Healthcare Response to Weapons of Mass Destruction: Biological, Chemical and Radiological


Terrorism is not a new problem; there have been countless examples throughout history. Biological, chemical and radiological threats, as well as more conventional explosives and arms have long been used against specific populations to further political, social and religious objectives.

Oklahoma City, OK, April 26, 1995 -- Search and Rescue crews work to save those trapped beneath the debris, following the Oklahoma City bombing. FEMA News Photo; courtesy of FEMA.

Despite the countless examples of terrorism throughout the world, including in the US, it was the attacks of September 11, 2001 that prompted Americans and the US government to focus on preparing for potential biological, chemical and radiological terrorism. In 2005 the State of Nevada issued The State of Nevada Hazardous Materials Emergency Response Plan that has plans for emergency response for biological, chemical and radiological emergencies. Healthcare organizations have responded by creating specific plans for how to respond to such emergencies and to make sure that their plans coordinate and integrate with local, state and federal public health and law enforcement agencies. Professionals are urged to seek out and follow such plans in their healthcare organizations.

In support the public's reliance on healthcare providers' knowledge about responding to acts of biological, chemical and radiological terrorism, the 2003 Nevada legislature passed Assembly Bill 250. This law requires that select healthcare professionals, including nurses, take four hours of continuing education "relating to the medical consequences of an act of terrorism that involves the use of a weapon of mass destruction."

Beginning January 1, 2005, all nurses renewing their licenses must have completed this four-hour bioterrorism course as part of their CE renewal requirement. On that date, the Board's random CE audits began to include auditing for proof that renewing nurses have completed the bioterrorism course.

The law specifies that the course of instruction must include:

  1. An overview of acts of terrorism and weapons of mass destruction;
  2. Personal protective equipment required for acts of terrorism;
  3. Common symptoms and methods of treatment associated with exposure to, or injuries caused by, chemical, biological, radioactive and nuclear agents;
  4. Syndromic surveillance and reporting procedures for acts of terrorism that involve biological agents; and
  5. An overview of the information available on, and the use of, the Health Alert Network.

Completing a bioterrorism course which meets the requirements of the law is a one-time requirement of all registered nurses (RNs) and licensed practical nurses (LPNs) with active Nevada licenses. Once the course is completed, it doesn't have to be taken again.

The required four hours may be counted as part of the 30-hour CE requirement for RN and LPN renewal, and as part of the 45-hour continuing education (CE) requirement for advanced practice nurse (APN) and certified registered nurse anesthetist (CRNA) renewal.

While the legislature didn't mandate the course for certified nursing assistants (CNAs), the Board for Nursing highly encourages them to take it as part of their 24 hour in-service training renewal requirement.

Healthcare Professionals Are a Critical Component of Response

Because of the specialized knowledge and skill of healthcare professionals, their services are critical in the event of a biological, chemical or radiological attack. However, as humans, healthcare professionals are likely to experience many of the same fears and concerns as their patients. Fears related to one's own health and safety, as well as the welfare of loved ones, the condition of one's home and property, responsibilities to family versus responsibilities to one's patients are among conflicting feelings that may be experienced.

Being prepared for such possibilities may help healthcare professionals to manage and mitigate some of these fears. In addition to the emergency plans that healthcare organizations have developed to respond to potential emergency situations, each person and family in the US should prepare a plan for emergencies. Such plans would have to integrate with others' plans. For example, families with children would need to integrate the parents' workplace emergency plans with the plans of their children's schools and/or daycare providers. The welfare of pets and those who may be at home must be addressed. Identifying meeting places or contacts in distant locations with whom to coordinate should occur; for example, everyone in the family may know to contact a relative who lives in another state in the event that phone lines and cell towers in the local area are impacted. Families should create an emergency kit in the event of evacuation or the need to shelter in place. Evacuation and sheltering in place will be covered later in this course. For more information about the recommended contents of an emergency kit, go to

Because a covert attack involving the release of a biological, chemical or radiological weapon may not be immediately detectable, healthcare providers should maintain a high degree of suspicion and be alert to patterns and diagnostic clues that might indicate unusual illness outbreaks.

Indications of intentional release of a biologic agent include (CDC, 2007):

  • An unusual temporal or geographic clustering of illness or patients presenting with clinical signs and symptoms that suggest an infectious disease outbreak (e.g., persons who attended the same public event or gathering; >2 patients presenting with an unexplained febrile illness associated with sepsis, pneumonia, respiratory failure, or rash or a botulism-like syndrome with flaccid muscle paralysis, especially if occurring in otherwise healthy persons);
  • An unusual age distribution for common diseases (e.g., an increase in what appears to be a chickenpox-like illness among adult patients, but which might be smallpox); and
  • A pattern of large numbers of persons exhibiting similar symptoms of relatively rarely occurring illnesses, should raise suspicions among healthcare providers. For example, a large number of cases of acute flaccid paralysis with prominent bulbar palsies, suggestive of a release of botulinum toxin.

Awareness of and recognition of these patterns of illnesses, on the part of healthcare providers, is particularly important because biological agents, unlike chemical agents, may not be detectable until hours, days or weeks pass.

In addition to being alert to emerging signs and symptoms within the population, healthcare providers must also become knowledgeable about how to protect themselves in the event of a biological, chemical or radiological attack. The specifics of how healthcare providers must respond in different cases will vary depending on the nature of the attack, and will be covered in detail in later sections throughout this course.

Continue on to Biological Agents