Decontaminate as Appropriate
Under most circumstances, victims of a bioterrorist attack will present hours or days later.
Patients will be triaged and screened in the emergency department where all clothing will be
removed and preserved for testing and as evidence. Decontamination of the patient is critical
in the case of a chemical, biologic, or radiologic attack and should take place in a designated
decontamination area, usually outside or adjacent to the emergency department. For most
agents, removal and securing of all clothing and a five- to six-minute shower with soap and
water is sufficient (56). Use of caustic solutions will harm the patient by damaging the skin and
mucous membranes, complicate care, without realizing any advantage in decontaminating the
patient (1). Standard solutions of hypochlorite are adequate to clean any surfaces contaminated
with any potential pathogen,but should never be applied to the patient(1,57).
Establish a Diagnosis
The most definitive diagnostic test for each pathogen is listed in Table 9 (1,6,11,58–71). It is
important to consider the possibility that the victim of bioterrorism may be infected or
poisoned by more than one agent. Combinations of bacterial and viral agents, and/or agents
with widely different incubation periods may be purposely employed to add confusion and
increase the lethality of the attack. Incubation periods in some cases are dose dependent
(72–74). Exposure concentrations will vary according to whether the pathogens are released
indoors or outdoors, air flow [status of a building’s heating ventilation air-conditioning
(HVAC) system] or wind, weather (sunlight, rain, relative humidity), distance from the point
of release, and, time when entering or remaining in a contaminated area or atmosphere after
release. In the case of the use of two or more agents, their individual physical properties may
allow for different distribution properties, and even organisms with similar incubation periods
may present at widely different times. Relapses may be part of the disease course or the
presentation of a second disease or intoxication.
Render Prompt Treatment
Table 10 outlines the recommended treatments for each of the pathogens (1,6,11,23,29,58–60,
75–98). Presumptive therapy and precautions must be initiated as soon as possible. As was our
experience during the Trenton-anthrax threat of 2001, definitive recommendations will come
from public health authorities once the pathogens are identified with sufficient certainty.
Practice Good Infection Control
Standard precautions are usually adequate to manage most patients with anthrax, tularemia,
brucellosis, Q fever, Venezuelan equine encephalitis, and toxin-mediated diseases. Table 4 lists
isolation precautions for potential threats.
Hand washing is the most basic and key component to infection control. A study
utilizingBacillus atrophaeusas a surrogate forB. anthracisspores found that hand washing
using a nonantimicrobial soap under running water or antibacterial (2% chlorhexidine
gluconate) agents was far superior to waterless hand hygiene agents containing alcohol. After
10 seconds of washing, there was no difference in reducing the spore count between the
antimicrobial soap and plain soap. There was also no difference between either soap by
increasing washing from 10 to 60 seconds. Chlorine-containing microfiber towels were inferior
to hand washing at 10 seconds duration, but superior at 60 seconds duration (56).
Alert the Proper Authorities
The hospital administration should notify local, municipal, state, and federal health and law
enforcement authorities. Bypassing the institutional chain-of-command and protocol will lead to
confusion, misinformation, and delay in responding appropriately. The first line of notification
in most if not all institutions is infection control or the designated institutional individual for any
suspected cases of a contagious disease, whether or not bioterrorism is suspected. All personnel
on all shiftsshould be familiar with the institution’s individual protocol.
(text continues on page 473)466 Cleri et al.