Early Warnings

Identification of bioterrorism and infectious disease emergency events has become a national priority and a moral imperative for occupational health and emergency department nurses.

THE anthrax incident of 2001 was a small bioterrorism attack in terms of the amount of agent used (the letter addressed to Senator Daschle contained only two to three ounces of anthrax spores, and the other letters contained similar amounts) and the resulting morbidity and mortality. (There were only 22 cases of anthrax and five deaths).1 Compared to the morbidity and mortality of other infectious diseases in the United States, such as tuberculosis or meningitis, the anthrax incident was miniscule. However, the overall impact of the bioterrorism attack was staggering.

Total costs have yet to be determined, but early estimates put the total cost at over $2.5 billion, and the psychological impact has been tremendous.2 Larger bioterrorism attacks using contagious agents, such as smallpox, would likely result in significantly higher morbidity, mortality, and costs than the 2001 attack.3 The potential consequences of being unprepared for such an event are enormous.3

With the changing political and social climate, the need for nursing involvement in bioterrorism planning and response has escalated sharply. As the largest group of health care workers, nurses play a critical role in the nation's bioterrorism preparedness efforts because they will be at the forefront in patient management. In recognition of nurses' vital role in bioterrorism response, the National Institute of Nursing Research has declared bioterrorism preparedness to be a necessity for nurses in all expertise and practice areas.4

There is an added benefit: Bioterrorism readiness prepares nurses to recognize and respond to any infectious disease emergency. This is because the response to these incidents is very similar. Whether naturally occurring (outbreaks of emerging pathogens) or man-made (bioterrorism), infectious disease emergencies pose a serious threat to the health and safety of U.S. citizens, can result in high morbidity and mortality, and can have a tremendous impact on citizens' mental health. Recent events, such as the 2001 anthrax incident and outbreaks of Monkeypox and severe acute respiratory syndrome (SARS), have illustrated how truly unprepared we are as a nation to adequately respond to various types of infectious disease emergencies.5,6 Many experts, including the Centers for Disease Control and Prevention, indicate it is only a matter of time before the world is facing a global outbreak of an infectious disease, such as avian influenza. It is imperative that nurses become better prepared to recognize and respond to this type of event.

Regardless of whether the event is naturally occurring or man-made, an infectious disease emergency would likely result in large numbers of victims and could easily become a global problem. Infectious diseases strike across all social lines and are not restricted by geographical borders. The SARS outbreak illustrated how rapidly a contagious disease can spread. SARS was first reported by a Vietnamese epidemiologist in March 2003 and within a few short days had spread to countries around the world.6,7,8 Another such event would result in large influxes of patients to health care facilities and could quickly overwhelm current medical capacities. In addition, an outbreak probably would also have a significant impact on industry because the absenteeism rate is likely to be much higher than normal.9

There are a number of topics with which Emergency Department and occupational health nurses should become familiar as part of infectious disease emergency preparedness. These topics include epidemiological clues of a potential incident, infection control prevention measures, patient triage and management, when and to whom to report an event, psychosocial issues, development of a personal response plan, and communication. Many of these topics are the same as for traditional emergency preparedness and will not be addressed in this article. The topic that will be addressed is identifying the epidemiological clues of a possible incident.

Recognition of a Bioterrorism Attack or Outbreak of an Emerging Infection
Infectious disease emergencies are unlike traditional disasters, such as earthquakes, floods, tornadoes, or terrorism attacks using incendiary devices, in that they may not be readily apparent or easily detected. Biological agents are odorless, colorless, and tasteless when aerosolized; thus, bioterrorism attack identification will likely be delayed until patients develop symptoms and access the medical system, which could occur days to weeks after the release.

Following a naturally occurring outbreak of an emerging pathogen, detection would also be delayed because initial cases probably will not seek medical care or will present to health care facilities in a slow trickle. Even when patients do access medical care, their disease will be difficult to diagnose because patients are likely to present with non-specific symptoms early in the disease course, and there are no available laboratory tests for many new or unusual pathogens. This was the scenario when SARS was first identified.6 The outbreak began slowly, built to a crest before falling off, and there were no rapid diagnostic tests. Despite this, it is crucial to identify these outbreaks and incidents as soon as possible. The sooner the event and individuals at risk are identified, the higher likelihood of decreasing morbidity, mortality, and associated costs.

Occupational health (OH) and Emergency Department (ED) nurses will play a vital role in identifying potential victims of bioterrorism or patients infected with an emerging pathogen because they are frontline health care providers.10 Identifying an infectious disease emergency requires that they maintain a high index of suspicion and rapidly implement response actions if they suspect an event. They should familiarize themselves with the clinical presentation, mode of transmission, and patient management of the diseases most likely to result from a bioterrorism attack. It is also helpful to become familiar with emerging pathogens, such as West Nile Virus, SARS, Monkeypox, and avian influenza.

However, it is impossible to know the clinical description of some new or emerging pathogens because little is known about them. In addition, it is not feasible to memorize all of the information necessary to respond to these various diseases. Therefore, it is best that they familiarize themselves with the basic epidemiological principles that might indicate an infectious disease emergency has occurred and identify accurate sources for information that can be consulted quickly.

The following clues might suggest that a bioterrorism attack or outbreak of an emerging pathogen has occurred in a community:

  • There is an influx of patients presenting with similar symptoms, especially if the symptom pattern includes unusual rashes, flu-like syndromes, or respiratory symptoms.
  • There is an increase of extremely ill patients and/or unexplained deaths in normally healthy individuals. One example is a previously healthy 30-year-old who develops a severe unknown illness that rapidly progresses to death.
  • A patient develops a disease with an unusual or impossible pathogen for your region. For example, plague is a bacterial infection that only occurs naturally in southwestern United States. If a case of plague occurs in the Midwest or Northeast and the person has no other risk factors (such as working in a laboratory, an animal exposure, or recent travel history to an endemic area), they should initiate an investigation.
  • Animals begin dying unexpectedly in the community. Some diseases that infect humans also can infect animals. For example, anthrax infects both cattle and humans. If cattle begin dying unexpectedly and the cause is found to be anthrax, bioterrorism should be a consideration; the unexpected death of cattle could be a precursor to human deaths. This is also true for emerging pathogens. The deaths of crows and blue jays are an early indication of West Nile Virus in a region and generally occur before the onset of human cases.

Patient diagnosis is not the responsibility of ED or OH nurses, nor is it within the scope of nursing practice. Therefore, the nurses do not need to establish a patient diagnose to recognize an infectious disease incident may be occurring. Instead, nurses should be familiar with the baseline health of their population and identify any increasing health trend. In that way, an early outbreak may be identified. For instance, ED and OH nurses should be aware of the approximate number of patients they encounter each day or who call in sick to work with flu-like symptoms. This number probably will fluctuate throughout the year because influenza season is typically October through March. Therefore, they would expect to see an increase in patients presenting to the ED or missing work due to flu-like symptoms during these months. However, if there is a sudden increase in patients with flu-like symptoms or worker absenteeism during summer months, an investigation is warranted.

OH nurses should track absenteeism rates and symptom patterns of sick workers in order to determine baseline illness patterns in their population. In the event of an infectious disease emergency, occupational health nurses may be the first to recognize an unusual event is occurring because sick persons are likely to call in sick to work during early disease onset, a day or more before they will seek medical care.10

As nurses, we represent the backbone of the health care system. It is essential that we have a core understanding of infectious disease emergencies and begin to use the strengths that characterize nursing. These strengths include the ability to evaluate situations and use evidence on which to base our actions. Early identification of an infectious disease emergency is one example of using nursing skills to strengthen emergency preparedness.

During an infectious disease emergency, nurses certainly will bear the burden of patient management. Because of this, the need for infectious disease emergency preparedness has become a national priority and a moral imperative for all nurses. One topic necessary for ED and OH nurses' preparedness has been discussed in this article, but nurses must take the initiative to learn more about disaster preparedness and incorporate these skills into everyday practice.

1. United States General Accounting Office. (2003). Bioterrorism. Public health response to anthrax incidents of 2001 (GAO-04-152). Washington, DC: United States General Accounting Office.

2. Barnes, K. (2001). Cost of anthrax attacks 'surges'. Retrieved from Web site Jan. 27, 2005: http://news.bbc.co.uk/1/hi/world/americas/1629872.stm.

3. Kaufmann, A. F., Meltzer, M. I., & Schmid, G. P. (1997). The economic impact of a bioterrorist attack: are prevention and postattack intervention programs justifiable? Emerging Infectious Diseases, 3, 83-94.

4. Sigmon, H. D., & Larson, E. L. (2002). Research opportunities in biodefense for the National Institute of Nursing Research. American Journal of Infection Control, 30(8), 490-494.

5. Altman, L., & Kolata, G. (2002, January 8). Anthrax missteps offer guide to fight next bioterror battle. NY Times, p.1.

6. Health Canada. (2003). Chapter 5: Building capacity and coordination: National Infectious Disease Surveillance, Outbreak Management, and Emergency Response. In: SARS in Canada. Pages 1-29. Retrieved from Web site on March 7, 2004.

7. Lingappa, J. R., McDonald, L. C., Simone, P., & Parashar, U. D. (2004). Wrestling SARS from uncertainty. Emerging Infectious Diseases, 10, 167-170.

8. McDonald, L. C., Simor, A. E., Su, I. J., Maloney, S., Ofner, M., Chen, K., Lando, J. F., McGreer, A., Lee, M., & Jernigan, D. B. (2004). SARS in healthcare facilities, Toronto and Taiwan. Emerging Infectious Diseases, 10(5), 777-781.

9. Sterling, D. A., Clements, B., Rebmann, T., Shadel, B. N., Stewart, L. M., Thomas, R., & Evans, R. G. (2005). Occupational Physician Perceptions of Bioterrorism. Journal of Hygiene and Environmental Health, 208, 127-134.

10. Gwerder, L. J., Beaton, R., & Daniell, W. (2001). Implications for the Occupational and Environmental Health Nurse. American Association of Occupational Health Nurses Journal, 49, 512-518.

This article appeared in the November 2005 issue of Occupational Health & Safety.

This article originally appeared in the November 2005 issue of Occupational Health & Safety.

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