Assist in the Epidemiologic Investigation and Manage the Psychological Consequences
The intensive care team will likely be the first caregivers with an opportunity to obtain detailed
information from the patient and/or family. Accurate history-taking (food and water sources,
occupation, place of employment, travel, modes of travel and commuting, human and animal
contacts, etc.) is essential. A comprehensive list of hospital personnel, caregiver, and visitor
contacts in the intensive care unit must be compiled as soon as the patient arrives at the
institution. Data on ambulance personnel or individuals transporting the patient should be
gathered upon the patient’s arrival. Protocol should exist detailing the regular and frequent
updating of this data, at least for every hospital shift. The number of different caregivers and
visitors for the suspect patient should be limited as much as is practical until an etiologic
diagnosis is established.
The intensive care unit team must consider the distinct possibility that an early casualty
may be one of the perpetrators. Clinical specimens should be clearly labeled and preserved for
laboratory examination. Establishment and implementation of protocols forchain-of-evidence
should be undertaken (99). Usually, the most difficult aspect of chain-of-evidence is
identification of the evidence by the individual who collected it.
Clothing and personal items may have already been collected from the patient elsewhere.
All clothing and personal items must (i) be considered contaminated, and (ii) must be
preserved as possible evidence. Patient specimens for culture and analysis should be treated as
evidence. They need to be clearly labeled and initialed by the individual collecting them.
Transportation to the laboratory should not be through the routine messenger service, but by a
person who is familiar with the chain-of-evidence protocol, and is prepared to document the
hand-off to the laboratory personnel. Methods of dealing with the psychological effects of a
bioterrorist threat is discussed elsewhere (100).
Maintain Proficiency and Spread the Word
Participation in disaster planning and drills is essential for effective and safe treatment of
victims of bioterrorism. Your institution’s disaster plan should be at hand (1). USAMRIDD’s
Medical Management of Biological Casualties Handbook,6th edition is both concise and a
sufficiently comprehensive reference manual that can easily be kept on-hand in clinical areas.
It is available online from any computer in the institution with Internet access.
SELECTED PATHOGENS (58)
A single death is a tragedy; a million deaths is a statistic.
—Joseph Stalin (December 18, 1878–March 5, 1953)The illnesses that are most likely to result in the need for “mass” critical care are
influenza, severe acute respiratory syndrome (SARS), viral hemorrhagic fevers, smallpox,
plague, tularemia, and anthrax. To this list, we add rabies, a pathogen that appears to be little
appreciated as a possible bioterrorist’s weapon. The virus should be classified as a Category A
agent: it is well known to the public, feared, widespread through nature, can be spread person-
to-person, may be disseminated by airborne means and through the gastrointestinal tract, has
practically a 100% mortality, and rabies vaccination is viewed by the public with great
apprehension.
Influenza and (H5N1) Avian Influenza (37,54,101,102)
H5N1 avian influenza virus is a single-stranded minus-sense RNA virus of the Orthomyx-
oviridae genus. Free-ranging waterfowl are the natural reservoir. Most naturally occurring
cases involved individuals with direct or indirect contact with poultry. The first cases occurred
in Hong Kong in 1997 (18 cases). A second wave of infection occurred in 2001 in poultry, while
human cases again occurred in February 2003 (37,101). Human-to-human transmission of this
wild-type virus does occur, but very inefficiently (54).
Incubation period: The incubation period after contact with a sick or dead bird is two to eight
days (54). Patients were ill an average of four days (2.9 days) before seeking medial care (37).
Contagious period: : Duration of illness. The World Health Organization (WHO) and the
CDC recommend contact and airborne precautions for all suspected cases (54). Respiratory
Bioterrorism Infections in Critical Care 473