Introduction

In 2004 the State of Texas instituted a new continuing education requirement for licensed practical nurses, registered nurses and advanced practice nurses. For either two year renewal cycle, preceding September 1, 2007, a license holder who renews a license to practice as a Nurse or Advanced Practice Nurse shall have completed not less than two contact hours of continuing education in bioterrorism as part of the total hours of continuing education required.

What does this mean for nurses? The Texas Board of Nurse Examiners (BNE) will begin the random audit of bioterrorism CE for those licensees renewing in September 2005 and continue through August 2007. For those who have already taken bioterrorism CE, the certificate must be maintained for a minimum of four years. Since the law and the rule state that this CE component must be completed for either two year renewal cycle preceding September 1, 2007, BNE will accept bioterrorism CE certificates dated anytime between September 1, 2003 through August 31, 2007.

The mandated education must meet the following requirements (taken directly from the Texas legislation.)

1. The minimum two contact hours required continuing education in bioterrorism shall include information relevant to preparing for, reporting medical events resulting from, and responding to the consequences of an incident of bioterrorism.
2. The bioterrorism continuing education program will be acceptable to the board for Type I or Type II credit if it meets the following criteria:
   1. the bioterrorism course must include information relating to preparing for an incidence of bioterrorism including the clues to bioterrorism attack and the signs, symptoms, and modes of transmission of high-priority agents of bioterrorism;
   2. the bioterrorism course must include information relating to the reporting of an incidence of bioterrorism including the ways in which to contact the proper authorities and correctly document the incidence of bioterrorism;
   3. the bioterrorism course must include information relating to the implementation of decontamination procedures, the identification of treatment locations and treatment personnel, the acquisition of treatment-related supplies, the awareness of any facility-organized response plans, and the development of a patient care plan to address the situation; and
   4. the bioterrorism course is designed for and targeted to Registered Nurses and Licensed Vocational Nurses.

I. What is Bioterrorism?

Following the events of 911 and the anthrax threat, the possibility that smallpox would be used as an agent of bioterrorism precipitated a large scale education, prevention, and treatment campaign in the U.S. Wide scale plans for pre-exposure vaccination and treatment plans were developed in every community. It is essential for that kind of comprehensive disaster planning to be done in advance of a bioterrorism attack.

Bacteria, viruses, and biological toxins can be used as weapons of bioterrorism. Although many countries signed the Biological Weapons Convention in 1972, prohibiting the development, production, and stockpiling of biological, toxic weapons, some countries and organizations have continued research and development. Some of these countries and organizations that are hostile to the United States are suspected of proliferating biological weapons for terrorist activity. According to the Department of the Army, there are at least ten countries around the world that have offensive biological weapons programs (US Army Medical Research Institute of Infectious Diseases [USAMRIID], 2001). For instance, the smallpox virus that is stored in only two laboratories, the CDC in Atlanta and the Institute for Viral Precautions in Moscow, may be available in other countries and could be used for bioterrorism. Not only are naturally occurring pathogens used by bioterrorists, there is fear that they may use agents that are genetically engineered to resist current treatment and vaccines. Biologic terrorism could produce thousands of American casualties if appropriate preparation and training are not undertaken (Hardin, 2002).

This course will discuss the following pathogens that have been identified as potential biological warfare agents: smallpox, anthrax, plague, botulism, tularemia, and viral hemorrhagic fevers.

In 2001 the Department of Health and Human Services identified the need for improved infectious disease surveillance, improved communication networks, upgraded laboratory facilities, improved diagnostic techniques, and expanded training of health care personnel in order to enhance preparedness and response in the event of a bioterrorist attack. In concert with those goals, healthcare professionals must increase their knowledge of bioterrorism, the agents used, the effects, and the signs and symptoms of such illnesses. Early diagnosis and prompt treatment can help save lives and limit transmission (CDC, 2001). Healthcare facilities must have plans to provide for decontamination and isolation of suspected victims and must maintain disaster plans and adequate supplies of personal protective equipment to ensure safety of staff and patients. Regional surveillance networks are needed to increase early detection and will help nurses recognize symptom clusters or signs of illnesses that may be related to a biological attack. Community disaster drills and simulations are vital and should be regular and ongoing. Healthcare personnel must be knowledgeable and up-to-date about prevention and intervention strategies as well as their responsibilities (Sawyer, 2003). Nurses are often first-line responders in key positions in schools, hospitals, emergency departments, etc. and their decisions can make critical differences!

II. High Priority Diseases/Agents of Bioterror

• can be easily disseminated or transmitted from person to person;
• result in high mortality rates and have the potential for major public health impact;
• might cause public panic and social disruption; and require special action for public health preparedness.

• Anthrax - (bacillus anthracis),
• Smallpox - (variola major),
• Botulism ? (clostridium botulinum toxin),
• Plague ? (yersinia pestis),
• Tularemia ? (francisella tularensis),
• Viral Hemorrhagic Fevers (filoviruses such as Ebola and Marburg and arenaviruses such as Lassa and Machupo)

Bacillus anthracis/Anthrax

Bacillus anthracis is an encapsulated, aerobic, gram-positive, spore-forming, rod-shaped (bacillus) bacterium (CDC, 2001a). The B. anthracis spore causes a rapidly progressing infection. It is resistant to sunlight, heat and disinfectants. Anthrax can be contacted by inhalation, ingestion, or cutaneous exposure (CDC, 2001b).

Following the terrorist attacks of September 11, 2001, 22 confirmed or suspected cases of Anthrax were identified in the United States in October and November 2001. Cases were reported from Florida, New York, New Jersey, the District of Columbia, and Connecticut (CDC, 2001c) and appeared to be related to transmission via letters delivered by the USPS. This lethal event provided the US healthcare system with the opportunity to update knowledge on the identification and treatment of B. anthracis exposure. It has recently been reported that there is a new test for anthrax that can be completed in two hours and has been 100% accurate in all cases (Stephenson, 2004). This can be effective in early treatment and prevention efforts. The CDC (2003) provided the following Fact Sheet that contains information on the bacillus, transmission, signs and symptoms, and treatment.

Anthrax: What You Need To Know (CDC, 2003b)

What Is Anthrax?

Anthrax is a serious disease caused by bacillus anthracis, a bacterium that forms spores. A bacterium is a very small organism made up of one cell. Many bacteria can cause disease. A spore is a cell that is dormant (asleep) but may come to life with the right conditions.

There are three types of anthrax:

• skin (cutaneous)
• lungs (inhalation)
• digestive (gastrointestinal)

How Do You Get It?

Anthrax is not known to spread from one person to another. Humans can become infected with anthrax by handling products from infected animals or by breathing in anthrax spores from infected animal products (like wool, for example). People also can become infected with gastrointestinal anthrax by eating undercooked meat from infected animals.

Anthrax as a Weapon.

Anthrax also can be used as a weapon. This happened in the United States in 2001. Anthrax was deliberately spread through the postal system by sending letters with powder containing anthrax. This caused 22 cases of anthrax infection.

How Dangerous Is Anthrax?

In most cases, early treatment with antibiotics can cure cutaneous anthrax. Even if untreated, 80 percent of people who become infected with cutaneous anthrax do not die. Gastrointestinal anthrax is more serious because between one-fourth and more than half of cases lead to death. Inhalation anthrax is much more severe. In 2001, about half of the cases of inhalation anthrax ended in death.

What Are the Symptoms?

The symptoms (warning signs) of anthrax are different depending on the type of the disease:
• Cutaneous: The first symptom is a small sore that develops into a blister. The blister then develops into a skin ulcer with a black area in the center. The sore, blister and ulcer do not hurt.
• Gastrointestinal: The first symptoms are nausea, loss of appetite, bloody diarrhea, and fever, followed by bad stomach pain.
• Inhalation: The first symptoms of inhalation anthrax are like cold or flu symptoms and can include a sore throat, mild fever and muscle aches. Later symptoms include cough, chest discomfort, shortness of breath, tiredness and muscle aches. (Caution: Do not assume that just because a person has cold or flu symptoms that they have inhalation anthrax.)

How Soon Do Infected People Get Sick?

Symptoms can appear within 7 days of coming in contact with the bacterium for all three types of anthrax. For inhalation anthrax, symptoms can appear within a week or can take up to 42 days to appear.

How Is Anthrax Treated?

Antibiotics are used to treat all three types of anthrax. Early identification and treatment are important.

Prevention after exposure. Treatment is different for a person who is exposed to anthrax, but is not yet sick. Health-care providers will use antibiotics (such as ciprofloxacin, levofloxacin, doxycycline, or penicillin) combined with the anthrax vaccine to prevent anthrax infection.

Treatment after infection. Treatment is usually a 60-day course of antibiotics. Success depends on the type of anthrax and how soon treatment begins.

Can Anthrax Be Prevented?

Vaccination. There is a vaccine to prevent anthrax, but it is not yet available for the general public. Anyone who may be exposed to anthrax, including certain members of the U.S. armed forces, laboratory workers, and workers who may enter or re-enter contaminated areas, may get the vaccine. Also, in the event of an attack using anthrax as a weapon, people exposed would get the vaccine.

What Should I Do if I Think I Have Anthrax?

If you are showing symptoms of anthrax infection, call your health-care provider right away.

What Should I Do if I Think I Have Been Exposed to Anthrax?

Contact local law enforcement immediately if you think that you may have been exposed to anthrax. This includes being exposed to a suspicious package or envelope that contains powder.

What Is CDC Doing To Prepare For a Possible Anthrax Attack?

CDC is working with state and local health authorities to prepare for an anthrax attack. Activities include:
• Developing plans and procedures to respond to an attack using anthrax.
• Training and equipping emergency response teams to help state and local governments control infection, gather samples, and perform tests. Educating health-care providers, media, and the general public about what to do in the event of an attack.
• Working closely with health departments, veterinarians, and laboratories to watch for suspected cases of anthrax. Developing a national electronic database to track potential cases of anthrax.
• Ensuring that there are enough safe laboratories for quickly testing of suspected anthrax cases.
• Working with hospitals, laboratories, emergency response teams, and health-care providers to make sure they have the supplies they need in case of an attack.

Variola virus/Smallpox

The Centers for Disease Control and Prevention (CDC) has been designated as the lead agency for the national public health response to biological terrorism. Smallpox was eradicated and no case has been diagnosed since 1980; and even though there are two World Health Organization (WHO) designated repository laboratories that are the only known sites where the virus exists, there is still fear that the virus may be in the hands of a state-sponsored group that could use it as a biological weapon. Smallpox is easily transmitted and has a high fatality rate, thereby making it the most serious of the biological threats. After September 11, 2001 concerns that a smallpox epidemic could occur. The CDC updated and developed the Smallpox Response Plan and Guidelines (CDC, 2002a) that incorporates, and extends, many of the concepts and approaches that were successfully employed 30 to 40 years ago to control smallpox outbreaks. The plan outlines the public health strategies to guide the public health response to a smallpox emergency and many of the federal, state, and local public health activities that must be undertaken in a smallpox outbreak. This plan will continue to be updated to reflect changes in capacities and resources for responding to a smallpox emergency. The Smallpox Response Plan and Guidelines can be accessed at http://www.bt.cdc.gov/agent/smallpox/response-plan/index.asp#guidef. The CDC has provided the following fact sheets for healthcare professionals (2004).

Smallpox Disease: What You Need to Know (CDC, 2004a)

The Disease

Smallpox is a serious, contagious, and sometimes fatal infectious disease. There is no specific treatment for smallpox disease, and the only prevention is vaccination. The name smallpox is derived from the Latin word for "spotted" and refers to the raised bumps that appear on the face and body of an infected person.

There are two clinical forms of smallpox. variola major is the severe and most common form of smallpox, with a more extensive rash and higher fever. There are four types of variola major smallpox: ordinary (the most frequent type, accounting for 90% or more of cases); modified (mild and occurring in previously vaccinated persons); flat; and hemorrhagic (both rare and very severe). Historically, variola major has an overall fatality rate of about 30%; however, flat and hemorrhagic smallpox usually are fatal. Variola minor is a less common presentation of smallpox, and a much less severe disease, with death rates historically of 1% or less.

Smallpox outbreaks have occurred from time to time for thousands of years, but the disease is now eradicated after a successful worldwide vaccination program. The last case of smallpox in the United States was in 1949. The last naturally occurring case in the world was in Somalia in 1977. After the disease was eliminated from the world, routine vaccination against smallpox among the general public was stopped because it was no longer necessary for prevention.

Where Smallpox Comes From

Smallpox is caused by the variola virus that emerged in human populations thousands of years ago. Except for laboratory stockpiles, the variola virus has been eliminated. However, in the aftermath of the events of September and October, 2001, there is heightened concern that the variola virus might be used as an agent of bioterrorism. For this reason, the U.S. government is taking precautions for dealing with a smallpox outbreak.

Transmission

Generally, direct and fairly prolonged face-to-face contact is required to spread smallpox from one person to another. Smallpox also can be spread through direct contact with infected bodily fluids or contaminated objects such as bedding or clothing. Rarely, smallpox has been spread by virus carried in the air in enclosed settings such as buildings, buses, and trains. Humans are the only natural hosts of variola. Smallpox is not known to be transmitted by insects or animals. A person with smallpox is sometimes contagious with onset of fever (prodrome phase), but the person becomes most contagious with the onset of rash. At this stage the infected person is usually very sick and not able to move around in the community. The infected person is contagious until the last smallpox scab falls off.

Smallpox Disease
Incubation Period (Duration: 7 to 17 days) Not contagious	Exposure to the virus is followed by an incubation period during which people do not have any symptoms and may feel fine. This incubation period averages about 12 to 14 days but can range from 7 to 17 days. During this time, people are not contagious.
Initial Symptoms (Prodrome) (Duration: 2 to 4 days) Sometimes contagious*	The first symptoms of smallpox include fever, malaise, head and body aches, and sometimes vomiting. The fever is usually high, in the range of 101 to 104 degrees Fahrenheit. At this time, people are usually too sick to carry on their normal activities. This is called the prodrome phase and may last for 2 to 4 days.
Early Rash (Duration: about 4 days) Most contagious Rash distribution:	A rash emerges first as small red spots on the tongue and in the mouth. These spots develop into sores that break open and spread large amounts of the virus into the mouth and throat. At this time, the person becomes most contagious. Around the time the sores in the mouth break down, a rash appears on the skin, starting on the face and spreading to the arms and legs and then to the hands and feet. Usually the rash spreads to all parts of the body within 24 hours. As the rash appears, the fever usually falls and the person may start to feel better. By the third day of the rash, the rash becomes raised bumps. By the fourth day, the bumps fill with a thick, opaque fluid and often have a depression in the center that looks like a bellybutton. (This is a major distinguishing characteristic of smallpox.) Fever often will rise again at this time and remain high until scabs form over the bumps.
Pustular Rash (Duration: about 5 days) Contagious	The bumps become pustules?sharply raised, usually round and firm to the touch as if there?s a small round object under the skin. People often say the bumps feel like BB pellets embedded in the skin.
Pustules and Scabs (Duration: about 5 days) Contagious	The pustules begin to form a crust and then scab. By the end of the second week after the rash appears, most of the sores have scabbed over.
Resolving Scabs (Duration: about 6 days) Contagious	The scabs begin to fall off, leaving marks on the skin that eventually become pitted scars. Most scabs will have fallen off three weeks after the rash appears. The person is contagious to others until all of the scabs have fallen off.
Scabs resolved Not contagious	Scabs have fallen off. Person is no longer contagious.

*Smallpox may be contagious during the prodromal phase, but is most infectious during the first 7 to 10 days following rash onset.

What You Should Know About a Smallpox Outbreak (CDC, 2004b)

The thought of a smallpox outbreak is scary, but public health officials are preparing to respond quickly and effectively to such an event. The public can prepare too, by being informed. This fact sheet was created to provide members of the public with basic information about the possible use of smallpox as a biological weapon and what to do if that happens. If a smallpox emergency occurs, more detailed information and instructions will be available on the Centers for Disease Control and Prevention (CDC) web site and through other channels such as radio and television.

Why Smallpox is a Concern

Because smallpox was wiped out many years ago, a case of smallpox today would be the result of an intentional act. A single confirmed case of smallpox would be considered an emergency. Thanks to the success of vaccination, the last natural outbreak of smallpox in the U.S. occurred in 1949. By 1972, routine smallpox vaccinations for children in the U.S. were no longer needed. In 1980, smallpox was said to be wiped out worldwide, and no cases of naturally occurring smallpox have happened since. Today, the smallpox virus is kept in two approved labs in the U.S. and Russia. However, credible concern exists that the virus was made into a weapon by some countries and that terrorists may have obtained it. Smallpox is a serious, even deadly, disease.

Possible ways to become infected with smallpox include: