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Course Sample:
NYSNA Continuing Education
NYSNA is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC) Commission on Accreditation.
All ANCC accredited organizations' contact hours are recognized by all other ANCC accredited organizations. Most states with mandatory continuing education requirements recognize the ANCC accreditation/approval system. Questions about the acceptance of ANCC contact hours to meet mandatory regulations should be directed to the Professional licensing board within that state.
NYSNA has been granted provider status by the Florida State Board of Nursing as a provider of continuing education in nursing (Provider number FBN3265.)
Introduction
The global threat of bioterrorism is here and it is serious. "It is a prospect so terrifying that the very thought of it can rob our world leaders of their sleep" states Michael T. Osterholm, Ph.D., MPH, former Minnesota State Epidemiologist and internationally recognized leader in the area of infectious diseases (Osterholm & Schwartz, 2000, p. xvii). The recent domestic episodes of the biological agent exposure of B. Anthracis has renewed concern for the tremendous effects that such exposures can have on our nation's health care system.
A bioterrorist attack may be initially difficult to identify. Unlike conventional weapons of mass destruction, explosives, an atomic bomb or chemical releases, the unique effects of biological agents could go undetected for days. Only when individuals present themselves to health care providers in emergency rooms and ambulatory clinics with symptoms would any evidence of the attack appear, and even then the initial symptoms might not be recognized and accurately diagnosed. Furthermore, those presenting themselves with symptoms could be at great distances from the original site of exposure by the time symptoms occurred. In order to enhance our preparedness for and response to a bioterrorist attack, according to the Department of Health and Human Services (2001), the United States needs an improved network of infectious disease surveillance, including improved communications, upgraded laboratory facilities, advanced diagnostic techniques and expanded training of health care personnel.
The registered nurse performing triage often will be the first health care professional a symptomatic victim will encounter when arriving in the emergency room or ambulatory clinic. Therefore, early detection and response by this first-line responder is imperative. As potential first-line responders, all registered nurses must know what to do in such situations because our decisions can have dire consequences on the greater health care system and on the public's health.
The purpose of this continuing education offering is to provide registered professional nurses with a basic understanding of the clinical presentation, transmission, diagnosis, pharmacological treatment, and post-exposure prophylaxis of some of the more common biological agents such as B. Anthracis (Anthrax), Variola virus (Smallpox), Yersinia pestis (Pneumonic Plague), and Clostridium botulinum (Botulism). In addition, an overview is provided of the recommended notification procedures for local and state public health departments in the event of a bioterrorist incident.
About the Authors
Laureen A. Otto, MS, RN
Associate Director,
Practice & Governmental Affairs Program, NYSNA
Latham, NY
Ms. Otto earned her MS in Nursing/Health Policy from the University of Maryland in 2000 and her Bachelors in Nursing from Winona State University in Minnesota in 1994. Ms. Otto also holds a Bachelors in Biology and Psychology from Luther College in Decorah, Indiana.
Ms. Otto has expertise in scope of practice and ethical practice issues affecting registered professional nurses in New York State. She also has expertise in health policy issues that impact the public good including: public health infrastructure issues such as disaster preparedness, nurse staffing and occupational health issues, and health care access/coverage issues.
Todd Traver, RN
Coordinator,
Bloodless Medicine & Surgery Program, Columbia Memorial Hospital
Hudson, NY
Mr. Tarver is currently a Masters Student at State University of New York At Albany. He also holds a Bachelors from the University of Massachusetts.
Mr. Traver has spent several years participating in US Army Reserve training exercises such as: Nuclear, Biological and Chemical Defense, Emergency Response to Hazmat, and Chemical Casualty Care. Currently he is a member of the Columbia County Hazardous Materials Response Team. Mr. Traver has been a professional registered nurse since 1993.
Overview of Bioterrorism
The use of biological weapons in warfare has been recorded throughout history. The Assyrians, in the 6th century B.C., contaminated enemy wells with poisonous herbs during the siege of Krissa. Smallpox was weaponized when the English provided Native Americans loyal to the French with contaminated blankets during the French and Indian War in the mid 18th Century. In 1978, the Bulgarian secret service used an umbrella to inject rice toxin to assassinate a Bulgarian exile. And more recently, in 1995, the chemical nerve agent, sarin gas, was used in the Tokyo subway system (USAMRIID, 2001).
According to the Department of the Army, there are at least ten countries around the world that have offensive biological weapons programs (U.S. Army Medical Research Institute of Infectious Diseases [USAMRIID], 2001). There is growing concern that the smallpox virus now stored in only two laboratories, the CDC in Atlanta and the Institute for Viral Precautions in Moscow, may be available in other countries. It is clear that the United States has recently experienced bioterrorism attacks using B. Anthracis spores sent through the postal system.
Preparedness for and response to an attack involving biological agents are complicated by:
- The large number of potential agents (most of which are rarely encountered naturally).
- The sometimes long incubation periods and consequent delayed onset of disease.
- The potential for secondary transmission.
In addition to naturally occurring pathogens, agents used by bioterrorists may be genetically engineered to resist current therapies and evade vaccine-induced immunity. Pathogens that have been identified as potential biological warfare agents include those that cause smallpox, anthrax, plague, botulism, tularaemia, and hemorrhagic fevers.
Given the US's recent experience with bioterrorism, most specifically with anthrax, the knowledge and information that is gained is evolving with each new case of disease. The information provided here is the current state of knowledge. However, the reader is cautioned to recognize that our understanding of bioterrorism and each specific agent is evolving and greater knowledge is gained with additional experience.
Common Biological Agents
Anthrax
The bacterial etiologic agent of anthrax is B. Anthracis. It is a large gram-positive, non-motile, spore-forming bacterial rod. The three virulence factors of B. anthracis are edema toxin, lethal toxin and a capsular antigen (CDC, 2001a). The B. anthracis spore is an exceptionally resilient bacteria; it is resistant to sunlight, heat and disinfectants. In the past, humans have become infected with anthrax after handling the contaminated hides, flesh, or manufactured products of infected cattle, sheep, or horses. The disease most commonly occurs in herbivores, which are infected by ingesting spores from the soil. In 1945, during an outbreak of anthrax in Iran, 1 million sheep died (Inglesby, et al, 1999).
Signs and Symptoms of Anthrax Disease
Human anthrax has three major clinical forms: cutaneous, inhalation, and gastrointestinal. If left untreated, anthrax in all forms can lead to septicemia and death.
Cutaneous anthrax is the most common naturally occurring type of infection (>95%) and usually occurs when the bacterium from contaminated meat, wool, hides, or leather from infected animals enters a cut or abrasion on the skin. In the US, 224 cases of cutaneous anthrax were reported between 1944 and 1994. The largest reported epidemic occurred in Zimbabwe between 1979 and 1985, when more than 10,000 human cases of anthrax were reported, nearly all of them cutaneous anthrax (Inglesby, 1999).
The incubation period ranges from 1-12 days. The skin infection begins as a small papule, or raised bump that resembles a spider bite. It progresses to a fluid-filled vesicle in 1-2 days followed by a painless necrotic ulcer or eschar, approximately 1-3 cm in diameter. The name "anthrax" comes from the Greek word for coal and refers to the characteristic blackened area of the lesion. Although the lesion is usually painless, patients also may have fever, malaise, headache, and regional lymphadenopathy. About 20% of untreated cases of cutaneous anthrax will result in death. Deaths are rare if patients are given appropriate antimicrobial therapy (CDC, 2001a).
Inhalational anthrax is the most lethal form of anthrax. Anthrax spores must be aerosolized in order to cause inhalational anthrax. In 1979, the accidental aerosolized release of anthrax spores from a military microbiology facility in Sverdlovsk in the former Soviet Union, resulted in at least 79 cases of anthrax infection and 68 deaths (Inglesby, 1999). Anthrax aerosol is odorless and invisible and has the potential to travel large distances; both persons indoors and outdoors are at risk (Inglesby, 1999). According to the CDC (2001a) 4,000 - 5,000 spores must be present to cause an infection. The last case of inhalational anthrax in the United States, before 2001, was in 1976 in California. The victim was a fiber artist; B. Anthracis was isolated from some of the imported yarns used by the patient (CDCa, 2001a).
The incubation period of inhalational anthrax among humans is unclear, but it is reported to range from 1 to 7 days, possibly ranging up to 60 days. It resembles a viral respiratory illness and initial symptoms include sore throat, mild fever, muscle aches and malaise, non-productive cough and mild chest discomfort. Severe respiratory distress follows and septicemia, shock and death occur within 24-36 hours after the onset of respiratory distress. Approximately half of cases are accompanied by meningitis.
Gastrointestinal anthrax is uncommon, however, outbreaks reported in Africa and Asia (Inglesby, 1999) usually follow the consumption of raw or undercooked contaminated meat. It has an incubation period of 1-7 days and is associated with severe abdominal distress followed by fever and signs of septicemia.
There are 2 distinct syndromes, the oral-pharyngeal and abdominal (Inglesby, 1999). In 1982 there were 24 cases of oral-pharyngeal anthrax in rural Thailand, following the consumption of contaminated buffalo meat. Involvement of the pharynx is usually characterized by lesions at the base of the tongue, sore throat, dysphagia, fever, and regional lymphadenopathy. In 1987, 14 cases of gastrointestinal anthrax were reported with both oral-pharyngeal and abdominal disease occurring (Inglesby, 1999). Abdominal anthrax includes lower bowel inflammation which causes nausea, loss of appetite, vomiting and fever followed by abdominal pain, vomiting blood, and bloody diarrhea (CDC, 2001a).
Detection/Diagnosis of Anthrax
The clinical presentation gives rise to the suspicion of anthrax, however, it is confirmed through laboratory testing. Hand-held assays (sometimes referred to as "Smart Tickets") are sold commercially for the rapid detection of B. Anthracis. These assays are intended only for the screening of environmental samples. First responder and law enforcement communities are using these as instant screening devices and should forward any positive samples to authorities for more sensitive and specialized confirmatory testing. The results of these assays should not be used to make decisions about patient management or prophylaxis. The utility and validity of these assays are unknown.
The CDC does not recommend the use of these assays at this time due to limited scientific data. The analytical sensitivity of these assays is limited by the technology. Data provided by manufacturers indicate that a minimum of 10,000 spores is required to generate a positive signal. This number of spores would suggest a heavy contamination of the sample. Therefore, a negative result does not rule out a lower level of contamination. Data collected from field use also indicates specificity problems with some of these assays. Some positive results have been obtained with spores of the non-anthrax Bacillus bacteria that may be found in the environment.
In patients with symptoms compatible with anthrax, providers should confirm the diagnosis by obtaining the appropriate laboratory specimens based on the clinical form of anthrax that is suspected (i.e., cutaneous, inhalational, or gastrointestinal).
- Cutaneous - vesicular fluid and blood
- Inhalational - blood, cerebrospinal fluid (if meningeal signs are present) or chest X-ray
- Gastrointestinal - blood
Before testing can begin, samples must be collected and arrive in the laboratory in a form suitable for testing.
Cutaneous Anthrax
Vesicular stage: The organism is best demonstrated in this stage. Soak two dry sterile swabs in vesicular fluid from a previously unopened vesicle.
Eschar stage: Rotate two swabs beneath the edge of the eschar without removing the eschar.
Gastrointestinal anthrax
If the patient is able to produce a stool specimen, stool cultures should be performed.
In later stages of disease, blood cultures will yield the organism, especially if specimens are obtained prior to antibiotic treatment.
Inhalation anthrax
If respiratory symptoms are present and sputum is being produced, obtain a specimen for culture and smear. In later stages of disease (2-8 days post exposure) blood cultures may yield the organism, especially if specimens are drawn before antibiotic treatment.
All state health departments are capable of obtaining results of tests on suspected infectious agents. Anthrax is diagnosed by isolating B. Anthracis from the blood, skin lesions, or respiratory secretions or by measuring specific antibodies in the blood of persons with suspected cases. Although blood cultures should not be routinely obtained on all patients with flu-like symptoms, who have no probable exposure to anthrax, they should be obtained for persons in situations in which bacteremia is suspected (CDC, 2001).
Testing itself is a two-step process. The initial screening tests may be positive within two hours if the sample is large and the concentration of bacteria is high. The confirmation tests take much longer, depending in part on how fast the bacteria grow, but are usually available 24-36 hours after the sample is received in the laboratory.
B. Anthracis is detectable by Gram stain blood culturing usually later in the course of infection and the white blood cell count rises:
Presumptive identification to identify to Genus level (Bacillus family of organisms) requires Gram stain and colony identification.
Presumptive identification to identify to species level (B. anthracis) requires tests for motility, lysis by gamma phage, capsule production and visualization, hemolysis, wet mount and malachite green staining for spores.
Confirmatory identification of B. anthracis carried out by CDC may include phage lysis, capsular staining, and direct fluorescent antibody (DFA) testing on capsule antigen and cell wall polysaccharide.
In cases of inhalation anthrax, chest x-ray may reveal a widened mediastinum and/or pleural effusion.
Table 1. Differences in symptoms between Flu and Anthrax
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Flu Symptoms |
Inhalation Anthrax |
Cutaneous Anthrax |
Intestinal Anthrax |
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Fever, muscle aches, headache, lack of energy, a dry cough, sore
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