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Vol. 7 •Issue 21 • Page 21
The Learning Scope


Nurses play a critical role in early recognition: A Texas case study

This offering expires in 2 years: September 26, 2007

The goal of this continuing education offering is to demonstrate operational responses to a public health emergency as well as the process and decision-making involved by many levels within and outside the healthcare delivery system. After reading this article, you should be able to:

1. Appreciate the challenges of detecting and identifying a public health emergency and determining whether it is a natural phenomenon or a suspected bioterrorist event.

2. Discuss the operational responses to a public health emergency.

3. Differentiate between category A, B and C agents.

4. List at least five indications that might suggest an intentional release of a biological agent.

You can earn 2 contact hours of continuing education credit in three ways: 1) For immediate results and certificate, go to Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $15 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. Make checks payable to Merion Publications Learning Scope (any checks returned for non-sufficient funds will be assessed a $25 service fee). 3) Fax the answer sheet (available with credit card payment only) to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 011-3-H-04), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. also is approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

Editor's note: This article fulfills a continuing education requirement for Texas nurses, who are required to earn contact hours in specific material on bioterrorism. While this article addresses a Texas case study, it contains valuable information for all nurses and can be used for contact hours in most states.

Saturday, July 17

Midsummer continues to grip Austin, TX, with very hot days and nights, so July entertainment activities tend to be held outdoors in the evenings or in air-conditioned facilities. Events include several art exhibits, food festivals, concerts and a variety of sporting events. This weekend features an art exhibition and Summerfest, a Sunday music festival featuring local talent.

Monday, July 19, 10 p.m.

Throughout the afternoon, a number of patients with high fevers, chills, headaches and coughs present themselves at healthcare facilities throughout the region. Although epidemics of influenza A and B have resulted in elevated mortality rates throughout the year, these cases represent a significant increase over what is typically seen at this time of year.

At Brackenridge Hospital, a physician working the evening shift is examining a patient, a 17-year-old male from South Austin. The boy's mother says her son developed a high fever this afternoon and has been unable to sleep due to a terrible cough with frequent expectoration and a painful headache.

Like most of the other patients seen during the day, the physician sends him home with instructions to rest, drink plenty of fluids and follow recommendations consistent with treating influenza. After the boy leaves, a nurse comments to the physician that these flu cases seem worse than normal.

Central Role for Nurses

The above scenario is part of a tabletop exercise that demonstrates the challenges of detecting and identifying a public health emergency and determining whether it is a natural phenomenon or a suspected bioterrorist event. Nurses can surmise their role depending on their level of involvement within the healthcare system.

The terrorist attacks of Sept. 11, 2001, and subsequent anthrax attacks changed how Americans view safety and security. Since then, the nation has focused on strengthening national security and emergency readiness. As part of America's vital healthcare infrastructure, nurses play a central role in that effort.

The attacks redefined the meaning of disaster readiness for all nurses. The nursing profession is compelled to be knowledgeable and participate in plans for what previously was unthinkable — intentionally inflicted disasters, involving large numbers of casualties and including the possibility of the use of chemical, biological or radiological agents. Time and energy must be invested to integrate bioterrorism possibilities into our routine practice and to know more about disaster management and response, especially in our own communities.

Increasing Number of Patients

Monday, July 19, midnight

A 25-year-old female with severe dyspnea and delirium is admitted to a local hospital. Upon examination, she is found to have chills and a fever of 103º F. Bacterial and viral blood cultures are ordered and the patient is started on a course of antibiotics. However, in the early morning, her condition progressively worsens. By 0700, she becomes increasingly unresponsive and slips into a coma.

Tuesday, July 20, 8 a.m.

An increasing number of patients, self-referred and transported by ambulance, complain of headache, muscle pain, malaise, shaking chills, prostration and gastrointestinal symptoms. Physicians continue to treat for influenza. Many are instructed to follow up the following week and return if symptoms worsen. Severe cases are admitted to city hospitals for observation and care.

Making the Call

Frontline clinicians may be the first to identify a possible bioterrorism attack. However, many pathogens produce early symptoms that mimic naturally occurring diseases. Some findings are so ubiquitous that rarely does a provider become suspicious, conduct an Internet search, or order further laboratory or radiographic tests early in the course of the disease. Many nurses have not evaluated, treated or cared for patients with many of the diseases produced by these agents.

Since a delay occurs between exposure and symptoms, patients present at various times to various care providers, rather than simultaneously to one location, making diagnosing and early treatment difficult.

Bioterrorism Defined

Bioterrorism is the dispensing of disease microbes by individuals, groups or governments for the express purpose of causing harm for ideological, political or financial gain.

Biological agents are infectious microbes or toxins that can produce illness or death in people, animals or plants. Biological agents can be dispersed as aerosols, liquid droplets, dry powders or airborne particles. Terrorists may use biological agents to contaminate food or water because they are extremely difficult to detect, are relatively inexpensive and do not require sophisticated technology to produce or deliver.

The CDC defines three categories — A, B or C — of biological agents with potential to be used as weapons, based on ease of dissemination or transmission, potential for major public health impact, potential for public panic and social disruption, and requirements for public health preparedness. The categories are ranked according to virulence and potential to cause public harm (see for complete listings of category A, B and C agents).

Agents in category A have the greatest potential for adverse public health impact with mass casualties, and most require improved surveillance and laboratory diagnosis and stockpiling of specific medications. Category A agents also have a moderate-to-high potential for large-scale dissemination or a heightened general public awareness that could cause mass public fear and civil disruption.

Most category B agents also have some potential for large-scale dissemination with illness, but are generally less severe and would be expected to have lower medical and public health impact. Biological agents that affect food and water safety are included in this category.

Category C agents are not believed to present high risk to the public, but could emerge in the future. Although these agents have not been "weaponized," they could have the potential for high mortality and morbidity.

Identical Symptoms

Tuesday, July 20, 3 p.m.

The volume of calls for EMS continues to increase during the day. Other hospitals are experiencing an increasing number of sick. Shortly after 3 p.m., the 25-year-old female admitted earlier has circulatory collapse and respiratory failure. Efforts to revive her are unsuccessful, and she is pronounced dead at 3:10 p.m.

Tuesday, July 20, 5 p.m.

City EDs note a continuing increase in the number of patients being brought in with severe flu-like symptoms and related complications. More of the hospitalized patients admitted earlier in the day have developed severe pneumonia, dyspnea, high fever and hemoptysis. Many others who were treated and released are returning as their conditions deteriorate. The Austin/Travis County EMS system is receiving information from hospitals outside Austin on the increase of patients with identical symptoms.

Time Lag Possible

In biological terrorism, the length of time from the onset of attack to the presentation of victims of the attack may be significant. For example, depending on the agent, the incubation period can be up to 60 days. It is highly probable that hospital staff, dermatologists, primary care/urgent care providers, school nurses, clinic staff, pharmacists and/or dentists may be among the first to recognize a bioterrorism event secondary to the unfolding epidemiology and gradual increase in attack rates of a communicable agent.

The initial signs and symptoms of many of the most deadly agents often are so subtle and nonspecific that many victims will present to a clinic or ED for treatment of flu. To help providers, a syndromic diagnostic approach is advocated by the CDC, focusing on the combination of symptoms a patient reports and the signs observed, as the most accurate method of recognizing a biological attack and other emerging infections.

Sending Samples

Tuesday, July 20, 5 p.m.

An astute nurse remembered a continuing education class on bioterrorism and visited the CDC Web site to obtain information and help with her differential diagnoses for what she suspected could be a bioterrorist event. Blood samples were drawn. She shares the information from the CDC with others on her staff and other hospitals.

Any patient suspected of having any of the category A diseases should have blood and other fluid samples sent to a confirmatory laboratory that is part of the Laboratory Response Network for Bioterrorism. A state or local health department or the CDC will be able to direct the clinicians to a laboratory that is part of the network within their region. For state and territorial public health laboratory contact information, see

Incident System Activated

Tuesday, July 20, 9 p.m.

At one of the hospitals, two maintenance workers from city services admitted earlier in the day are in the ICU with severe pneumonia and high fever. Because a number of hospitalized patients are exhibiting similar symptoms as well as sudden and rapid deterioration, the attending physician orders multiple lab tests and cultures and notifies hospital infection control personnel.

Area hospitals and clinics begin to use the emergency management operation phones to discuss information on patient load, bed status, hospital closures and hospital diversion status.

At this point, hospitals would use their Hospital Emergency Incident Command System (HEICS). This system, adapted from a system used by fire protection agencies, was developed to help institutions strive for efficient operations when faced with an extraordinary crisis. A medical disaster within the community; a sudden, unforeseen shortage of resources; a severe compromise of the hospital's environment — these are just some of the conditions that may jeopardize an institution's performance and possibly have a bearing on the morbidity and mortality of people affected by the disaster.

HEICS provides an incident command within the hospital's chain of command system, under which all nurses and physicians will work during an emergency. It uses standardized language to promote communication and efficiency both inside the hospital and with outside entities.

Raising Further Suspicion

The University of Texas student health center also is inundated with students showing flu-like symptoms. All beds at the health center are full. With high numbers of student and faculty absenteeism, it is unclear whether classes will be canceled.

The emergency operations duty officer, noticing an increase in activity in EMS and the hospital status, initiates a partial activation of the emergency operations center (EOC).

Tuesday, July 20, 9:15 p.m.

A patient is brought into another hospital and goes into cardiac arrest shortly after arrival. The ED staff tries to revive him, but without success. He is pronounced dead at 9:30 p.m. The patient's wife states he called in sick to work on July 19 and 20. He was complaining of fever, chills, cough and dyspnea. Although the deceased was asthmatic, he had no history of cardiac problems, was only 35 years old and was in good physical condition. His wife reports her husband worked concessions during the last Summerfest concert on July 18. A postmortem is ordered by the medical examiner.

Healthcare providers may be the first people to recognize whether a client presentation is either typical or unusual of an infectious disease. The epidemiological pattern (unusual infection disease outbreak and any clustering) will probably be the main sign that a bioterrorism attack has occurred, so healthcare providers need to have a high index of suspicion. This may be a challenge, as busy staff may have difficulty picking up signs and symptoms of diseases that can take days or weeks to develop, are nonspecific and occur in patients of different ages presenting at different locations.

The covert release of a biological agent may not have an immediate impact because of the delay between exposure and illness onset, and outbreaks associated with intentional releases might closely resemble naturally occurring outbreaks. This delay in onset of symptoms is one of the reasons the use of biological agents is attractive to terrorists, because it allows the terrorist to escape the area before detection. The speed and accuracy with which healthcare workers recognize and report the suspicion of biological agent use can directly impact mortality and morbidity.

Pattern Emerges

Tuesday, July 20, 11 p.m.

The EMS medical director updates the county health authority that the city still is experiencing a dramatic increase in calls to EMS. Most of the callers describe victims with severe flu-like symptoms, including high fever, severe headache and respiratory distress. The EMS medical director confirms to the county that area hospital admissions show a similarly troubling increase.

The CDC indicates that the following might portend an intentional release of a biologic agent:

• unusual geographical clustering of unusual illness, deaths of people or animals; or

• unusual age distribution of illness.

Wednesday, July 21, 6 a.m.

Austin hospitals report 150 patients requiring ICU treatment. Hospitals cannot accept additional patients requiring critical care. The Texas Department of Health is notified. A charge nurse notes the majority of patients admitted to her hospital attended the Summerfest event on July 18.

Wednesday, July 21, 8 a.m.

Several EMS workers, ED nurses and other hospital employees who were on duty yesterday have called in sick.

The EMS medical director continues to record a dramatic increase in the number of ambulance requests. To date, more than 375 people have been transported to area hospitals. Approximately 50 deaths have been reported. The majority of deaths are the result of circulatory collapse and respiratory failure.

Based on signs and symptoms, and after consultation with the Texas Department of Health, the county health department believes the illnesses to be the consequences of an unknown pathogen. The mayor, city council, county commissioners, county judge and director of Austin's Office of Emergency Management are updated. After the briefing, the mayor signs a city disaster declaration.

Mass Casualty Disasters

Multiple casualty disasters are characterized by significant loss of life and/or injury, and often exceed the ability of normal local community resources to effectively manage the response. Mass casualty disasters overwhelm the resources of individual hospitals and/or a community's entire healthcare system.

Mass casualty disasters demand more than the typical incident command system response structure. In large disasters, the local government will activate its EOC. The local EOC mobilizes and coordinates government and other agency resources. Representatives involved in response come together to share information and coordinate needs.

Wednesday, July 21, 2 p.m.

The number of seriously ill and dying is increasing throughout the city and region. Frantic calls from citizens reporting deaths at home also are increasing. EMS is unable to keep up with requests for emergency assistance and patient transport. The hospitals in Austin are overwhelmed and additional bed space is being sought.

The Texas Department of Health contacts the CDC for advice and possible assistance. Media sources are sending crews to the hospitals. Evening newscasts on the major broadcast networks lead with reports on an unexplained "epidemic" in Austin.

Mass casualty incidents can have a variety of causes, but share some common characteristics:

• The number of patients may be out of proportion to the available rescue and healthcare personnel and transport means.

• Victims are found, triaged and treated at the scene or hospitals.

• Special morgue operations are initiated.

• Next of kin and families need assistance.

• Media interest will be considerable.

• There is heavy use of a wide range of healthcare providers (hospitals, public health, mental health).

• Governmental regulatory agencies are involved.

• Evacuations and mass sheltering may be required.

• There are immediate and long-term emotional needs.

• There is damage to the local economy.

Wednesday, July 21, 8 p.m.

Media reports heighten anxiety, and some citizens begin seeking medical attention although they are asymptomatic. Others, fearing contagion, begin self-evacuating from the city. Several major traffic jams and accidents are reported as people leave the city or try to get to area medical facilities.

Wednesday, July 21, 9 p.m.

There are now approximately 90 dead and 615 showing pneumonia-like signs and symptoms in various degrees of severity. There are calls to EMS and the police department for the removal of deceased victims throughout the city, including a number in downtown hotels and office buildings. The number of "worried well" reporting to healthcare facilities is not yet estimated.


According to the FBI, terrorism is the use of force or violence against people or property in violation of the criminal laws of the United States for purposes of intimidation, coercion or ransom.

Following a bioterrorism-related event, fear and panic can be expected from both patients and healthcare providers. Psychological responses following a bioterrorism event may include horror, anger, panic, unrealistic concerns about infection, fear of contagion, paranoia, social isolation or demoralization.

Mental health support personnel (e.g., psychiatrists, psychologists, mental health nurses, social workers, clergy and volunteer groups) can be mobilized. Local, state and federal media experts can provide assistance with communication needs.

Thursday, July 22, 6 a.m.

Autopsy results on the 35-year-old male from one hospital show the cause of cardiac arrest was a fulminating Gram-negative bacillary pneumonia. Another hospital reports that Yersinia pestis was cultured from the 25-year-old female who died July 20. The hospital's chief pathologist is alerted and orders the test repeated and cultures on all upper respiratory cases. The city and county health departments are notified of the findings. They, in turn, notify the Texas Department of Health, which notifies the CDC. The police department and the FBI also are notified. They immediately suspect biological terrorism.

Biological Agent

Y. pestis, a rod-shaped, nonmotile, non-sporulating, Gram-negative, bipolar-staining, facultative anaerobic bacterium, causes plague. Plague is transmitted from rodent to man via the bite of an infected flea, but also can be transmitted between humans via inhalation of droplets after purposeful aerosol dissemination of the organisms (and by coughing).

After an incubation of 1-4 days, early clinical features of pneumonic plague include severe malaise, high fever, headache, ecchymosis, cough with muco-purulent sputum (Gram-negative rods may be seen on Gram stain), hemoptysis and chest pain. A chest X-ray will show evidence of bronchopneumonia. The disease progresses rapidly and the victim dies from respiratory failure and circulatory collapse.

Highly contagious, both standard and droplet precautions are used. Antibiotics should be given within 24 hours of the first symptoms. Antibiotic of choice is streptomycin, 30 mg/kg/day for 5-7 days or gentamicin (5 mg/kg IM or IV once daily).

In a mass casualty setting, parenteral therapy may not be possible, so oral therapy, preferably with doxycycline (100 mg orally twice daily) or ciprofloxacin (500 mg orally twice daily) for 10 days should be administered. Tetracycline is also effective. The penicillins are not effective.

Patients with pneumonic plague should be isolated until they have had at least 48 hours of antibiotic therapy and have shown clinical improvement. If large numbers of patients make isolation impractical, groups of patients may be quarantined. Patients should wear tight-fitting disposable surgical masks while they are being transported.

People having direct and close contact with someone with pneumonic plague should wear tight-fitting disposable surgical masks. Other respiratory droplet precautions (gown, gloves and eye protection) also should be used by individuals caring for pneumonic plague cases.

Anyone who has had close contact (2 m or less) with people having untreated pneumonic plague also should receive post-exposure prophylaxis and be monitored for fever and cough. Doxycycline (100 mg orally twice daily) is the first-choice antibiotic for post-exposure prophylaxis and should be given for 7 days. Tetracycline, fluoroquinolones, sulfonamides and chloramphenicol are alternative antibiotics.

Once plague is confirmed or strongly suspected in a particular area, anyone in that area with fever (of 38.5º C or higher) or cough should be treated immediately for presumptive pneumonic plague.

Resources Mobilized

Thursday, July 22, 6 a.m.

With the passage of another week, massive resources continue to pour into the area. The public and private sectors are cooperating; meanwhile, the number of deaths continues to climb. Elected officials, religious leaders and other organizations, e.g., American Red Cross, are leading efforts to muster aid and extend sympathy and support.

Thursday, July 22, 8 a.m.

With the dramatic rise in deaths (now 200), health departments, police and FBI launch an epidemiological investigation to identify the source. CDC is scheduled to arrive. The governor, after consulting with city and state officials, requests federal assistance and activation of the National Disaster Medical System, and deployment of specialized teams including disaster medical assistance teams, disaster mortuary teams and the national medical response teams.

Thursday, July 22, 2 p.m.

In consultation with his cabinet, the president declares a federal emergency. The White House directs FEMA and the FBI, in close cooperation with the Department of Health and Human Services (HHS) and other federal agencies, to provide assistance to state and local authorities.

CDC, in conjunction with the U.S. Public Health Service, notifies state public health agencies across the country of the public health emergency and identifies a 24-hour reporting number for the identification of possible pneumonic plague victims in their states. Immediate information on the care and treatment of pneumonic-plague infected victims is disseminated as widely as possible to healthcare providers.

HHS and other supporting federal agencies under Emergency Support Function #8 (Health and Medical Services) of the Federal Response Plan assist with medical services and support. Law enforcement agencies are put on alert across the country for the possibility of additional terrorist attacks.

Bioterrorism Preparedness & Response

The Department of Justice, acting through the FBI, is the lead agency for managing the federal response to a terrorist incident or threat, as well as the lead agency in charge of crisis management during a terrorist event or a credible threat to public safety.

HHS provides technical assistance to the FBI during all phases of threat assessment and alerts law enforcement if the threat first appears in the health arena in the form of unexplained illness or death.

FEMA is the lead federal agency in charge of consequence management. As in other types of disaster responses under the Federal Response Plan, FEMA would request HHS to provide necessary health, medical and health-related services to the victims.

Thursday, July 22, 5 p.m.

A fax is sent to all major news organizations in Austin. The authors, claiming to be members of a previously unknown terrorist group, take credit for releasing wet plague in the city of Austin. National and international media are consumed by the story. They provide a steady stream of alarming and frequently inaccurate reports on the potential consequences of the attack. Analysts openly speculate over the airwaves that additional attacks could occur.

Thursday, July 22, 9 p.m.

With a public disclosure of a possible plague attack, the president goes on national television to assure Austin residents and citizens across the country that the full resources of the nation have been mobilized to care for the victims of the attack and to apprehend the perpetrators. Reactions range from fear and anger to total panic. Thousands of residents flee the city, while many more converge on city hospitals and clinics demanding treatment.

Thursday, July 22, 11 p.m.

Reports bring the total number of identified pneumonic plague cases to nearly 700. Of those cases, 400 have died. Demand for antibiotics greatly outstrips available local supplies. First responders and most hospital staffs are reaching the point of exhaustion.

Strategic National Stockpile

As part of the federal initiative to address local and state deficiencies in the capability to respond to a bioterrorism attack, the Office of Emergency Preparedness of the HHS established National Medical Response Teams, and the CDC instituted the Strategic National Stockpile (SNS) program.

The SNS program works with governmental and non-governmental partners to upgrade the nation's public health capacity to respond to a national emergency. The SNS is a national repository of antibiotics, chemical antidotes, antitoxins, life-support medications, IV administration, airway maintenance supplies and medical/surgical items. The SNS is designed to supplement and re-supply state and local public health agencies in the event of a national emergency anywhere and at anytime within the United States or its territories.

Casualty Reports for Austin as of July 31:

Total number of people seen by medical community = 7,823

Symptomatic/currently hospitalized = 368

Examined and released (asymptomatic, worried well, psychosomatic, presymptomatic) = 6,750

Total deceased = 1,073

One of the most troubling issues facing the community is the short- and long-term management of victims still in need of medical and mental health attention.

At the Forefront

Nurses need to be resources to the community. Being a resource means having enough information about biological, chemical, nuclear and incendiary ways terrorists may want to inflict harm on innocent civilians. Nurses also need to know how their local community prepares and responds to disasters and where they, as nurses, based on skills, abilities and knowledge, can fit.

Chaos usually reigns in emergencies, and confusion can be compounded if the disaster site is considered a crime scene. Many players from different levels of government, private and public organizations and others will add to the complexity of response. It is easy to get overwhelmed if caught unaware.

Nurses are at the forefront of bioterrorism preparedness. We play a critical role in early recognition, keeping ourselves and our families safe, and allaying anxieties of our neighbors and community. Nothing arouses the concern of emergency planners more than the possibility of the use of biological agents as an act of war or terrorism. In a large-scale covert incident, nurses and other healthcare providers play a first-responder role in the detection, evaluation and response to a biological threat.


American Red Cross. Disaster services. Retrieved March 28, 2005 from the World Wide Web:,1082,0_319_,00.html

CDC. Agents, diseases and other threats. Retrieved March 28, 2005 from the World Wide Web:

Emergency Management Institute. EMI courses and schedule. Retrieved Sept. 1, 2005 from the World Wide Web:

Koenig, K., & Boatright, C. (2003). Derm and doom: The common rashes of chemical and biological terrorism. Critical Decisions in Emergency Medicine, 17(6).

O'Byrne, W., et al. (2003). A primer on biological weapons for the clinician, part 1. Advanced Studies in Medicine, 3(2), 75-85.

O'Byrne, W., et al. (2003). A primer on biological weapons for the clinician, part 2. Advanced Studies in Medicine 3(3), 157-166.

Marilyn Pattillo is an assistant professor at the University of Texas at Austin. She serves on the Austin Travis County Interagency Disaster Council, representing the University of Texas in planning and training of the Austin and the University of Texas response in the event of mass casualties. The author wishes to acknowledge the U.S. Department of Defense and Steve Collier and Lindy McGinnis of the City of Austin Office of Emergency Management. Collier heads the coordination of the citywide response to large-scale emergencies and disasters. This includes planning and activities for preparedness, response and recovery phases of a disaster.


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