Through several agencies, including the Centers for Disease Control and Prevention (CDC) (2003b), the Federal Emergency Management Agency (FEMA) (2003), and the United States Army Medical Research Institute of Infectious Diseases (USARMIID) (2003), the United States has worked to improve the nation’s capabilities to respond to terrorist acts. The events of September 11, 2001 and the bioterrorism-related anthrax episodes served as wakeup calls to the American government and the public at large that terrorism is a reality. These experiences escalated efforts to better prepare the country.
Bioterrorism is unique among forms of terrorism because it would make significant demands on the country’s public health and health care systems. While it is anticipated that a chemical attack would also be burdensome, bioterrorism would impose an especially stressful load (Moodie, Ban, Manzi, & Powers, 2000). Even so, educational programs that review chemical and biological terrorism often emphasize chemical preparedness to the point that key components of bioterrorism readiness, such as early identification, are overshadowed.
The importance of advance planning, education, and organization is clear. The CDC (2001) recommends heightened surveillance for unusual disease trends or elevated numbers of illnesses that may be associated with terrorist attacks. Hospitals are urged to develop bioterrorism-readiness plans, using a template developed by the Association for Professionals in Infection Control and Epidemiology (APIC), in collaboration with the CDC (APIC & CDC, 1999). In addition, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (2003) standards require accredited organizations to conduct emergency preparedness drills and education on an annual basis. Most accredited schools of nursing do not require this level of preparation.
Early recognition and management of biological attacks are largely dependent on warning networks, such as the public health reporting infrastructure and the clinical expertise of frontline health care personnel. Frontline health care providers need education to identify and manage the biological agents that could be used in biological terrorism. Unfortunately, agents such as smallpox, anthrax, and tularemia are given little or no attention in medical and nursing schools (Bakken, 2002; Moodie et al., 2000).
According to the American Association of Colleges of Nursing (AACN) (2001), nurses are recognized as integral to disaster response efforts. The AACN (2001) is working through strategic partnerships and collaborative efforts to develop bioterrorism response competencies for nurses. A study conducted by Rose and Larrimore (2002) found that domestic terrorism knowledge and awareness is low among nurses, nursing students, physicians, and medical students, supporting the need for increased emphasis on terrorism education.
Given this information, schools of nursing should integrate bioterrorism education into their curricula to better prepare students for this growing component of health care management. This article outlines the necessary components of bioterrorism education for nurses, reviews examples of available resources to facilitate its inclusion, and suggests ways to integrate this material into nursing curricula.
Bioterrorism Education Content
According to Moodie et al. (2000), O’Connell, Menuey, and Foster (2002), and Rose and Larrimore (2002), nursing education on bioterrorism should address several key elements imperative to appropriate response:
- Detection and reporting of an unusual outbreak or syndrome.
- Treatment of casualties.
- Implementation of control measures.
- Resource acquisition and preparedness planning.
- Management of public reactions to bioterrorism.
Each element has key components that should be incorporated into bioterrorism education programs. Table 1 contains a summary of bioterrorism education content.
Bioterrorism Education Content Elements and Components
Detection and Reporting of an Unusual Outbreak or Syndrome
According to the CDC (2001), education related to the detection and reporting of an unusual outbreak or syndrome should include:
- Indications of intentional release of a biological agent, such as an unusual temporal or geographical clustering of illness.
- Processes for reporting to appropriate hospital and public health authorities.
- The CDC’s categorization of biological agents with potential to be used as weapons and the clinical features of these agents.
- Syndrome surveillance.
Anthrax, smallpox, botulism, plague, tularemia, and viral hemorrhagic fevers are some of the diseases that should be included, at least minimally, in bioterrorism education (Arnon et al., 2001; Borio et al., 2002; Dennis et al., 2001; Henderson et al., 1999; Inglesby et al., 2000, 2002). The biological agents that cause these infectious diseases are classified as category A agents by the CDC. Category A agents are of highest concern because they are considered a risk to national security, could cause public panic and disturbance, can be easily disseminated and transmitted from person to person, necessitate special action for public health preparedness, and cause high mortality rates (CDC, 2003a).
Treatment of Casualties
Important components of education regarding treatment of casualties include basic prophylactic guidelines, vaccination of exposed individuals when applicable, and other care management needs specific to each biological agent. To date, education programs have emphasized decontamination procedures as a response component. The emerging consensus is that decontamination of people exposed to biological agents is unnecessary (Moodie et al., 2000). However, decontamination processes should be mentioned because when the agent is a powder, it may not be recognized as a chemical or biological agent. In this situation, casualties should be decontaminated under chemical hazard materials guidelines until the causative agent is identified.
Implementation of Control Measures
This element is imperative as protection of frontline workers, other patients, and the public is important in preventing additional cases. Not all potential bioterrorism agents are transmitted person to person (APIC & CDC, 1999). Standard precautions should be used when caring for every patient in health care environments, including individuals with symptoms of suspected or confirmed bioterrorism-related illnesses. Some diseases, such as smallpox and pneumonic plague, require additional precautions to reduce the risk of transmission. Standard precautions, including hand hygiene and isolation practices (where appropriate), should be reviewed. Other factors that require review include patient placement and transport; cleaning, disinfection, and sterilization of equipment, linen, and the environment; discharge management; postmortem care; and triage and management of large-scale exposures (APIC & CDC, 1999; CDC, 2000, 2001, 2002).
Resource Acquisition and Preparedness Planning
A bioterrorism event will place tremendous strain on the health care community and pubic health infrastructure (Moodie et al., 2000). Health care providers need to know how to obtain appropriate resources during a crisis. These resources include, but are not limited to: additional medical equipment, medication, personal protective equipment, negative-air machines, and additional personnel. For this reason, resource acquisition and prepared-ness planning education should include information about key communication networks, including the state bioterrorism response network, and examples of mechanisms used by communities to obtain needed supplies, such as mutual aid agreements with other agencies.
Preparedness planning should be reviewed and include the importance of a clearly outlined communication process between health care providers, public health agencies, and other response entities, such as the Federal Bureau of Investigation (FBI) and local emergency management agencies. Nurses, as key professions on the front lines, must be knowledgeable about their organization’s bioterrorism-readiness plans and be able to access the processes if there is a need to report a suspicious trend. Education programs should also include some dialogue that describes the integration of a hospital’s bioterrorism plan into the community’s bioterrorism plan.
Management of Public Reactions to Bioterrorism
Public response to a terrorist event can include fear and panic, which can eventually lead to chaos (Glass & Schoch-Spana, 2002; Rose & Larrimore, 2002). Comprehensive bioterrorism plans will include mechanisms to facilitate the identification and management of public reactions. According to the APIC and CDC (1999), education related to management of the public response to a bioterrorism event should include:
- Reviewing the need to communicate clearly with victims, explaining risks and disease processes.
- Offering expedient medical assessment.
- Avoiding unnecessary isolation and quarantine.
Other key factors include collaboration with the media to provide assistance with communication needs; the need for an infrastructure of support from mental health professionals and volunteers to help cope with public concerns; and a review of the treatment of anxiety in people who were not exposed but who are experiencing somatic symptoms.
Available Educational Resources
Textbooks currently used by schools of nursing do not include comprehensive information about bioterrorism preparedness. However, there are many resources available that can be used to educate nursing students. A variety of different teaching methods are represented, which is helpful, as the choice of method may need to be varied according to the time allocated to the topic and the learning styles of nursing students (APIC, 2003; Brooks & Dauenhauer, 2003; CDC, 2003a; Collaborative Genetics, 2003; Moodie et al., 2000; O’Toole, 2000; RN.com, 2003; Saint Louis University School of Nursing, 2003; Veenema, 2002). Faculty can obtain timely information and educational tools from several Web sites, and a variety of distance learning programs that can be easily accessed online by students are available (Table 2).
Selected Internet Sites for Bioterrorism Resources
The CDC (2003a, 2003b) Web site is one of the main resource centers for information about bioterrorism. In-depth information about biological agents is provided in simple fact-sheet format, and publications such as the Morbidity and Mortality Weekly Report, which provides an overview of infectious diseases, are available. The public health emergency preparedness and response page on the CDC’s Web site has a clinical registry for terrorism and emergency response updates and educational opportunities ( http://www.bt.cdc.gov/clinregistry/userMaintenance2.asp). Participating clinicians receive regular e-mail updates on terrorism, other emergency issues, and educational opportunities. Faculty may benefit from registering for this service. The CDC also conducts many Web-based satellite teleconferences on bioterrorism topics, such as what clinicians should know about anthrax. The contents of these teleconferences are also accessible through the CDC’s Web site.
The APIC Web site is also useful. Bioterrorism resources are divided into categories, and information is readily accessible. Every aspect of bioterrorism preparedness is addressed by information available on this Web site.
Online courses are also available, but these vary in content. Some programs are very comprehensive and could serve as basic content for bioterrorism education (e.g., the online program on bioterrorism found on the http://www.RN.com  Web site). To complete the course, participants must read the material, which can be downloaded at no cost; study the terminology; access Web sites contained in the materials; and complete a posttest. The material provided is detailed and offers the most timely resources to participants. The posttest does require a fee of $19.95. Participants receive two contact hours of continuing education credit.
Another online course that is free of charge can be found on the American Board of Quality Assurance and Utilization Review Physicians Web site (O’Keefe, 2003). The course is an overview of bioterrorism, covering the various biological agents and how to properly manage and treat victims.
The use of tabletop exercises and scenarios is one method to effectively teach nursing students and lead to the synthesis of the recently learned information. This method educates students by having them work through a hypothetical bioterrorist attack. Participants learn through group discussion and interaction. There is minimal written material, and an effective facilitator is required to direct the process. Tabletop exercises are most useful when students have some knowledge of the subject being tested and can put that knowledge to use in a problem-solving setting (Moodie et al., 2000).
Integration of Bioterrorism Education into Nursing Curricula
Many nursing schools across the United States have taken steps to address terrorism education but, in most cases, appear to be focusing on the development of education programs for nurses, not nursing students. For example, the Saint Louis University School of Nursing (2003) developed an online continuing nursing education program, which uses the distance learning model and gives participants the opportunity to take the course at their own pace. The course description does not mention whether nursing students can take the course. The school of nursing at the University of Texas at Austin is one of the first to offer a course, Disaster Nursing, during the 2003 summer semester as an elective, open to both undergraduate and graduate nursing students (University of Texas at Austin, 2003).
The Vanderbilt University School of Nursing established a National Center for Emergency Preparedness in December 2002 (Jones, 2002). The Center will continue its collaboration with the National Health Professions Preparedness Consortium, which has several objectives, including the development of comprehensive professional curricula specifically designed for nurses and other health care professionals. However, the target audience of these efforts is not nursing students but practicing nurses.
Nurses require some basic educational competencies related to disaster preparedness, including bioterrorism. Schools of nursing can integrate this topic into the undergraduate curriculum in a variety of ways. In the future, emergency preparedness may become a full-semester course in undergraduate curricula. Currently, nursing schools already have courses regarding community health nursing, with attention given to community-based nursing practice. There is a focus on a knowledge synthesis in nursing, public health, and related disciplines, addressing issues specific to pubic health problems. Bioterrorism education fits well with this curriculum.
The content can be covered using a variety of educational methods, as described above. The current world situation demands that faculty access and use timely resources to ensure students obtain an optimal knowledge base. Faculty could integrate bioterrorism information into the traditional class lecture and supplement this with a project assignment for each student. Students could pick from a list of associated subject matter (e.g., smallpox, anthrax, bioterrorism readiness plans) and make a brief in-class presentation. This method allows student participation in the educational process and reduces the class lecture component.
Online education programs also provide a way to teach basic content on bioterrorism. Students could be assigned the responsibility to participate in the online education program. Class time could then be dedicated to discussion and synthesis of the information through the use of tabletop scenario exercises.
The threat of bioterrorism is real. Nurses are integral to the identification and management of bioterrorist events and need education to meet this challenge. Schools of nursing are in a position to prepare future nurses by integrating bioterrorism education into the undergraduate curricula. While current nursing texts do not address bioterrorism in a comprehensive way, there are other resources readily available to nursing faculty. Currently, teaching bioterrorism as a component of community health nursing seems to be an appropriate placement of the subject matter in the curriculum. Schools of nursing also should more formally address the need to outline required competencies of nurses in the area of bioterrorism preparedness.
- American Association of Colleges of Nursing. (2001). American Association of Colleges of Nursing leads efforts to further the education of nurses to combat bioterrorism. Retrieved August 9, 2003, from http://www.aacn.nche.edu/Media/NewsReleases/bioterrorism.htm
- Arnon, S.S., Schechter, R., Inglesby, T.V., Henderson, D.A., Bartlett, J.G. & Ascher, M.S. et al. (2001). Consensus statement: Botulinum toxin as a biological agent, medical and public health management. Journal of the American Medical Association, 285, 1059–1070. doi:10.1001/jama.285.8.1059 [CrossRef]
- Association for Professionals in Infection Control and Epidemiology. (2003). Bioterrorism resources. Retrieved August 9, 2003, from http://www.apic.org/educ/readinow.cfm
- Association for Professionals in Infection Control and EpidemiologyCenters for Disease Control and Prevention. (1999). Bioterrorism readiness plan: A template for healthcare facilities. Retrieved August 9, 2003, from http://www.apic.org/bioterror/
- Bakken, S. (2002). Biodefense and nursing informatics. American Journal of Nursing, 102(9), 79–80. doi:10.1097/00000446-200209000-00052 [CrossRef]
- Borio, L., Inglesby, T., Peters, C.J., Schmaljohn, A.L., Hughes, J.M. & Jahrling, P.B. et al. (2002). Consensus statement: Hemorrhagic fever viruses as biological weapons, medical and public health management. Journal of the American Medical Association, 287, 2391–2405. doi:10.1001/jama.287.18.2391 [CrossRef]
- Brooks, K.L. & Dauenhauer, S.A. (2003). The anthrax team: A novel teaching approach to increase anthrax and bioterrorism awareness. American Journal of Infection Control, 31, 176–177. doi:10.1067/mic.2003.21 [CrossRef]
- Centers for Disease Control and Prevention. (2000). Biological and chemical terrorism: Strategic plan for preparedness and response. Morbidity and Mortality Weekly Report, 49(RR-4), 1–14.
- Centers for Disease Control and Prevention. (2001). Recognition of illness associated with the intentional release of a biologic agent. Morbidity and Mortality Weekly Report, 50(41), 893–897.
- Centers for Disease Control and Prevention. (2002). Notice to readers: Updated post-event smallpox response plan and guidelines. Morbidity and Mortality Weekly Report: CDC Alert, 51(38), 1–14.
- Centers for Disease Control and Prevention. (2003a). Bioterrorism agents/diseases. Retrieved August 9, 2003, from http://www.bt.cdc.gov/agent/agentlist-category.asp
- Centers for Disease Control and Prevention. (2003b). Emergency preparedness and response. Retrieved August 9, 2003, from http://www.bt.cdc.gov
- Collaborative Genetics. (2003). HAZMAT & WMD training and consulting services. Retrieved August 9, 2003, from http://www.collaborativegenetics.com/PDF/Trainingbrochure.pdf
- Dennis, D.T., Inglesby, T.V., Henderson, D.A., Bartlett, J.G., Ascher, M.S. & Eitzen, E. et al. (2001). Consensus statement: Tularemia as a biological weapon, medical and public health management. Journal of the American Medical Association, 285, 2763–2773. doi:10.1001/jama.285.21.2763 [CrossRef]
- Federal Emergency Management Agency. (2003). Emergency management institute. Retrieved on August 9, 2003, from http://www.training.fema.gov/emiweb/
- Glass, T.A. & Schoch-Spana, M. (2002). Bioterrorism and the people: How to vaccinate a city against panic. Clinical Infectious Diseases, 34, 217–223. doi:10.1086/338711 [CrossRef]
- Henderson, D.A., Inglesby, T.V., Bartlett, J.G., Ascher, M.S., Eitzen, E. & Jahrling, P.B. et al. (1999). Consensus statement: Smallpox as a biological agent, medical and public health management. Journal of the American Medical Association, 281, 2127–2137. doi:10.1001/jama.281.22.2127 [CrossRef]
- Inglesby, T.V., Dennis, D.T., Henderson, D.A., Bartlett, J.G., Ascher, M.S. & Etizen, E. et al. (2000). Consensus statement: Plague as a biological weapon, medical and public health management. Journal of the American Medical Association, 283, 2281–2290. doi:10.1001/jama.283.17.2281 [CrossRef]
- Inglesby, T.V., O’Toole, T., Henderson, D.A., Bartlett, J.G., Ascher, M.S. & Eitzen, E. et al. (2002). Consensus statement: Anthrax as a biological weapon, updated recommendations for management. Journal of the American Medical Association, 287, 2236–2252. doi:10.1001/jama.287.17.2236 [CrossRef]
- Joint Commission on Accreditation of Healthcare Organizations. (2003). Hospital accreditation standards. Oakbridge Terrace, IL: Author.
- Jones, J. (2002). School of nursing houses national emergency center. The Reporter: Vanderbilt Medical Center. Retrieved August 9, 2003, from http://www.mc.vanderbilt.edu/reporter/index.html?ID=2441
- Moodie, M., Ban, J., Manzi, C. & Powers, M.J. (2000). Bioterrorism in the United States: Threat, preparedness, and response. Retrieved April 23, 2003, from http://www.cbaci.org/CDCSectionLinksMain.htm
- O’Connell, K.P., Menuey, B.C. & Foster, D. (2002). Issues in preparedness for biological terrorism: A perspective for critical care nursing. AACN Clinical Issues, 13, 452–469. doi:10.1097/00044067-200208000-00010 [CrossRef]
- O’Keefe, D. (2003). Complimentary bioterrorism course: Module 1 bioterrorism. Retrieved August 9, 2003, from http://www.abqaurp.org/module.asp?CourseID=11
- O’Toole, T. (2000). Smallpox: An attack scenario. Emerging Infectious Diseases, 5(4), 1–12.
- RN.com. (2003). Bioterrorism online course. Retrieved August 9, 2003, from http://www.rn.com/main.php?uniq=490063&com-mand=manage_courselist&data%5Bsubmit_value%5D=Display%20Course&data%5Bcourselist_data%5D%5Bid%5D=218
- Rose, M.A. & Larrimore, K.L. (2002). Knowledge and awareness concerning chemical and biological terrorism: Continuing education implications. The Journal of Continuing Education in Nursing, 33, 253–258.
- Saint Louis University School of Nursing. (2003). Online continuing nursing education: Disaster preparedness for nurses certificate program. Retrieved on August 9, 2003, from http://www.slu.edu/colleges/NR/cne_disaster_prep_content.html
- United States Army Medical Research Institute of Infectious Diseases. (2003). About USAMRIID. Retrieved August 9, 2003, from http://www.usamriid.army.mil/aboutpage.htm
- University of Texas at Austin. (2003). School of nursing leads effort in mass casualty education. The Eyes of Texas, 1(35). Retrieved August 9, 2003, from http://www.utexas.edu/opa/pubs/eyesoftexas/02eot_issues/07eot/eotv1n35.pdf
- Veenema, T.G. (2002). Chemical and biological terrorism: Current updates for nurse educators. Nursing Education Perspectives, 23, 62–71.
Bioterrorism Education Content Elements and Components
|Element 1: Detection and reporting of an unusual outbreak or syndrome|
Element 2: Treatment of casualties
Indications of intentional release of a biological agent.
Processes for reporting to appropriate hospital and public health authorities.
The CDC’s categorization of biological agents with potential to be used as weapons and the clinical features of these agents.
Laboratory support and confirmation.
Element 3: Implementation of control measures
Basic prophylactic guidelines.
Vaccination of exposed individuals, when applicable.
Care management needs specific to each biological agent*.
Decontamination for unknown powder event.
Element 4: Resource acquisition and preparedness planning
Methods of transmission of biological agents.
Standard precautions and isolation procedures.
Patient placement and transport.
The cleaning, disinfection, and sterilization of equipment, linen, and the environment.
Triage and management of large-scale exposures.
Element 5: Management of public reactions to bioterrorism
State bioterrorism response networks.
Hospital/agency bioterrorism response plans, including communication processes.
Community bioterrorism plans.
Clear communication to victims and public regarding risk and disease processes.
Mental health professional support.
Treatment of anxiety in people who were not exposed but who are experiencing somatic symptoms.
Selected Internet Sites for Bioterrorism Resources
|Organization (Internet Address)||Bioterrorism Resources Available|
|American Board of Quality Assurance and Utilization Review Physicians (http://www.abqaurp.org/module.asp?CourseID=11)||This site offers a complimentary bioterrorism course by Dianna O’Keefe.|
|Association for Professionals in Infection Control and Epidemiology (http://www.apic.org/bioterror/default.cfm)||This site contains a bioterrorism page with links, and information about biological agents; economic impact; epidemiology, identification, and diagnosis; management and treatment; vaccination; meetings, symposiums, and proceedings; readiness planning, scenarios; and resources and references.
Note: This Web site is currently under reconstruction following the 2004 APIC convention updates. Please check back.|
|Center for Biosecurity of the University of Pittsburgh Medical Center (http://www.upmc-biosecurity.org/)||This site includes information from both the University of Pittsburgh Center for Biosecurity and the Johns Hopkins Center for Civilian Biodefense Strategies. The site contains the clinician’s biodefense network, information about biological agents, and resources, news, and events.|
|Center for the Study of Bioterrorism (http://www.bioterrorism.slu.edu/index1.html)||This site offers education and training resources such as satellite broadcasts, online training tools, and training courses, and products such as CD-ROMs, reference cards, and disease fact sheets.|
|Centers for Disease Control and Prevention (http://www.bt.cdc.gov)||This site features a public health emergency preparedness and response page; information about agents, diseases, and threats; preparation and planning, emergency response preparedness and children; laboratory-related topics; surveillance; news and media relations; and training; and access to Morbidity and Mortality Weekly Report; a clinician registry for terrorism and emergency response updates and training opportunities; and a health alert network.|
|Collaborative Genetics (http://www.collaborativegenetics.com/training-brochures.htm)||This online brochure provides information about the organization’s HAZMAT and WMD training and consulting services. The organization offers live education courses on bioterrorism response for health care professionals.|
|Federal Emergency Management Agency, Emergency Management Institute (http://training.fema.gov/emiweb/edu/)||This site features information about courses, and programs and activities.|
|RN.com (http://w3.rn.com/course_list.asp #Infectious_Disease, click on “Bioterrorism)||This site offers an online bioterrorism education course (expiration: December 16, 2004).|