Communicable Diseases, Disasters, and Bioterrorism

National Notifiable Diseases

● Anthrax

● Botulism

● Cholera

● Congenital rubella syndrome (CRS)

● Diphtheria

● Giardiasis

● Gonorrhea

● Hepatitis A, B, C

● HIV infection

● Influenza‑associated pediatric mortality

● Legionellosis/Legionnaires' disease

● Lyme disease

● Malaria

● Meningococcal disease

● Mumps

● Pertussis (whooping cough)

● Poliomyelitis, paralytic

● Poliovirus infection, nonparalytic

● Rabies (human or animal)

● Rubella (German measles)

● Salmonellosis

● Severe acute respiratory syndrome-associated

coronavirus disease (SARS‑CoV)

● Shigellosis

● Smallpox

● Syphilis

● Tetanus/C. tetani

● Toxic shock syndrome (TSS) (other than Streptococcal)

● Tuberculosis (TB)

● Typhoid fever

● Vancomycin-intermediate and vancomycin-resistant

Staphylococcus aureus (VISA/VRSA)

agents of bioterrorism

Category A

Category B

Category C

Category A Biological Agents

highest priority - risk to national security because they are easily transmitted and have high mortality rates

Examples include smallpox, botulism, anthrax,

tularemia, viral hemorrhagic fevers (e.g., Ebola),

and plague.

Category B Biological Agents

The second-highest priority because they are

moderately easy to disseminate, and have high

morbidity rates and low mortality rates.

Examples include typhus fever, ricin toxin,

diarrheagenic E. coli, and West Nile virus

Category C Biological Agents

third highest priority - comprising emerging pathogens that can be engineered for mass dissemination because they are easy to produce and/or have a high potential for high morbidity and mortality rates

Examples include hantavirus, influenza virus,

tuberculosis, and rabies virus.

Inhalational anthrax

MANIFESTATIONS:

● Headache

● Fever and chills

● Muscle aches

● Chest discomfort

● Severe dyspnea

● Shock

PREVENTION:

-Anthrax vaccine for those at high-risk for exposure to anthrax.

-Ciprofloxacin and doxycycline are recommended by the CDC for prevention of anthrax following exposure.

TREATMENT:

Antitoxin and IV antibiotics are administered

if manifestations of an anthrax infection are present.

Botulism

MANIFESTATIONS:

● Double or blurred vision

● Slurred speech

● Difficulty swallowing

● Progressive muscle weakness

● Difficulty breathing

No Approved Vaccine for Prevention

TREATMENT:

-Airway management with possible mechanical

ventilation

-Administration of antitoxin

ELIMINATION OF TOXIN: Induction of vomiting, enemas, surgical excision of wound tissue

SUPPORTIVE CARE: Nutrition, fluids, prevent complications

Smallpox

MANIFESTATIONS:

● High fever

● Fatigue

● Head and body aches

● Rash that begins on face and tongue; quickly spreads to the trunk, arms, and legs, then hands and feet; then turns to pus‑filled lesions

● Vomiting

PREVENTION:

-Vaccine for those at high‑risk (provides 10 years of immunity); can vaccinate within 3 days of exposure

-Contact and airborne precautions

TREATMENT: No Cure

SUPPORTIVE CARE: Hydration, pain medication,

antipyretics, antibiotics for secondary infections

Ebola

MANIFESTATIONS

● Fever

● Severe headache

● Joint and muscle aches

● Fatigue and weakness

● Hemorrhage

● Vomiting and diarrhea

● Shock

Prevention:

-No approved vaccine available

-Don impermeable gown or coverall; disposable gloves(two pairs), boot covers, and apron; and an N95 mask.

-Recommend a second caregiver supervise doffing.

-Maintain droplet isolation precautions.

TREATMENT:

-Supportive care IV fluids, dialysis, airway management, psychological counseling.

-Minimize invasive procedures.

Plague

Pneumonic plague: fever, headache, weakness,

pneumonia with shortness of breath, chest pain, cough, and bloody or watery sputum

Bubonic plague: swollen, tender lymph nodes, fever, headache, chills, and weakness

Septicemic plague: fever, chills, weakness, prostration, abdominal pain, shock, disseminated intravascular coagulation (DIC), gangrene of nose and digits

PREVENTION

-Vaccine no longer available in the U.S.

-Contact precautions till decontaminated

-Droplet precautions till 72 hr after antibiotics

TREATMENT: Gentamicin and fluoroquinolones

Tularemia

MANIFESTATIONS:

● Sudden fever, chills, headache, diarrhea, muscle aches, joint pain, dry cough, progressive weakness

● If airborne, life-threatening pneumonia and systemic

infection

Prevention: Vaccine under review by the Food and Drug Administration but not currently available

Treatment

-Streptomycin or gentamicin is the antibiotic of choice.

-In mass causality, use doxycycline or ciprofloxacin.

Delivery Methods for Biological Agents

Direct contact (subcutaneous anthrax)

Simple dispersal device (airborne, nuclear)

Water and food contamination

Droplet or blood contact

ROLE OF THE COMMUNITY HEALTH NURSE

Participate in planning and preparation for immediate response to a bioterrorism event.

Identify potential biological agents for bioterrorism.

Survey for and report bioterrorism activity (usually to the local health department).

Promptly participate in measures to contain and

control the spread of infections resulting from

bioterrorism activity

Assessment of the Threat

Is the population at risk for sudden high disease rates?

Is the vector that normally carries a specific disease available in the geographical area affected?

Is there a potential delivery system within the community?

Recognition of a Bioterrorism Event

Is there a rapidly increasing disease incidence in a

normally healthy population?

Is a disease occurring that is unusual for the area?

Is an endemic occurring at an unusual time? For example, is there an outbreak of influenza in the summer?

Are there large numbers of people dying rapidly with similar presenting manifestations?

Are there any individuals presenting with

unusual manifestations?

Are there unusual numbers of dead or dying animals, unusual liquids/vapors/odors?

PRIMARY PREVENTION: Bioterrorism planning

Prepare with bioterrorism drills, vaccines, and ensuring the availability of antibiotics for exposure prophylaxis.

Design a bioterrorism response plan using the most probable biological agent in the local area.

Identify the chain of command for reporting

bioterrorism attacks.

Define the nursing roles in the event of a

bioterrorism attack.

Set up protocols for different levels of infection control and containment.

SECONDARY PREVENTION: Early recognition

Activate bioterrorism response plan in response to a bioterrorism event.

Immediately implement infection control and

containment measures, including decontamination, environmental disinfection, protective equipment, community education/notification, and quarantines.

Screen the population for exposure, assessing rates of infection and administering vaccines as available.

Assist with and educate the population regarding the identification of manifestations and management (immunoglobulin, antiviral, antitoxins, and antibiotic therapy, depending on the agent).

Monitor mortality and morbidity

TERTIARY PREVENTION: Rehabilitation of survivors

Monitor medication regimens and referrals.

Evaluate effectiveness and timeliness of the

bioterrorism plan