32.2 Biological Terrorism

Categorization of Bioterrorism Agents

As discussed in Pandemics and Infectious Disease Outbreaks, biological agents that would likely be used as agents of bioterrorism include bacteria, viruses, and toxins. The CDC categorizes these agents by risk threat (see Table 32.2 for examples). Most biological agents are difficult to grow and maintain, as many are destroyed quickly when exposed to sunlight and other environmental factors (CDC, 2018; Siegel et al., 2023). Other agents, such as anthrax spores, are heartier and live much longer, especially on surfaces. Biological agents can be dispersed by spraying them into the air, infecting animals that carry the disease to humans, and contaminating food and water (Bland, 2014). Delivery methods include:

• Aerosols: Biological agents are circulated into the air via a fine mist that may carry for miles. Inhaling the agent may cause disease in people or animals.
• Animals: Diseases are spread by insects and animals, such as fleas, mice, flies, mosquitoes, and livestock.
• Food and water contamination: Pathogenic organisms and toxins are released into food and water supplies. If contamination is known, most microorganisms can be killed and toxins deactivated by cooking food and boiling water for 1 minute or longer.
• Person-to-person: Communicable diseases such as smallpox and plague can be spread via close human contact.

Anthrax, a Category A agent, has been used for almost a century as an effective biological weapon, as it can be released quietly and discreetly. Anthrax spores are easily available in nature, can be produced in a laboratory, and remain persistent in the environment for a long period. The microscopic spores can be deployed in a powder or spray and can be used to contaminate the air, food, and water supplies. They may be invisible to the naked eye, odorless, and tasteless (CDC, 2020). The German Army used biological agents against enemy countries during World War I, attempting to directly infect animals and contaminate their feed with anthrax (Frischknecht, 2003).

Anthrax was used in the worst biological attack in U.S. history, known as “Amerithrax” (FBI, n.d.). Following the terrorist attacks of September 11, 2001, letters laced with anthrax began circulating through the U.S. Postal Service (USPS), addressed to the offices of U.S. senators and national media outlets in Washington D.C., South Florida, and New York. Opening the letters released anthrax powder into the offices, where it was inhaled, ultimately causing the deaths of five victims and illness in 17 individuals. Panic and fear spread around the country, as it was unknown how many people had come into contact with these letters or how many other letters might be contaminated. This biological attack resulted in one of the largest and most complex law enforcement investigations to date (FBI, n.d.). The costs of human life, emotional distress, and resources were significant. Over 32,000 people exposed to anthrax were required to take prophylactic antibiotics, the USPS purchased 4.8 million masks and 88 million gloves for its employees, and 300 postal facilities were tested for anthrax. The investigation required extensive law enforcement resources. The Amerithrax Task Force comprised 25 to 30 full-time FBI investigators, the U.S. Postal Inspection Service, other law enforcement agencies, and federal prosecutors from the District of Columbia, and the Justice Department’s Counterterrorism Section spent hundreds of thousands of investigative hours on the case. These efforts involved more than 10,000 witness interviews on six different continents, the execution of 80 searches, and the recovery of more than 6,000 items of potential evidence during the investigation. More than 5,750 grand jury subpoenas were issued, and 5,730 environmental samples were collected from 60 sites. These efforts ultimately did not result in a conviction, as the suspect took his own life (FBI, n.d.).

Identification and Management of Biological Casualties

Nurses within the community and acute care facilities must be prepared to identify and manage biological casualties. The United States remains vulnerable to bioterrorism. Biological agents like anthrax, botulinum toxin, and bubonic plague can cause a large number of illnesses or deaths in a short amount of time. An attack using a biological agent can mimic a natural outbreak or event, complicating public health assessment and response. Biological agents capable of secondary transmission can lead to epidemics, so early recognition of unusual circumstances is essential in prevention and response (WHO, 2023a).

The first step in identification is recognizing potential exposure to a biological casualty. Indications of biological agent exposure include (Bland, 2014):

• Reports of unexplained or unusual symptoms, such as headache, burns, vision problems, chest tightness, difficulty breathing, excessive secretions, nausea, vomiting, convulsions
• Multiple casualties with an unidentified cause
• Unusual taste, smell, or mist
• Unexplained dead animals or plants

Whenever the nurse suspects individual exposure to a biological agent, a thorough assessment should be completed only after ensuring personal safety. For example, the biological agent may have contaminated the individual’s clothing, putting the nurse in danger of exposure. The nurse in this situation should don appropriate PPE, direct the individual to remove contaminated clothing, and follow procedures for decontamination, which include washing with soap and water.

In the event of biological exposure and contamination, decontamination may be necessary. Biological contamination occurs when infectious agents come into contact with a body surface, inanimate objects, or food or water supplies. Biological decontamination includes disinfection or sterilization of the area to reduce the number of microorganisms to a safe level (Table 32.3) (Dembeck et al., 2011).

The nurse compares individual assessment data to signs and symptoms of common biological agents to assist in diagnosis and potential treatment options. Table 32.4 describes common agents of bioterrorism, method of transmission, signs and symptoms, and treatments. The nurse reports biological agent exposure to the local health department and the CDC.

Mass exposure to biological agents must be identified and managed as quickly as possible to prevent additional exposure. Principles of mass exposure management include (Bland, 2014):

• Recognition of exposure
• Ensuring safety of the area through evacuation of nonessential personnel, use of PPE, and limiting additional exposure
• Establishing zones for decontamination, treatment, and safe or clean zones; see Zoning of Care Areas
• Setting up a command center and establishing a chain of communication
• Triage, assess, treat, and transport exposed individuals

The U.S. government remains in a constant state of readiness to protect Americans against the potential release of biological agents in terrorist threats and attacks. The Strategic National Stockpile (SNS) is part of the federal medical response infrastructure. The SNS supplements MCMs for states, tribal nations, territories, and metropolitan areas during public health emergencies. The stockpile has supplies, medicines, and devices for lifesaving care that can be used in the short term when the immediate supply of critical medical assets is unavailable or insufficient to meet the community’s needs (Administration for Strategic Preparedness and Response [ASPRN], n.d.).

Federal law enforcement and health and safety agencies focus on risk assessments and ensuring that preventative medical countermeasures (MCM) are safe, effective, and secure. The U.S. Food and Drug Administration (FDA) Medical Countermeasures Initiative (MCMi) works at local, state, national, and international levels of government to support MCM-related public health preparedness and response efforts (FDA, n.d.). MCMs are used to prevent, diagnose, or treat conditions associated with biological agents and include:

• Biologic products, such as vaccines, blood products, and antibodies
• Drugs, such as antimicrobial medications, antiviral medications, antidotes, or radiation treatments
• Devices, including diagnostic tests to identify threat agents, and personal protective equipment (PPE), such as gloves, respirators, face masks, and gowns

The Nurse’s Role in Bioterrorism Preparedness and Response

Nurses are essential members of the public health system. Public health and community health nurses must be prepared for the possibility of terrorist activity at any time. The American Nurses Association (2016) has developed policies, resources, and educational opportunities for nurses on disaster preparedness and acknowledges the importance of preparation so that nurses are equipped to respond to critical events. Nurses have a role in primary, secondary, and tertiary prevention for bioterrorism preparedness and response (Table 32.5). Refer to Pandemics and Infectious Disease Outbreaks for more information on conducting surveillance.