International Council of Nurses [Fact Sheet - Terrorism and Bioterrorism]

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Terrorism and Bioterrorism:
Nursing Preparedness

The September 11 terrorist attacks in New York City and Washington, DC, and the subsequent anthrax outbreak, have heightened attention to the growing threats of terrorism, including chemical, and biological agents as weapons of terrorism. Nurses and other health personnel need to be aware and vigilant to the health consequences of terrorism and the potential use of these biological agents to instil fear and to spread disease.

What People May Experience Following a Terrorist Attack
People who have experienced or witnessed a terrorist attack may respond with acute stress reaction. They may feel one or all of these symptoms: ¹

Recurrent thoughts of the attack
Fear of everything, refusal to leave the house, or isolating oneself
Survivor guilt -- "Why did I survive? I should have done something more."
A sense of great loss
Reluctance to express feelings, losing a sense of control over life

What Nurses and Others Can Do to Help Victims of Terrorism
The ICN policy paper on Disaster Preparedness outlines actions, including risk assessment and multi-disciplinary management strategies, as critical to the delivery of effective responses to the short, medium, and long-term health needs of a disaster-stricken population ². In the event of terrorist attacks nurses and other health professionals need to work with other groups and the public to address concerns and provide health services. These include:

Help people to cope with aftermath of terrorism ³.

Assist people to deal with feelings of fear, vulnerability, and grief.
Use groups who have survived terrorist attacks as useful resource for victims.

Allay public concerns and fear of bioterrorism.

Disseminate accurate information on the risks involved, preventive measures, use of antibiotics, vaccines, reporting suspicious letters or packages to the police or other authorities.
Address hoax messages, false alarms and threats and any perceived threat to the public health must be investigated.

Identify the feelings that you and others may be experiencing.

In the aftermath of terror even health care professionals can feel bias, hatred, vengeance, and violence towards ethnic or religious groups that are associated with terrorism. These feelings can compromise their ability to provide care for these groups. Yet as the ICN Code of Ethics for Nurses affirms, nurses are ethically bound to provide care to all people ⁴.
Explain that feelings of fear, helplessness and loss are normal reaction to a disruptive situation.
Work with people and help them think of what they did that helped them overcome fear and helplessness in previous situations.
Encourage people to talk to others about their fears.
Encourage others to ask for help and provide resources and referrals
Remember that those in the helping professions e.g. Nurses, physicians, social workers . may find it difficult to seek help.
Convene small groups in workplaces with counsellors/mental health experts.

Assist victims to think positively and to move to the future.

Remind others that things will get better.
Be realistic about the time it takes to feel better.
Help people to recognise that the aim of terrorist attacks is to create fear and uncertainty.
Encourage people to continue with the things they enjoy in their lives and to live their normal life.

Prepare nursing personnel to be effective in a crisis/emergency situation ⁵.

Incorporate disaster preparedness awareness in educational programmes at all levels of nursing curriculum.
Provide continuing education to ensure a sound knowledge base, skill development, and ethical framework for practice.
Network with other professional disciplines, governmental and non-governmental agencies at local, regional, national, and international levels.

BIOTERRORISM

What agents are most likely to be used in a bioterrorist attack?
A number of bacterial diseases such as anthrax, cholera and plague have been developed as weapons for biological warfare. And viral diseases such as smallpox, plague, equine encephalitis and viral hemorrhagic fevers can also be used in biological warfare. Other biological toxins include tetanus, diphtheria, botulinium and staphylococcal enterotoxin.

According to experts, anthrax is the most likely to be used in a bioterrorist attack. The others, including plague, botulism, smallpox, and viral haemorrhagic fever agents are rated of low probability. ⁶

How easily can these biological agents be spread into the population?
In order to be used as agents of terror, micro-organisms must be "weaponised". This involves packaging and/or treating the agent so that it can be distributed to a large area. For example, manufacturing anthrax spores as a fine powder or aerosol increases the ability of the spores to become airborne and thus inhaled. However while some nations have the capacity to weaponise biological agents for terrorist attacks, the ability for most is limited ^7,8.

Two biological agents often featured in the media as threats are smallpox and anthrax.

Smallpox is caused by the Variola virus and is spread by droplets or aerosols produced by sneezing or coughing. There are no known animal or insect reservoirs for the virus. If aerosolised, the virus is believed to retain its infectivity for at least several hours if not exposed to sunlight or ultraviolet light. ⁹

Small pox can be spread from person to person, but people infected with smallpox virus are generally too sick to move around and spread the infection. Smallpox was eradicated in 1977 and its re-emergence through biological terrorism is unlikely. However, there is agreement that even a single case of smallpox anywhere in the world would be an international public health emergency that would seriously threaten large populations. This is because national vaccination programmes against smallpox were stopped since the early 1980s and, as a result, many people do not have immunity against the disease.

There is an effective vaccine for smallpox. However, WHO believes that because of the high risk of adverse side effects, mass vaccination is not warranted if there is no or little real risk of exposure". ¹⁰

Anthrax is caused by the bacterium, Bacillus anthracis, whose spores can survive in the environment for years. There are three types of anthrax in humans: cutaneous anthrax which occurs when a spore enters the skin through a cut or an abrasion; gastrointestinal tract anthrax, contracted from eating contaminated meat from an infected animal; and pulmonary or inhalation anthrax from breathing in airborne anthrax spores.

As recent events in the U.S.A. have demonstrated, anthrax can be weaponised and distributed through the postal service. Widespread immunization against anthrax is not a feasible option due to side effects, and given the positive response to antibiotics. As a result vaccines are recommended only for high occupational risk or exposure during military operations.

Anthrax is sensitive to antibiotics such as penicillin and doxycycline, which are also used as prophylaxis in high-risk populations. It is vital that people not attempt to use antibiotics to treat or protect themselves without first seeking medical advice as misuse can lead to drug resistance. With early detection and rapid medical intervention, most, if not all, cases of exposure to anthrax spores can be treated and disease prevented.

References

1. Fields, R.M., Margolin, J (2001), American Psychological Association. Fact Sheet on Coping with Terrorism. http://www.apa.org/

2. International Council of Nurses (2001), ICN Position Statement on Nurses and Emergency Preparedness. Geneva; ICN

3. Fields, R.M., Margolin, J (2001), American Psychological Association. Fact Sheet on Coping with Terrorism. http://www.apa.org/

4. International Council of Nurses (2000), Code of Ethics for Nurses. Geneva: ICN.

5. International Council of Nurses (2001), ICN Position Statement on Nurses and Emergency Preparedness. Geneva; ICN

6. Health Canada. http://www.hc-sc.gc.ca

7. Gould R. Assessing the public health response to US bioterrorism initiatives. Program and abstracts of the American Public Health Association 129th Annual Meeting; October 21-25, 2001; Atlanta, Georgia

8. Health Canada. http://www.hc-sc.gc.ca

9. http://www.who.int/

10. Statement WHO/16; 20 October 2001. http://www.who.int

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