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    A readied response: Bioterrorism

    RN/MCPHU Home Study Program

    A readied response: Bioterrorism

    CE credit is no longer available for this article. (Expired March 2004)

    Originally posted March 2002

    A readied response

    Long before the intentional release of anthrax this past fall, it was important for nurses to be knowledgeable about treating victims of terrorism; since then, it's become crucial. As anthrax victims began to arrive in EDs from Florida to Connecticut starting in October, healthcare providers across the country were reminded of how much—or little—they knew about such threats and appropriate medical interventions. With those needs in mind, we introduce our four-part series on terrorism called "A readied response."

    In this first installment, we look at the different biological agents that could be used in a terrorist attack, how to recognize and prevent the spread of the diseases they create, and how to care for those who have been exposed. The next two installments will cover similar information on chemical and nuclear attacks. The final installment will help you to assess whether your facility is ready to handle the victims of a terrorist attack, and what to do if it isn't.



    RENÉ STEINHAUER is a nurse at Northbay Medical Center in Fairfield, Calif., a paramedic with Medic Ambulance in Vallejo, Calif., and the author of International Medicine: Your Passport for Adventure (www.international medicineonline.com ). He's currently serving with the U.S. Air Force Reserve in support of Operation Enduring Freedom.

    KEY WORDS: biological agent, terrorism, anthrax, plague, smallpox, botulism. viral hemorrhagic fevers (VHF), tularemia

    As recent events have made all too clear, the threat of a biological attack is real—and anthrax isn't the only available weapon. That puts nurses, especially those in EDs and clinics, on the front lines for early recognition and intervention.

    Jump to:

    On October 5, 2001, 63-year-old Robert Stevens died of inhalational anthrax; his death was the direct result of an attack with a biological agent. By year's end, four other individuals had died as a result of exposure to anthrax. These incidents have proven a chilling point: Terrorists have biological agents and they're willing to use them.

    Bioterrorism is the deliberate release of pathogenic microorganisms—bacteria, viruses, fungi, or toxins—into a community.1 The diseases most likely to be involved are anthrax, plague, smallpox, botulism, viral hemorrhagic fevers (VHF), and tularemia.

    All of these diseases are classified by the Centers for Disease Control and Prevention (CDC) as "category A," which means they pose a risk to national security because they can be easily disseminated or transmitted, cause high mortality, cause public panic, and require special action for public health preparedness.2 Although most are treatable, the insidious nature of their onset and the hysteria they can create make them frighteningly effective terrorist weapons. Your early recognition that a biological agent may be at work, and prompt intervention, however, can change that.

    Is it the flu, or something else?

    Victims of attacks are either directly inoculated with the disease through contact with the infectious agent (as occurs with anthrax) or inoculated by a vector carrying the disease, such as mosquitoes, fleas, or an individual who has purposely infected himself.

    There's no immediate way to identify a patient as a victim of a biological attack. As you would do in your routine care of patients, you need to look for signs of acute illness and the potential of the illness being contagious. The signs may include sudden acute fever, rapid onset of symptoms, coughing, weeping sores, and unusual skin manifestations.

    Many of these diseases start with symptoms similar to those of a cold or flu that become progressively worse. Each has its own incubation period, which may range from two to 50 days, depending upon the specific disease and the patient's health. For some of them, it's only when the disease process is near the terminal stage that the real cause becomes apparent.

    Identifying an unusual epidemiology is critical for recognizing a biological attack. According to the CDC, healthcare workers should be alert to such patterns as an unusual temporal or geographic clustering of illnesses, such as among people who attended the same gathering, or an unusual age distribution for common diseases, such as chickenpox-like symptoms in adults.3 Other warning signs are patients presenting with illnesses that are not endemic to their local area and a sudden onset of out-of-season illness, such as a surge of patients with influenza in the summer.

    If you suspect a biological attack, follow your facility's procedure for properly reporting such incidents, which typically involves notifying the local or state public health representative. State public health agencies are required to immediately notify the FBI and local law enforcement agencies, and then voluntarily report any incident of apparent or threatened bioterrorism to the CDC.

    Anthrax to tularemia—what you must know

    The following is a description of the six diseases most likely to be involved in a biological attack and the currently recommended protective measures and interventions.


    Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis.4 Anthrax can manifest itself in three separate forms: cutaneous, gastrointestinal, and inhalational.5 Cutaneous anthrax results from the introduction of the spore through the skin; gastrointestinal anthrax, through ingestion; and inhalational anthrax, through the respiratory tract.6 (Gastrointestinal anthrax, which usually follows the consumption of raw or undercooked contaminated meat, is not likely to be seen as the result of a terrorist act and therefore will not be discussed here.)

    Recognition. Cutaneous infection begins with an area of local edema that develops into a pruritic macule or papule, which enlarges and ulcerates after two to three days.3 Shortly thereafter, small vesicles may surround the ulcer. After a few days, the vesicle will turn to a dark black scab with eschar. The syndrome also may include lymphangitis and painful lymphadenopathy.

    Inhalational anthrax—the cause of the five deaths last fall—is characterized by fever (with or without chills), sweats, fatigue, malaise, cough, shortness of breath, chest discomfort, and pleuritic pain.7 Other symptoms include nausea, vomiting, diarrhea, abdominal pain, headache, myalgias, and sore throat. Patients with inhalational anthrax have a normal to elevated WBC count with neutrophilia with bands. Chest radiograph may reveal mediastinal widening, pleural effusion, and pulmonary infiltrate. About 50% of patients with inhalational anthrax develop meningitis; septicemia, shock, and death occur within 24 – 36 hours of respiratory distress.1 Gram's stain of blood or blood cultures may confirm B. anthracis, but only in later stages of the disease, well past the point of successful medical intervention.8

    Protective measures. Because person-to-person transmission of anthrax hasn't been documented,4 these patients don't require special isolation or decontamination, and standard precautions are recommended. The only patients who may require decontamination are those who believe they were recently exposed and have not changed clothing and bathed since that time. Careful adherence to universal precautions is required when performing invasive procedures on patients with anthrax.

    Interventions. Rapid administration of antimicrobial therapy is essential for effective treatment of anthrax.9 While most cases of cutaneous anthrax respond well to therapy, the mortality rate from untreated inhalational anthrax is estimated at 90% – 100%.5

    For the treatment of cutaneous anthrax in adults, the latest CDC recommendations call for the administration of either ciprofloxacin HCl (Cipro) 500 mg PO bid or doxycycline (Vibramycin, Monodox, others) 100 mg PO bid for 60 days.9 For children, the CDC recommends ciprofloxacin 10 – 15 mg/kg PO every 12 hours (not to exceed 1 gm/day) or doxycycline every 12 hours at the following dosages: older than 8 years and weighing more than 45 kg (99 pounds), 100 mg; older than 8 years and weighing 45 kg or less, 2.2 mg/kg; and 8 years or younger, 2.2 mg/kg. These are the same recommendations for prophylaxis of inhalational anthrax after a confirmed or suspected exposure.

    For cases of diagnosed inhalational anthrax, the CDC recommends IV ciprofloxacin or doxycycline plus one or two antimicrobial agents predicted to be effective.9 Those other antimicrobials include rifampin (Rifadin, Rifamate, others), vancomycin HCl (Vancocin), imipenem (Primaxin), chloramphenicol (Chloromycetin), penicillin, ampicillin, clindamycin HCl (Cleocin), and clarithromycin (Biaxin).

    For adults, the recommended therapy is 400 mg IV ciprofloxacin every 12 hours or 100 mg doxycycline every 12 hours and one or two additional antimicrobials given IV initially. Patients can be switched to oral ciprofloxacin or doxycycline only when clinically appropriate, based on their progress. The duration of the combined IV and oral therapies is 60 days.

    IV ciprofloxacin or doxycycline and one or two additional antimicrobials are also recommended for children diagnosed with inhalational anthrax. Ciprofloxacin should be given 10 – 15 mg/kg every 12 hours. If doxycycline is chosen, administer every 12 hours at the following dosages: 100 mg for children older than 8 years and weighing more than 45 kg; 2.2 mg/kg for those older than 8 years and weighing 45 kg or less; and 2.2 mg/kg for children under 8 years old. Children also can be switched to oral therapy when clinically appropriate.

    A vaccine has been developed for anthrax that is protective against invasive disease, but it is currently recommended only for high-risk populations, such as military personnel deployed to areas where they face exposure to anthrax, or laboratory personnel who work directly with the organism.6


    Plague is caused by the Yersinia pestis bacillus and can present as pneumonic, septicemic, or bubonic plague. Pneumonic plague is caused by inhalation of the bacilli, as in an aerosol cloud. It's the most likely form to be used in a biological attack10 and the focus of our discussion here. Person-to-person transmission occurs through respiratory droplets. The incubation period for pneumonic plague is between one and six days, and the fatality rate approaches 100% for those who do not receive treatment within 24 hours of symptom onset.10

    Recognition. Because there are no widely available tests for rapidly identifying pneumonic plague, and because its initial presentation is similar to that of other severe respiratory illnesses, it's important to stay on top of public health alerts. Most likely, the first indication of a terrorist attack with plague would be a sudden outbreak of illness presenting as severe pneumonia and sepsis.10 Fever, dyspnea, and cough are the initial symptoms. Bloody, watery, or purulent sputum and gastrointestinal symptoms such as nausea, vomiting, pain, and diarrhea are less common.

    The sudden appearance in the ED of a large number of previously healthy patients with these symptoms and a rapidly progressing course that leads to death should immediately raise the possibility of pneumonic plague.10

    Protective measures. During a biological attack, an aerosol spray would remain in an area for no more than a few hours. The bacteria are weak and killed easily by sunlight. Consequently, symptomatic patients do not require decontamination.

    However, because human-to-human transmission of pneumonic plague occurs through respiratory droplets, patients presenting with pneumonic plague require respiratory isolation during the first 48 hours of antibiotic therapy and until clinical improvement occurs.10 Standard precautions when treating these patients include wearing a gown, gloves, eye protection, and a surgical mask, and limiting the patient's movement and transport.11 Patients should wear surgical masks while being transported.10 People who have had direct face-to-face contact with the patient require prophylactic antibiotic therapy.

    Interventions. Treatment for patients with pneumonic plague consists of antibiotic therapy and management of symptoms related to the disease. The antibiotic recommended when there are only a small number of patients is either streptomycin, adults 1 gm IM twice daily, or gentamicin sulfate (Garamycin, Cidomycin, others) 5 mg/kg IM or IV once daily or 2 mg/kg loading dose followed by 1.7 mg/kg IM or IV three times daily.10 For dosing information for children and pregnant women, see http://jama.amaassn.org/issues/v283n17/fig_tab/jst90013_t2.html .

    In the event of mass casualties when IV or IM administration may be impractical or impossible, the suggested oral antibiotics for adults are doxycycline or ciprofloxacin. Tetracycline HCl (Tetracyn, Panmycin, others) and chloramphenicol have also been effective.12

    The following antibiotics should not be used because they have been shown to have poor or modest efficacy: rifampin, aztreonam (Azactam), ceftazidime (Fortaz, Tazidime, others), cefotetan disodium (Cefotan), and cefazolin sodium (Ancef, Kefzol, others).10


    Smallpox, which is caused by variola virus, was eradicated worldwide in 1977, and in 1980 it was recommended that all countries stop smallpox vaccinations.13 Routine vaccination for smallpox in the United States ended in 1972. Since the level of immunity of people vaccinated before then is uncertain, these immunized individuals are assumed to be susceptible.14 Because of concerns about the risk of a smallpox attack, the CDC recently contracted with a manufacturer to accelerate production of the vaccine.15

    In a bioterrorist attack, smallpox can be released by aerosol. It spreads from person to person by infected saliva droplets as well as by direct contact with contaminated items like blankets and clothing.13 The mortality rate may be as great as 30%, and there are no proven treatments.14 The disease has an average incubation period of 12 – 14 days, which provides ample opportunity for the infection to spread. Patients are most contagious during the first week of illness, but the risk of transmission lasts until all scabs have fallen off.

    Recognition. The acute clinical symptoms of smallpox resemble those of other acute viral illnesses, such as influenza.3 Patients typically experience high fever, malaise, and prostration with headache and backache, sometimes accompanied by severe abdominal pain and delirium.13 A maculopapular rash develops on the mucosa of the mouth and pharynx and on the face and forearms and then spreads to the trunk and legs. Within one to two days, the rash becomes vesicular and, later, pustular. The pustules are characteristically round, tense, and deeply embedded in the skin. They develop into scabs on about the eighth or ninth day of the rash.

    Several clinical features can be used to differentiate the rash of smallpox from that of chickenpox (varicella). Rash associated with chickenpox is prominent on the trunk and develops in groups of lesions over several days. With smallpox, the rash is most prominent on the face and extremities, and lesions develop at the same time.

    Lab testing is important for confirming smallpox. Samples, however, should be sent to a local or state health department capable of studying them within a high-containment environment.13

    Protective measures. Smallpox is spread not only by respiratory nuclei but also by oral secretions and drainage from lesions. Smallpox transmission within hospitals has long been recognized as a serious problem.13 In the event of a limited outbreak with few cases, patients should be admitted to the hospital but confined to rooms that are under negative pressure and equipped with high-efficiency particle air filtration. In larger outbreaks, home isolation and care should be the goal for most patients.13 Individuals who have had contact with the patient, including healthcare workers, should be vaccinated against the virus. The vaccine can lessen the severity of illness, or even prevent it, if given within four days after exposure.14

    Healthcare workers should observe strict contact and airborne precautions—gloves, gowns, eye shields, shoe covers, and correctly fitted masks—and the number of people selected for direct contact with smallpox patients should be limited.16

    Interventions. Because there's no proven treatment for smallpox, care is basically supportive in nature. Secondary bacterial infections are rare and can be treated with appropriate antibiotics. Postexposure vaccination is important for preventing continued transmission of the disease.


    Botulism is a muscle-paralyzing disease caused by a toxin made by the Clostridium botulinum bacterium.17 The toxin is one of the most poisonous substances known. Three kinds of human botulism occur naturally: foodborne, which occurs when a patient ingests food contaminated with the toxin; infant, when susceptible infants harbor C. botulinum in their intestinal tracts; and wound, when wounds become infected with C. botulinum. A fourth form is man-made: inhalational botulism, which would result from the release of an aerosolized botulinum toxin.18 Botulism is not transmitted from person to person.

    All forms of botulism create virtually identical neurological effects, though the neurological effects of foodborne botulism may be preceded by abdominal cramps, nausea, vomiting, or diarrhea.18 When the toxin is absorbed, botulinum neurotoxins irreversibly bind to presynaptic receptors of peripheral nerves and subsequently inhibit the release of acetylcholine. Both the neuromuscular junctions and cholinergic autonomic synapses are affected, resulting in skeletal muscle and bulbar paralysis. Recovery can take weeks to months, requiring the regeneration of presynaptic axons and formation of new synapses.19

    Recognition. Botulism is not easy to recognize and the symptoms are sometimes misdiagnosed as processes of Guillain-Barré syndrome or myasthenia gravis. The signs of botulism begin with descending cranial nerve paralysis. Symptoms include drooping eyelids (ptosis), difficulty articulating speech, blurred vision, dry mouth, and decreased facial tone. As symptoms progress, the patient may experience extreme muscle weakness that descends through the body, and loss of head control and gag reflex. He may become unable to maintain a patent airway, requiring intubation.

    Unlike a stroke, botulism causes bilateral paralysis. Despite appearing comatose, the patient will maintain complete cognitive function. Another important finding is that the patient is afebrile.

    Protective measures. Healthcare workers should use standard precautions when caring for patients suffering from botulism.1 Because there's no evidence of human-to-human transmission, patients don't need to be isolated.18 Contaminated clothing and items, however, should be washed in warm water using any commercial laundry product.1

    Interventions. Early recognition of botulism may allow for successful use of passive immunization with botulinum antitoxin.18 If the antitoxin is used early in the onset of the disease, it may stop or reduce further paralysis, but it will not reverse paralysis that has already occurred. Other care is supportive in nature and may involve advanced airways and long-term support on a ventilator. Patients with suspected botulism should be closely monitored for impending respiratory failure. Antibiotics are not indicated for the treatment of botulism.

    In the past 50 years, the proportion of patients with botulism who die has fallen from about 50% to 8%.20 However, intensive and prolonged nursing care is required for most patients.1

    Viral hemorrhagic fevers

    Viral hemorrhagic fevers are a group of illnesses caused by several distinct families of viruses. Many of these illnesses are severe and life-threatening.21 They include Ebola, Marburg, Lassa, Argentine, Crimean-Congo, Bolivian, Rift Valley, Yellow, and Dengue fevers, among others.

    Although each disease has unique characteristics, hemorrhagic fevers frequently present with a sudden onset of fever and signs and symptoms of circulatory compromise. The term "hemorrhagic" is misleading, as it's rare for patients to suffer life-threatening bleeding. However, hypovolemia may occur as a result of damage to the vascular endothelium and the consequential increase in capillary membrane permeability.22

    All of the viruses associated with VHF are zoonotic (animal-borne), lipid-enveloped, RNA viruses. Some—such as Ebola, Marburg, Lassa, and Crimean-Congo—can be spread from person to person.

    All of the VHF viruses (except for the one responsible for Dengue fever) are infectious by aerosol and could conceivably be used in a biological attack.1

    Recognition. Signs and symptoms vary by the type of VHF, but common presenting complaints include fever, myalgias, and prostration. An exam may reveal conjunctival injection, mild hypotension, flushing, and petechial hemorrhages.1 Later symptoms include vomiting, diarrhea, shock, and hemorrhage. Some types of VHF are associated with renal failure.

    Protective measures. Blood and body secretions and tissue specimens from infected patients will carry the virus responsible for VHF. The risk for person-to-person transmission of VHF is highest during the latter stages of the disease.23

    The CDC recommends various isolation precautions, including a negative-pressure room with an anteroom, depending on the stage of VHF disease.23 Healthcare workers should use personal protective equipment including respirators, face shields, gowns, gloves, and shoe and head covers. They should handle all sharps with extreme care to avoid percutaneous exposure.

    Interventions. Other than supportive care, there's no treatment or proven cure for VHF. Ribavirin (Virazole) has been effective in treating some patients with Lassa fever or hemorrhagic fever with renal syndrome (HFRS). Supportive care includes the use of sedatives, pain relievers, and amnesics.1 Aspirin and other anti-clotting drugs should be avoided, as should IV lines, catheters, or other invasive devices.


    Tularemia is caused by the bacterium Francisella tularensis. With a mortality rate between 30% and 60% when untreated,24 tularemia is not nearly as deadly as anthrax or plague, but it's nonetheless regarded as a dangerous potential weapon because of its extremely infectious nature and the ease with which the bacteria can be dispersed and cause illness.25

    The disease can be contracted via aerosol inhalation and contaminated water, food, and soil. As a biological weapon, the most likely form would be aerosolization of the bacteria.

    Recognition. Tularemia produces nonspecific febrile symptoms. Inhalational tularemia will likely cause pulmonary complications such as bronchiolitis or pleuropneumonitis. Symptoms usually begin three to five days after exposure and include a sudden onset of fever, nonproductive or minimally productive cough, substernal tightness, pleuritic chest pain, chills, headache, anorexia, fatigue, malaise, and, rarely, hemoptysis. X-rays will not usually show infiltrates within the first few days of infection. If left untreated, the disease can rapidly progress to respiratory failure.

    There are no cardinal signs of tularemia and no current methods for rapid identification of it. The disease won't likely be recognized without some suspicion of a potential biological attack. Specimens of blood and secretions should be collected and sent for testing.

    Protective measures. Universal precautions are recommended. Given the lack of human-to-human transmission, isolation is not required.25

    Intervention. For small outbreaks of tularemia, 10 days of parenteral antibiotic therapy with either streptomycin or gentamicin is indicated as follows: adults—streptomycin, 1 gm IM twice daily or gentamicin, 5 mg/kg IM or IV once daily; and children—streptomycin, 15 mg/kg IM twice daily (should not exceed 2 gm/day) or gentamicin, 2.5 mg/kg IM or IV three times daily.25 In cases where there are large outbreaks, oral doxycycline or ciprofloxacin are the drugs of choice. For postexposure prophylaxis, either doxycycline or ciprofloxacin is recommended for 14 days.25

    Clearly, there's much we can do in the face of a biological attack—whether it involves tularemia, anthrax, or any of the other diseases covered here. Knowing how to recognize, and intervene, when a biological agent is at work can minimize the toll this form of terrorism takes on the public.


    1. California Department of Health Services. "California hospital bioterrorism response planning guide." 2001. www.dhs.ca.gov/BioTerrorism%20Headline/Revised%20BT%20Response%20master%20document.pdf (11 Dec. 2001).

    2. Centers for Disease Control and Prevention, Public Health Emergency Preparedness and Response. "Biological diseases, category A." 2001. www.bt.cdc.gov/Agent/Agentlist.asp (11 Dec. 2001).

    3. Centers for Disease Control and Prevention. (2001). Recognition of illness associated with the intentional release of a biological agent. MMWR, 50(41), 893.

    4. Centers for Disease Control and Prevention. (2001). Update: Investigation of anthrax associated with intentional exposure and interim public health guidelines, October 2001. MMWR, 50(41), 889.

    5. Centers for Disease Control and Prevention. "Anthrax: Technical information." 2001. www.cdc.gov/ncidod/dbmd/diseaseinfo/anthrax_t.htm (11 Dec. 2001).

    6. Centers for Disease Control and Prevention. "Anthrax: General information." 2001. www.cdc.gov/ncidod/dbmd/diseaseinfo/anthrax_g.htm (11 Dec. 2001).

    7. Centers for Disease Control and Prevention. (2001). Update: Investigation of bioterrorism-related anthrax and interim guidelines for clinical evaluation of persons with possible anthrax. MMWR, 50(43), 941.

    8. Gwerder, L. J., Beaton, R., & Daniell, W. (2001). Bioterrorism: Implications for the occupational and environmental health nurse. AAOHN Journal, 49(11), 512.

    9. Centers for Disease Control and Prevention. (2001). Update: Investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001. MMWR, 50(42), 909.

    10. Inglesby, T. V., Dennis, D. T., et al. (2000). Plague as a biological weapon: Medical and public health management. JAMA, 283(17), 2283.

    11. United States Army Medical Research Institute of Infectious Diseases. "USAMRIID's medical management of biological casualties handbook (4th ed.)." 2001. www.usamriid.army.mil/education/bluebook/appxb.doc (11 Dec. 2001).

    12. Centers for Disease Control and Prevention. "Facts about pneumonic plague." 2001. www.bt.cdc.gov/DocumentsApp/FactSheet/Plague/About.asp (11 Dec. 2001).

    13. Henderson, A. A., Inglesby, T. V., et al. (1999). Smallpox as a biological weapon. JAMA, 281(22), 2127.

    14. Centers for Disease Control and Prevention. "Facts about smallpox." 2001. www.bt.cdc.gov/DocumentsApp/FactSheet/SmallPox/About.asp (11 Dec. 2001).

    15. Centers for Disease Control and Prevention. "FAQs about smallpox." 2001. www.bt.cdc.gov/DocumentsApp/FAQsmallpox.asp?link=2 (11 Dec. 2001).

    16. Centers for Disease Control and Prevention. (2001). Vaccinia (smallpox) vaccine recommendation of the Advisory Committee on Immunization Practices (ACIP), 2001. MMWR, 50(RR10), 1.

    17. Centers for Disease Control and Prevention. "Facts about botulism." 2001. www.bt.cdc.gov/DocumentsApp/FactSheet/Botulism/about.asp (11 Dec. 2001).

    18. Arnon, S. S., Schechter, R., et al. (2001). Botulism toxin as a biological weapon. JAMA, 285(8), 1059.

    19. New York City Department of Health, Bureau of Communicable Disease. "Medical treatment and response to suspected botulism: Information for health care providers during biologic emergencies." 2000. www.ci.nyc.ny.us/html/doh/html/cd/botmd.htm (11 Dec. 2001).

    20. Centers for Disease Control and Prevention. "Botulism: General information." 2001. www.cdc.gov/ncidod/dbmd/diseaseinfo/botulism_g.htm (11 Dec. 2001).

    21. Centers for Disease Control and Prevention. "Viral hemorrhagic fevers: Fact sheets." 2001. www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/vhf.htm (11 Dec. 2001).

    22. Franz, D. R. (1997). Clinical recognition and management of patients exposed to biological warfare agent. JAMA, 278(5), 406.

    23. Centers for Disease Control and Prevention (1995). Update: Management of patients with suspected viral hemorrhagic fever—United States. MMWR, 44(25), 475.

    24. New York City Department of Health, Bureau of Communicable Disease. "Medical treatment and response to suspected tularemia: Information for health care providers during biologic emergencies." 2000. www.ci.nyc.ny.us/html/doh/html/cd/tulmd.html (11 Dec. 2001).

    25. Dennis, D. T., Inglesby, T. V., et al. (2001). Tularemia as a biological weapon: Medical and public health management. JAMA, 285(21), 2763.

    The decontamination process

    In most cases, the medical staff treating a victim of a biological attack isn't likely to be at risk of becoming contaminated. Due to the diseases' incubation periods, by the time most patients come to an ED with symptoms, it's unlikely they'll still be carrying the biological agent on their skin or clothing. And with the exception of smallpox, viral hemorrhagic fevers (VHF), and pneumonic plague, most infectious diseases caused by biological agents are rarely transmitted from person to person.1

    However, if the patient's body and clothing are contaminated, the healthcare staff will need to implement precautions to keep the agent from spreading to others.

    Decontamination should occur in a room designed specifically for that purpose or at decontamination sites set up outside of the hospital. If a hospital doesn't have a decontamination facility, it can buy portable showers to use for this purpose. The showers can be set up in the hospital parking lot or on an adjacent street. The local fire department and hazardous response team can manage decontaminating patients in these showers.

    If such personnel aren't available, the patient (if physically able to do so) should decontaminate himself while medical personnel provide direction from a distance. The patient should be instructed to place all of his clothing in a red biohazard bag for disposal and then shower, washing from head to toe and ensuring that all skinfolds and crevices are clean.


    1. California Department of Health Services. "California hospital bioterrorism response planning guide." 2001. www.dhs.ca.gov/BioTerrorism%20Headline/Revised%20BT%20Response%20master%20document.pdf (11 Dec. 2001).

    Additional resources

    Centers for Disease Control and Prevention
    Public Health Emergency Preparedness and Response
    (800) 311-3435
    (770) 488-7100 (24-hour emergency hotline)

    Johns Hopkins University
    Center for Civilian Biodefense Strategies
    (410) 223-1667

    U.S. Army Medical Research Institute of Infectious Diseases
    [email protected]

    U.S. Food and Drug Administration
    (888) 463-6332


    Emil Vernarec, ed. Rene Steinhauer III. A readied response: Bioterrorism. RN 2002;3:48.

    Published in RN Magazine.
    Rene Steinhauer, III, RN, EMT-P
    Rene Steinhauer is a nurse at Northbay Medical Center in Fairfield, CA, a paramedic with Medic Ambulance in Vallejo, CA, and the author ...