BIOTERRORISM

terroristic activities in which biological substances/weapons are used to kill or cause harm to other
people
biological weapons include chemicals, radiations, or any organism such as bacteria, viruses,
or fungi or toxin found in nature

POSSIBLE BIOLOGICAL WARFARE AGENTS

Bacteria
Bacillus anthracis (anthrax)
Yersinia pestis (plague)
Francisella tularensis (tularemia)
Brucella species (brucellosis)
Coxiella burnetii (Q fever)
Viruses
Variola virus (smallpox)
Equine encephalitis viruses (viral equine encephalitides)
Arenaviruses, bunyaviruses, filoviruses, flaviviruses (hemorrhagic fevers)
Toxins
Staphylococcal enterotoxin B
Ricin
Botulinum toxins
Trichothecene mycotoxins
Saxitoxin

*The common thread among all diseases is the entry of AGENTS into the body
Most common routes of entry of agents into the body are
Inhalation: vapor, aerosol, solid
Absorption: liquid, vapor, solid
Ingestion: solid, liquid
Injection: liquid

HISTORY of BIOTERRORISM
400 BC - Scythian archers infected their arrows by dipping them in decomposing bodies or in blood mixed
with manure
300 BC - Persian, Greek, and Roman used to contaminate wells & other sources of water
190 BC in Battle of Eurymedon, Hannibal won a naval victory over King Eumenes II of Pergamon by
firing earthen vessels full of venomous snakes into the enemy ships.
12th century AD - In battle of Tortona, Barbarossa used bodies of dead & decomposing soldiers
to poison wells.
14th century AD - the attacking Tatar forces hurled plague-infected corpses into the Kaffa city in an
attempt to cause an epidemic within enemy forces.
1710 - when the Russians besieging Swedish forces at Reval in Estonia catapulted bodies of people who
had died from plague.
18th century AD - British forces under the direction of Sir Jeffrey Amherst gave blankets that had been
used by smallpox victims to the Native Americans in a plan to spread the disease
HISTORY
(Modern times, 1900s)
World War I - the German Army developed anthrax, glanders,cholera, and a wheat fungus to spread
plague in Russia, infected mules with glanders in Mesopotamia, and attempted to do the same with the
horses of the French Cavalry.
The Geneva Protocol of 1925 was signed by 108 nations. This was the first multilateral agreement that
extended prohibition of chemical agents to biological agents. Unfortunately, no method for verification of
compliance was addressed.
World War II - Japanese forces operated a secret biological warfare research facility (Unit 731) in
Manchuria that carried out human experiments on prisoners. They exposed more than 3000 victims to
plague, anthrax, syphilis, and other agents
1942-1944 - the US formed the War Research Service. Anthrax and botulinum toxin initially were
investigated for use as weapons, stockpiled to allow unlimited retaliation if the German forces first used
biological agents. The British also tested anthrax bombs for the same reason.
1951-1954 - harmless organisms were released off both coasts of the United States to demonstrate the
vulnerability of American cities to biological attacks.
1966 - a test substance was released in the New York City subway system.
Vietnam War - Viet Cong guerrillas used needle-sharp punji sticks dipped in feces to cause severe
infections after an enemy soldier had been stabbed
1979 - accidental release of anthrax from a weapons facility in Sverdlovsk, USSR, killed at least 66 people.
The Russian government claimed these deaths were due to infected meat, and maintained this position
until 1992 - Russian President Boris Yeltsin finally admitted to the accident
1985 - Iraq began producing anthrax, botulinum toxin, and aflatoxin. 751 people were intentionally
infected with Salmonella in Oregon.
1994 - a Japanese sect of the Aum Shinrikyo cult attempted an aerosolized (sprayed into the air) release of
anthrax from the tops of buildings in Tokyo.
1995 -2 members of a Minnesota militia group were convicted of possession of ricin, for use in retaliation
against local government officials.
1996 - an Ohio man attempted to obtain bubonic plague cultures thru mail.
2001 - anthrax delivered by mail to US media & government offices caused 4 deaths.
2002 - 6 terrorist suspects were arrested in Manchester, England cause of "ricin laboratory."
2003 - British police found traces of ricin, Chechen separatist plan to attack the Russian embassy with the
toxin
2004 - 3 US Senate office buildings closed after the toxin ricin found in mailroom of Senate Majority Leader
Bill Frist's office.

BIOLOGICAL WARFARE AGENTS

CHEMICAL AGENTS
Are available and well-known
Can exists in an aerosol, gas (vapor), liquid, or solid state
Can cause major injury and death, and result in panic and social disruption
Includes nerve agents, vesicants, blood agents, and pulmonary agents

NERVE AGENTS
odorless, colorless, and volatile liquids in their pure form (organic phosphorus pesticides,
carbamate pesticides, sarin, soman, tabun, VX)
absorbed through the mucous membranes by inhalation and thru the skin
Produces symptoms sec-min (inhaled), min-hr (skin absorbed)
EFFECTS:
prevents proper functioning of the nervous system
hyperexcitability of the nervous system
Signs & Symptoms:
Miosis, Visual disturbances, Substernal spasm, Indigestion, Rhinorrhea, Brochospasm/laryngeal
spasm, Bradycardia, AV block, copious secretions, apnea (PARASYMPATHETIC overactivity)
Increased GI motility, Nausea & vomiting, Diarrhea, Salivation, Lacrimation (Increase
PARASYMPATHETIC tone or overstimulation)
Confusion, forgetfulness, insomnia, impaired judgment, depression, irritability, loss of
consciousness, seizures, apnea (Penetration of blood-brain barrier by nerve agents)
Weakness, fasciculations (Prolonged stimulation of receptors at the neuromuscular
junction)

D iarrhea, U rination, M iosis, B bronchospasm, B radycardia, E mesis, L acrimation, S

alivation

Diagnostic Tests:
ABGs: assess ventilation
Cardiac telemetry: detect arrhythmias
EEG in unresponsive clients: detects nonconvulsive status epilepticus
Treatment & Management:
Decontamination: large amount of soap and water or saline solution for 20 min, dont wipe
Maintain airway
Suction frequently
IV atropine 2-4 mg then 2 mg every 3-8 min up to 24 hrs treatment
Pralidoxine 1-2 mg in 100-150 mL NSS given over 15-30 min; activates cholinesterase
Diazepam (valium)
What can harm the client?
recontamination
coma
Resp. distress
MI

VESICANTS
 Colorless or yellowish/brown chemicals that cause blistering (lewesite, phosgene, nitrogen mustard,
sulfur mustard)
Typically persistent oily liquids that can cause symptoms from within sec (lewisite, phosgene) to 24-
36 hrs (mustard)

Cause cellular damage or death within minutes when absorbed

Eyes, skin, & resp. tract are most affected
Signs & Symptoms:
Skin exposure: burn, erythema, vesicles, cancer
Respiratory: purulent discharge, cough, violent sneezing, copious mucus production, obstructed
airways, recurrent infxns, lung fibrosis, asmatic bronchitis, upper airway cancers
Eye exposure: pain, photophobia, lacrimation, decreased vision, conjunctivitis, corneal ulcer,
corneal edema
GI: n/v, bloody diarrhea, constipation, upper GI bleeding
*Protect yourself by wearing personal protective equipment (PPE)
Diagnostic Tests:
Urinalysis: identify metabolite
Serum WBC: falls several days
Chest X-ray
Pulse oximetry
ABG
Stool for occult blood
Treatment & Management:
Maintain airway
Rapid decontamination
Eye irrigation
Topical or systemic antibiotics
Lubricating ointment to eyelids
Dark glasses
Bronchodilators & steroids
O2 assisted ventilation
Intubation
Bronchoscopy & suctioning
Dimercaprol (BAL in oil) IV
Analgesics
Topical antibiotics
Topical antipruritics
What can harm the client?
secondary bacterial infxn
laryngospasm
hemorrhagic pulmonary edema
resp. failure
Bone marrow suppression
Sepsis

BLOOD AGENTS
Highly volatile chemicals that present as colorless gas or liquids (arsine, carbon monoxide,
cyanogen chloride, cyanide, sodium monoflouroacetate)
Absorbed thru vapor inhalation or ingestion, wet skin (cyanide)
Onset of Symptoms 10-15 sec to min
Cause:
failure of central resp. drive (cyanide/CO)
renal failure (arsine)
Signs & Symptoms:
Cyanide
Rapid pulse, profound hypotension, pink skin (initial) to cyanosis, deep resp. to dyspnea to gasping
then cessation of resp., n/v, excited (initial) to depression, giddiness, irrational behavior, ataxia,
convulsions, possible coma, weak, drowsy
Arsine
Abdominal pain, bloody urine, jaundice
Initial Sx: thirst, shivering, malaise, weakness, dizziness, dyspnea, abdominal & back pain,
hepatomegaly, n/v
Diagnostic Tests:
CBC: (+) anemia
ABG: metabolic acidosis
Urinalysis: (+) hematuria & protein
Serum globulin, CPK, lactate, & liver enzymes: elevated
PT time: prolonged
Treatment & Management:
Decontamination
Respiratory support: intubation & ventilator
Amyl nitrite pearls crushed & placed in ventilator reservoir: antidote for cyanide; relaxes blood
vessels & increases blood supply
 Sodium nitrite 300 mg IV slowly greater than 5 min: preferred treatment for cyanide poisoning
Sodium thiosulfate 12.5 g IV over 10 min: antidote for cyanide & the only med given to patient with
CO poisoning when concomitant cyanide poisoning is suspected

What can harm the client?

resp. arrest
coma
Sepsis
cardiac arrest

PULMONARY AGENTS
gases or volatile liquids absorbed thru the body primarily thru inhalation, although mucosal &
dermal absorption is possible (ammonia, bromine, chlorine, HCl, methyl bromide, methyl
isocyanate, osmium tetroxide, phosgene, phosphine, phosphorus, & sulfuryl flouride)
S/Sx appear in sec-min.
Cause:
alveolar-capillary membrane disruption
O2 reduction fluid fills interstitium & alveoli
Signs & Symptoms:
Pulmonary edema
Cough
Dyspnea
Chest discomfort to tightness
Hypoxemia
Rales
Pulmonary edema leading to intravascular depletion resulting to hypotension
Diagnostic Tests:
O2 sat
ABG
Chest X-ray
Treatment & Management:
Decontamination
Restore & maintain airway
Administer O2
Beta 2 agonists
Suction excess secretions
Corticosteroids
What can harm the client?
resp. arrest
cardiac arrest
recontamination

RADIATION
Acute radiation syndrome is the major illness associated with radiation exposure
Thorough decontamination should be performed to all exposed clients
Limit yourself from exposure to radiation
Minimize time spent near radiation sources
Maximum practical distance should be maintained
Use shielding sources
Acute Radiation Syndrome
Occurs as a result of high dose of radiation exposure (min. 100 rad)
Determinants of radiation sickness
Degree of exposure
Pre-existing state of health
Age
Genetics
Sex
Cause:
Invisible exposure to radiation
external irradiation: radiation passes completely through the body; not a medical emergency-
client not radioactive
Contamination: gases, liquids, or solids are exposed to body externally or internally; requires
immediate medical mgt to prevent incorporation
Incorporation: radioactive material is taken up by the cells, tissues, & susceptible organs kidneys,
bone, liver, & thyroid; requires immediate medical mgt to decontaminate & administer treatment
Signs & Symptoms:
Hematologic: hemolysis, neutropenia, thrombocytopenia, spleen & lymph nodes atrophy,
lethargy, anorexia, n/v, hemorrhage, fever, sepsis
GI: vomiting, bloody diarrhea, fluid loss, electrolyte imbalance, shock, sepsis, opportunistic
infections, fever
CNS: cerebral edema, n/v, headache, tremors, ataxia, shock, increased ICP, cardiovascular collapse
 Skin: erythema, radiation dermatitis, necrosis
Trauma 2o to radiation blast: burn, crushing injury, severed limbs

*Protect yourself by wearing personal protective equipment (PPE)

Diagnostic Tests:
Monitor CBC
Urinalysis
Swab body orifices & wounds
24-hr urine & feces collection
ABG
Treatment & Management
Secure ABCs
Treat major trauma, burns & resp. injury
Decontamination
GI symptoms: IVF replacement, antiemetics, antidiarrheal, prophylaxis for GI ulcerations
Prevention & treatment of infections in neutropenic patients
RBC or Platelet transfusion
Psychological support
Comfort measures/pain mgt
Consult with radiation, hematology, radiotherapy experts for prognosis & treatment
What can harm the client?
resp. distress
cardiovascular collapse
kidney failure
coma
cancers
PTSD

ANTHRAX (Bacillus Anthracis)

Naturally occuring spore that lives throughout the world
Spores are very resistant to drying, heat, & UV radiation, & can survive for decades
Causes shock & death when host is infected
Caused by replicating bacteria that release toxins resulting in hemorrhage, edema, & necrosis
Incubation period: 1-6 days
Method of infection: skin contact, inhalation, GI ingestion
Signs & Symptoms:
Skin contact: edema, pruritis, macule, papule, ulceration, vesicle, painless eschar
GI ingestion: fever, n/v, abdominal pain, bloody diarrhea, ascites, sepsis
Inhalation: mimic flu symptoms (fever, malaise, cough, & myalgia), advanced (blood-tinged
sputum, dyspnea, pleuritic pain, n/v, chest heaviness, hemorrhagic pleural effusion, shock, death)
Diagnostic Tests:
Culture results
Chest X-ray
Treatment & Management:
Maintain airway
Provide supplemental Oxygen
Antibiotics penicillin, erythromycin, chloramphenicol, gentamicin, or doxycycline: death can be
prevented if antibiotics are given within 24 hrs after exposure
*After death, patients should be cremated to prevent the survival of spores that can cause threat to
morticians & forensic medicine personnel

SMALL POX
DNA virus
Caused by variola virus
Incubation period: 12 days (7-17 days)
Extremely contagious & is spread by direct contact
Signs & Symptoms:
High fever, malaise, headache, backache, abdominal pain, delirium
Maculopapular rash on face, mouth, & forearms; rash progresses to trunk & becomes vesicular &
pustular
Dusky erythema, petechiae, hemorrhage of skin & mucous membranes, death
Diagnostic Tests:
Wound sample
CBC
Treatment & Management:
Decontamination of clients room
Antibiotics
Antiviral
Isolation
Cremation
What can harm the client?
 immunosuppression
Malnutrition
Infection