people acting nervous or running away.

If perioperative nurses are involved in a biological crisis, they need to be watchful for patients presenting with similar symptoms as the initial patient. Do subsequent patients have anything in common (eg, public events, restaurants, churches, schools) with the initial patient? If contamination is suspected, decontaminate the patient and environment following the facility's decontamination policies and procedures. Nurses should assess, diagnose, and treat patients by following CDC guidelines for the biological agent involved. Involving the facility's infection control and disaster response officers and the local public health department ensures that the proper authorities are alerted. In some counties, the public health department alerts other agencies, such as the state laboratory, local police and fire departments, the Federal Bureau of Investigation (FBI), and the CDC, for support services.

Health care facilities can enhance infection control techniques by providing staff members with annual education offerings on practicing standard isolation precautions and good hand washing techniques. Nurses also should participate in the epidemiology investigation because they may be asked about their level of involvement with the patient, which will determine their possible exposure risk. Perioperative nurses can educate and train others by sharing their knowledge and expertise with others in the facility and learning not to take patients' complaints at face value. They also should use their critical thinking skills to ferret out issues that do not seem to fit.

If perioperative nurses find that they have credible evidence that a patient is infected with a biological agent, they should follow the facility's policies and procedures and those of the public health department for biological exposure. In most areas, the public health department has jurisdiction over the medical response to bioterrorism and what should be sent to the state laboratory. Any criminal investigation will be handled by the FBI.

If a health care facility has a patient who is contaminated with a biological agent, caregivers should use PPE as defined by their facilities and depending on the agent, if it is known. This could include an N95 respirator mask, such as that used in tuberculosis treatment, or a surgical mask; gloves; a waterproof gown or jumpsuit; and hair and shoe coverings.

If the contaminated patient is incapacitated, the perioperative nurse should place the patient on a plastic sheet covered gumey and carefully remove his or her clothing and valuables; place the items in an impervious, labeled plastic bag; secure the bag's contents for possible evidence gathering; wash the patient with warm water and soap; and remove the patient from the contaminated gumey to a clean gurney, making sure the posterior side of the patient has been cleaned. Nurses then should remove their contaminated PPE, place it in a hazardous waste bag, cover the patient in appropriate clean attire, thoroughly wash their hands, regown and reglove, and proceed to meet any medical needs of the patient. Lastly the nurse should document his or her assessment and evaluation of the situation and implementation of patient care provided during this process.

Equipment and clothing that has been in contact with a patient found to be infected with a biological agent can be cleaned with a 5% sodium hypochlorite solution with a contact time of 30 minutes before normal cleaning and rinsing. Re-oiling maybe necessary for metal surfaces. Sterilizing with dry heat for two hours at 160[degrees] C (320[degrees] F) renders these biological agents completely harmless. Equipment can be steam sterilized at 121[degrees]C [250[degrees] F] and 15 pounds psi) for 20 minutes, depending on volume.

COUNTERTERRORISM MEASURES

The most important factor is to remain calm. Following standard and infection precautions and using good hand washing techniques lessen the possibility of exposure. Humans have coexisted with microorganisms for centuries and survived. Each new challenge, such as the bubonic plague, poliomyelitis, smallpox, HIV, anthrax, and E-coli, have inspired scientific creativity to find ways to combat, lessen the impact of, or incapacitate these microbes. Researchers around the world are working on innovative methods to deal with biological agents. The use of phages, biological agent detectors, and DNA coding are some of the new technologies being developed today. The human body cannot survive without several microbes living inside. In the perioperative setting, caregivers deal with the suspicion that these same microbes are stalking surgical suites daily. To put it in perspective, the odds are greater that a caregiver will be injured in an automobile accident than in a biological incident.

What process will ensure the care provider's continued survival and that of patients who might be harboring a biological agent? Perioperative nurses need to be vigilant in assessing themselves and others to ensure that they follow these guidelines.

* Wash hands appropriately after each patient contact.

* Change mask in between procedures or when leaving the surgery suite.

* Use PPE (eg, gown, gloves, mask or shield, hair covering). High risk of exposure to an unknown or known agent may necessitate that an N95 respirator mask be used.

* Do not comprise aseptic techniques or standard precautions for the sake of turnover times and short cuts.

* Mentor others.

* Use preoperative assessment time to watch for signs of disease and notify the surgeon, anesthesia care provider, and supervisor of any findings.

* Believe in intuitive reasoning, and follow a hunch if something is suspicious.

* Share knowledge with others who are fearful.

* Share knowledge of forensic evidence handling and chain of command with others in the hospital.

* Participate in department and hospital preparedness plans and drills.

* Participate in department responses to a disaster or disaster drill.

* Have a family care plan in place in the event of a disaster.

* Know the response to a disaster callback in the face of a biological epidemic.

* Know if the department has resources to obtain the supplies (eg, PPE, IV fluids, waste management) needed for a 72-hour period.

* Know the chain of command if the director or supervisor is unable to lead the team.

* Know which decontaminate agent is adequate and available for biological contamination.

* Review death in surgery procedures.

* Ascertain whether there is a system in place to provide psychological support for staff members, victims, and victim's family members.

Along with these preparations, the emergency preparedness officer should be coordinating with local and state officials on how to provide emergency services to the community. Other agencies involved would include the emergency medical system; fire, police, and state patrol departments; utility companies; state transportation and roads departments of the local government; state laboratories; the FBI; the Secret Service; and the Bureau of Alcohol, Tobacco and Firearms. For more in-depth planning, see the "Bioterrorism Readiness Plan: A Template for Healthcare Facilities" published by the CDC and the Association for Professionals in Infection Control and Epidemiology, Inc. (18)

CONCLUSION

Being prepared and armed with knowledge about how bioterrorism works, what agents may be used, and how diseases progress and are treated allows perioperative nurses to have a clear perspective of the situation. They may be called upon by their facilities to step out from behind the OR doors and help in other areas as needed. Per/operative RNs must be prepared to act as a resource to peers, patients, family members, and friends. An attack may not be preventable, but its impact can be softened by perioperative nurses' ability to keep those around them from becoming fearful and panicky. According to Donna E. Shalala, former US Secretary of Health and Human Services, "We need unprecedented cooperation among the federal government, state and local health agencies, and the medical community." (19) Perioperative RNs should become active in dispelling the tear and myths created by the threat of bioterrorism in their departments, hospitals, and communities.

Editor's note: The views expressed in this article ore those of the author end do not reflect the official policy or position of the US Deportment of the Army, US Deportment of Defense, or the United Stores Government,

NOTES

(1.) S D McColloch et al, "Biological warfare and the implications of biotechnology," class presentation in Chemistry 420 presented at California Polytechnic, Pomona, Caalif, 1999, 1-7.

(2.) D O'Leary, "Prepared witness testimony: A review of federal bioterrorism preparedness programs from a public health perspective," Subcommittee on Oversight and Investigations, House Committee on Energy and Commerce (Oct 10, 2001) http://com-notes.house.gov/107/hearings/10102001Hearing390/OLeary627.htm (accessed 15 July 2002).

(3.) "History of biological warfare," ThinkQuest Internet Challenge Library, http://library.thinkquest.erg/21659/agents/history.html (accessed 11 July 2002).

(4.) "The 1972 Biological and Toxin Weapons Convention (BWC)," The Harvard Sussex Program on CBW Armanent and Arms Limitation, http://www.fas.harvard.edu/~hsp/biologic.html (accessed 11 July 2002).

(5.) J B Tucker, "Historical trends related to bioterrorism: An empirical analysis," Emerging Infectious Diseases, http://www.cdc.gov/ncidod/eid/vol5no4/tucker.htm (accessed 11 July 2002.)

(6.) "National Pharmaceutical Stockpile Program," National Center for Environmental Health, http://www.cdc.gov/nceh/nps/ (accessed 11 July 2002).

(7.) D A Henderson, "The looming threat of bioterrorism," Science 283 (Feb 26, 1999) 1279-1282.

(8.) McColloch et al, "Biological warfare and the implications of biotechnology," 1-7.

(9.) Ibid.

(10.) R Taylor, "All fall down," New Scientist 150 (May 11, 1996) 32.

(11.) Henderson, "The looming threat of bioterrorism," 1279-1282.

(12.) M Kortepeter, USAMRIID's Medical Management of Biological Casualties Handbook, fourth ed (McLean, Va: International Medical Publications, February 2001) 15-21.

(13.) Ibid, 58-63.

(14.) "Study seeks to determine effectiveness of diluted smallpox vaccine," National Institute of Allergy and Infectious Diseases, http://www.niaid.nih.gov/factsheets/btsmallpox.htm (accessed 30 July 2002).

(15.) Kortepeter, USAMRIID's Medical Management of Biological Casualties Handbook, fourth ed, 4045.

(16.) Ibid, 86-94.

(17.) Reuter Medical News, "New Supply of Anthrax Vaccine Highly Unlikely to be Available before 2002," (Sept 2001).

(18.) J F English, et al, "Bioterrorism readiness plan: A template for healthcare facilities" Centers for Disease Control and Prevention, http://www.cdc.gov/ncidod/hip/Bio/13apr99APIC-CDC Bioterrorism. PDF (accessed 15 July 2002).

(19.) D E Shalala, "Bioterrorism: How prepared are we?" Journal of Emerging Infectious Diseases 5 (July/August 1999) 492-493.

RESOURCES

Centers for Disease Control and Prevention, http://www.cdc.gov/ (accessed 15 July 2002).

The Terrorism Research Center, http://www.terrorism.com/index.shtm 1 (accessed 15 July 2002).

Johns Hopkins University, Center for Civilian Biodefense Strategies. http://www.hopkins-biodefense.org (accessed 15 July 2002).

Department of Defense, Anthrax Vaccine Immunizations Program, http://www.defenselink.mil/specials/Anthrax/anth.htm 1

Federal Emergency Management Agency, Emergency Management Institute, http://training.fema.gov/EMIWeb/ (accessed 15 July 2002).

Federal Emergency Management Agency, http://www.fema.gov (accessed 15 July 2002).

U.S. Army Medical Research Institute of Infectious Diseases, http://www.usamriid.army.mil/ (accessed 15 July 2002).

AHA Disaster Readiness Advisory, http://www.hospitalcon nect.com/ashcsp/files/2nd_AHA_Disaster_Readiness_Advisory.doc (accessed 15 July 2002).

Kristina Stillsmoking, RN, BSN, MEd, CNOR, is an education and employee health coordinator at Capital Medical Center, Olympia, Wash.

COPYRIGHT 2002 Association of Operating Room Nurses, Inc.
COPYRIGHT 2002 Gale Group