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The goal of the
Biological and Chemical Terrorism course is to acquaint healthcare
professionals with the overall concepts; raise the healthcare
professional’s awareness of their role as a front line identifier of
unusual trends in the community; and provide some familiarity with
biological and chemical agent that may be used for terrorism.
After completion of this course, the
learner will be able to:
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Discuss the vulnerability of
the US to bioterrorist
activity |
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Discuss the role of
healthcare worker in
identifying bioterrorism
activity |
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Identify critical agents
that terrorists might use |
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Discuss infection control
practices for patient
management |
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Identify the presentation
and basic care
recommendations for common
biological agents that could
be used in bioterrorist
activity |
After the bioterrorist actions of
September 11, 2001 on the World
Trade Center and the discovery of a
case of inhalational anthrax in
Florida October 4, 2001, the
practice of medicine changed in the
United States. These attacks
demonstrated how vulnerable the
United States is to outside attacks.
Consequently, President Bush in his
State of the Union address that year
instructed leaders of the FBI, CIA,
Homeland Security Department and the
Department of Defense to develop a
Terrorist Threat Integration Center
to merge and analyze all types of
threat information in a single
location. His goal was to have the
right people in the right places to
protect our citizens.
How and when an act of biological or
chemical terrorism might occur is
unpredictable. Anthrax, botulinum
toxin, ricin, plague, smallpox,
tularemia and viral hemorrhagic
fevers are on the top of the Center
for Disease Control and Prevention's
(CDC) list of biological weapons,
considered "Category A" weapons most
likely to be used in an attack. The
acts could range from dissemination
of aerosolized anthrax spores to
food product contamination. Despite
its unpredictable nature, the
possibility of biological or
chemical terrorism should not be
ignored because the consequences of
being unprepared are devastating.
Thousands could die, but the
fundamental motive would be to
strike panic and fear in millions of
people.
The United State’s vulnerability to
the use of biological and chemical
agents has been highlighted by
recognition of substantial
biological weapons development
programs and arsenals in foreign
countries, attempts to acquire or
possess biological agents by
militants, and high-profile
terrorist attacks. The country’s
local, state, and federal
infrastructure is already strained
as a result of other important
public health problems and now has
to deal with the dangers of
terrorists.
The United States Government
recognizes the significance of
emergency preparedness and has
committed substantial resources to
the fight on terrorism. After the
events of 9-11, the US government
investigated the ability of
hospitals to handle surge capacity
in the event of a major disaster. To
implement Bioterrorism Preparedness,
funding became a necessity and
consequently, it was approved by the
Senate Appropriations Committee to
provide $550 million for the Health
Resources and Services
Administration's Bioterrorism
Hospital Preparedness program (AAMC
Legislative and Regulatory Updates,
June 2007). Further appropriations
have been made to the preparations
for bioterrorist attacks and
consequentially the pandemic
influenza in the amount of $8
billion (Preleg, Kellermann, &
Golub, 2009).
Funds alone will not be effective
against bioterrorism. After the 9-11
tragedy The CDC joined with law
enforcement, intelligence, and
defense agencies in addition to
traditional CDC partners to address
a national security threat.
A coalition developed after the 9-11
tragedy established a CDC Strategic
Plan to implement Preparedness and
Response to Biological and Chemical
Terrorism. Steps for strengthening
public health and healthcare
capacity to protect the United
States against these dangers were
created and are updated as needed
(CDC, 2006).
The events of 9-11 have proven that
no nation is free of terrorist
activities. Incidents of terrorism
involving bacterial pathogens, nerve
gas, and chemical agents have
demonstrated that the United States
is vulnerable. Directions for
preparing homemade agents are
readily available at the touch of a
button on the internet. Reports of
arsenals of military bio-weapons
raise the possibility that
terrorists might have access to
highly dangerous agents, which have
been engineered for mass
dissemination as small-particle
aerosols. Such agents as the variola
virus (smallpox) are highly
contagious and often fatal.
Responding to large-scale outbreaks
caused by these agents will require
the rapid mobilization of public
health workers, emergency
responders, and private health-care
providers. Many hospitals are not
prepared for a large scale surge of
patients. One of the most vital
steps for any hospital is to
communicate with their community and
practice preparing for large scale
outbreaks using the Hospital
Incident Command System based on the
military model of command now being
considered a standard with the Joint
Commission who in 2009 dedicated an
entire chapter to Life Safety and
Emergency Management (McIsaac,
2008).
Most planning for emergency response
to terrorism has been concerned with
overt attacks like bombings.
Chemical terrorism acts are likely
to be overt because the effects of
chemical agents are usually
immediate and obvious. This type of
attack elicits immediate response
from police, fire, and EMS
personnel.
Biological agent attacks are more
likely to be covert. A biological
agent in a public place will not
have an immediate impact because of
the delay between exposure and onset
of illness after incubation. This
presents different challenges and
requires additional planning that
involves the public health system in
an emergency response. Physicians or
other primary healthcare providers
probably will identify the first
casualties of a covert attack.
In the event of a covert release of
a biological agent, like smallpox,
patients will appear in doctors'
offices, clinics, and emergency
rooms during the first or second
week. They will complain of symptoms
that may initially appear as an
ordinary virus. As the disease
progresses, physicians may not
recognize the disease because it is
rare. The terrorist will be far away
and the disease will be disseminated
through the population by the time
the first patients begin to die.
A short window of opportunity will
exist between the time the first
cases are identified and a second
wave of the population becomes ill.
During that brief period, public
health officials will need to
determine that an attack has
occurred, identify the organism, and
prevent more casualties. To save
more lives there is a need for
prompt diagnoses of unusual or
suspicious health problems in
animals as well as humans.
Many hazardous chemicals are used in
industry (for example, chlorine,
ammonia, and benzene). Others are
found in nature (for example,
poisonous plants). Chemical agents
can also be delivered covertly
through contaminated food or water.
Some chemicals are from animal
excretions. An example is the recent
national outbreak of contaminated
spinach. There were four fields
farmed in San Benito and Monterey
counties in California, that were
irrigated with contaminated
irrigation water, containing manure
from cattle that were infected with
a strain of E.Coli bacteria (strain
O157:H7), that causes harm to the
intestines. The most common effect
of an E.Coli food poisoning is
severe and often bloody diarrhea.
Healthy adults generally recover
within a week, but elderly or very
young patients are most likely to
develop complications, which may
include kidney failure (Seasilver
News Oct, 2006).
A large-scale attack with smallpox,
aerosolized anthrax spores, a nerve
gas, or a food borne biological or
chemical agent would overwhelm the
local and possibly the national
public health system. Large numbers
of patients, including both infected
persons and people afraid they have
the infection, would seek medical
attention, with a corresponding need
for medical supplies, diagnostic
tests, and hospital beds. Emergency
responders, healthcare workers, and
public health officials might be at
special risk. Everyday life would be
disrupted as a result of widespread
fear of contagion. Special planning
and preparation is needed.
The National Bioterrorism Hospital
Preparedness Program (NBHPP)
enhances the ability of hospitals
and health care systems to prepare
for and respond to bioterrorism and
other public health emergencies.
Program priority areas include
improving bed and personnel surge
capacity, decontamination
capabilities, isolation capacity,
pharmaceutical supplies, and
supporting training, education, and
drills and exercises (Health
Resources and Service
Administration, 2007).
Preparedness for terrorist-caused
outbreaks and injuries is an
essential component of the U.S.
public health surveillance and
response system. This system is
designed to protect the population
against any unusual public health
event like influenza pandemics,
contaminated water supplies, or
intentional dissemination of the
plague. The epidemiologic skills,
surveillance methods, diagnostic
techniques, and physical resources
required to detect and investigate
unusual or unknown diseases are
similar to those needed to identify
and respond to an attack with a
biological or chemical agent.
However, additional preparation
would be needed for mass casualties
or the use of rare agents.
Detection, diagnosis, and mitigation
of illness and injury caused by
biological and chemical terrorism
are complex processes. It involves
numerous partners and activities and
requires special emergency
preparedness in all cities and
states. CDC provides public health
guidelines, support, and technical
assistance to local and state public
health agencies as they develop
coordinated preparedness plans and
response protocols.
CDC also provides self-assessment
tools for terrorism preparedness,
including performance standards,
attack simulations, and other
exercises. In addition, CDC
encourages and supports applied
research to develop innovative tools
and strategies to prevent or
mitigate illness and injury caused
by biological and chemical
terrorism.
The National Hospital Ambulatory
Medical Care Survey is conducted
annually by CDC's National Center
for Health Statistics (NCHS) to
determine training for terrorism
related conditions in hospitals. The
following was found:
Teaching hospitals were better
trained than other hospitals for
bioterrorism, and Joint Commission
accredited hospitals had prepared
more of their physicians, physician
assistants, nurse practitioners,
nurses and lab staff for such
emergencies.
Eighty-eight percent of hospitals
surveyed in 2003 and 2004 said their
nurses had been trained in how to
recognize and treat patients exposed
to at least one of seven pathogens
including smallpox, anthrax, plague,
botulism, tularemia, viral
encephalitis and hemorrhagic fever,
and chemical or radiological
attacks. Eighty-six percent of the
clinical staff in hospitals with
24-hour emergency departments or
outpatient clinics was trained to
recognize and treat smallpox, and 82
percent were trained to recognize
and treat anthrax infection.
Taking steps toward national
biodefense most would consider being
the responsibility of the
government. Four main areas to
consider would be threat awareness,
prevention and protection,
surveillance and detection, and
response recovery (Homeland
Security, n.d.). Although one might
think all steps should fall under
the scrutiny of the government,
healthcare workers must be involved
in all phases of the biodefense.
Maintaining a clear line of
communication is vital to the
successful completion of each phase.
Early detection and control of
biological or chemical attacks
depends on a strong and flexible
public health system at the local,
state, and federal levels.
Healthcare providers will invariably
be the initial contact for those
presenting with symptoms of the
invading organism. Therefore,
education of presenting signs and
symptoms is imperative to protect
both the patient and the healthcare
provider. At first presentation the
healthcare provider may not realize
what he or she has been presented.
Many of the symptoms of the Category
A agents and diseases present with
flu like symptoms before progressing
to more severe illnesses. Only after
having several patients present to
triage or the doctor’s office with
similar symptoms will the pieces
begin to fall into place and the
healthcare provider realize there is
an epidemic at hand. The following
are examples of what the healthcare
provider might see to trigger
thoughts of an epidemic.
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increased disease incidence
(e.g., within hours or days)
in a normally healthy
population, |
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an epidemic curve that rises
and falls during a short
period of time, |
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an unusual increase in the
number of people seeking
care, especially with fever,
respiratory, or
gastrointestinal complaints,
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an endemic disease rapidly
emerging at an
uncharacteristic time or in
an unusual pattern, |
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lower attack rates among
people who had been indoors,
especially in areas with
filtered air or closed
ventilation systems,
compared with people who had
been outdoors, |
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clusters of patients
arriving from a single
locale, |
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large numbers of rapidly
fatal cases |
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any patient presenting with
a disease that is relatively
uncommon and has
bioterrorism potential
(e.g., pulmonary anthrax,
tularemia, or plague). |
Potential biological and chemical
agents are numerous, and the public
health system must be equipped to
quickly resolve crises that would
arise from a biological or chemical
attack. Agents that are highly
contagious or that can be engineered
for widespread dissemination via
small-particle aerosols would have
the largest impact. The CDC
classifies the most important human
pathogens into three categories, A,
B, and C. Category A is the highest
priority and includes the agents
that are easiest to disseminate and
transmit and cause the greatest
public health crisis. Addendum A, at
the end of this course, lists
Category A agents and diseases with
their method of spread, onset of
symptoms, signs and symptoms,
treatments, need for
decontamination, and prevention.
Category B agents are second-highest
priority, are moderately easy to
disseminate, and cause moderate
morbidity and low
mortality. Category C
includes emerging pathogens that
could potentially be developed into
bio-weapons.
The preparedness efforts must be
focused on these agents. The
following are lists of critical
biological and chemical agents (CDC,
2006).
Category A
High-priority agents include
organisms that pose a risk to
national security because they can
be easily disseminated or
transmitted person-to-person; cause
high mortality, with potential for
major public health impact; might
cause public panic and social
disruption; and require special
action for public health
preparedness. Category A agents
includes:
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Variola major (smallpox),
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Bacillus anthracis
(anthrax), |
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Yersinia pestis (plague),
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Clostridium botulinum toxin
(botulism), |
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Francisella tularensis
(tularaemia), |
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Filoviruses, |
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Ebola hemorrhagic fever, |
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Marburg hemorrhagic fever, and |
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Arenaviruses, |
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Lassa (Lassa fever), |
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Junin (Argentine hemorrhagic fever)
and related viruses. |
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Category B
The second highest priority agents
include those that are moderately
easy to disseminate; cause moderate
morbidity and low mortality; and
require specific enhancements of
CDC's diagnostic capacity and
enhanced disease surveillance.
Category B agents include:
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Coxiella burnetti (Q fever).
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Brucella species
(brucellosis), |
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Burkholderia mallei
(glanders), |
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Alphaviruses, |
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Venezuelan encephalomyelitis, |
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eastern and western equine
encephalomyelitis, |
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Ricin toxin from Ricinus
communis (castor beans),
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Epsilon toxin of Clostridium
perfringens, and |
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Staphylococcus enterotoxin
B. |
A subset of List B agents includes
pathogens that are food or
waterborne. These pathogens include
but are not limited to:
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Salmonella species, |
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Shigella dysenteriae, |
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Escherichia coli O157:H7,
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Vibrio cholerae, and |
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Cryptosporidium parvum.
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Category C
The third highest priority agents
include emerging pathogens that
could be engineered for mass
dissemination in the future because
of availability; ease of production
and dissemination; and potential for
high morbidity/mortality and major
health impact.
Category C agents include
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Nipah virus, |
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Hantaviruses, |
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Tickborne hemorrhagic fever
viruses, |
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Tickborne encephalitis
viruses, |
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Yellow fever, and |
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Multidrug-resistant
tuberculosis. |
The CDC has a key role in protecting
the public's health in an emergency
involving the release of a chemical
that could harm people's health. A
chemical emergency occurs when a
hazardous chemical has been released
and the release has the potential
for harming people's health.
Chemical releases can be
unintentional, as in the case of an
industrial accident, or intentional,
as in the case of a terrorist
attack. Hospitals generally are not
prepared to perform decontamination
for large numbers of patients
involved in chemical exposures.
Hospitals commonly expect the county
emergency medical system to serve as
the primary decontamination team,
however, there will be those
patients who self triage and show up
at the emergency department after an
exposure.
The primary concern at the time of
presentation will be to not only
keep the patient safe, but to keep
the facility safe. Once the patient
crosses the threshold of the
facility, off gassing will create a
situation for the organization
requiring the area to be closed and
all those in contact with the
patient may need to be
decontaminated or treated for
injuries sustained. As a general
rule, removing the patient’s
clothing will remove approximately
85% of the contaminate. Remove the
patient from the building, and alert
the authorities in your organization
of the situation in order to
determine the best course of events
for your organization.
Some chemicals that are hazardous
have been developed by military
organizations for use in warfare.
Examples are nerve agents such as
sarin and VX, mustards such as
sulfur mustards and nitrogen
mustards, and choking agents such as
phosgene. It might be possible for
terrorists to get these chemical
warfare agents and use them to harm
people.
Some chemicals could be made from
everyday items such as household
cleaners. These types of hazardous
chemicals also could be obtained and
used to harm people, or they could
be accidentally released. Therefore,
there is a need for prompt diagnoses
of unusual or suspicious health
problems in animals, plants, as well
as humans.
Chemical agents that might be used
by terrorists range from warfare
agents to toxic chemicals commonly
used in industry. Criteria for
determining priority chemical agents
include chemical agents already
known to be used as weaponry;
availability of chemical agents to
potential terrorists; chemical
agents likely to cause major
morbidity or mortality; potential of
agents for causing public panic and
social disruption; and agents that
require special action for public
health preparedness.
Categories of chemical agents
include (CDC, 2006):
Nerve agents,
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tabun (ethyl N,
N-dimethylphosphoramidocyanidate),
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sarin (isopropyl
methylphosphanofluoridate),
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soman (pinacolyl methyl
phosphonofluoridate), |
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GF
(cyclohexylmethylphosphonofluoridate),
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VX
(o-ethyl-[S]-[2-diisopropylaminoethyl]-methylphosphonothiolate);
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Blood agents,
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hydrogen cyanide, |
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cyanogen chloride, |
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Blister agents,
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lewisite (an aliphatic
arsenic compound,
2-chlorovinyldichloroarsine),
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nitrogen and sulfur
mustards, |
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phosgene oxime; |
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Heavy metals,
Volatile toxins,
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benzene, |
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chloroform, |
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trihalomethanes; |
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Pulmonary agents,
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phosgene, |
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chlorine, |
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vinyl chloride; |
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Incapacitating agents,
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BZ (3-quinuclidinyl
benzilate); |
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Pesticides, persistent and
nonpersistent;
Dioxins, furans, and polychlorinated
biphenyls (PCBs);
Explosive nitro compounds and
oxidizers,
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ammonium nitrate combined
with fuel oil; |
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Flammable industrial gases and
liquids,
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gasoline, |
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propane; |
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Poison industrial gases, liquids,
and solids,
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cyanides, |
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nitriles; and |
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Corrosive industrial acids and
bases,
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nitric acid, |
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Sulfuric acid. |
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Because of the hundreds of new
chemicals introduced internationally
each month, treating exposed persons
by clinical syndrome rather than by
specific agent is more useful for
public health planning and emergency
medical response purposes. Public
health agencies and first responders
might render the most aggressive,
timely, and clinically relevant
treatment possible by using
treatment modalities based on
syndromic categories like burns and
trauma, cardio-respiratory failure,
neurologic damage, and shock (Kahn,
et al., 2000).
Preparing the nation to address
these dangers is a major challenge.
Early detection requires increased
biological and chemical terrorism
awareness among front-line
healthcare providers because they
are in the best position to report
suspicious illnesses and injuries.
Also, early detection will require
improved communication systems
between those providers and public
health officials. State and local
healthcare agencies must have
enhanced capacity to investigate
unusual events and unexplained
illnesses. Diagnostic laboratories
must be equipped to identify
biological and chemical agents that
rarely are seen in the United
States. Fundamental to these efforts
is comprehensive, integrated
training designed to ensure core
competency in public health
preparedness and the highest levels
of scientific expertise among local,
state, and federal partners.
Agents of bioterrorism are generally
not transmitted from person to
person and re-aerosolization of
these agents is unlikely. All
patients in healthcare facilities,
including symptomatic patients with
suspected or confirmed
bioterrorism-related illnesses,
should be managed utilizing Standard
Precautions. Additional precautions
are imperative for disease syndromes
like pneumonic plague or smallpox to
reduce the likelihood of
transmission to others (APHL, 2006).
In small-scale events, routine
facility patient placement and
infection control practices should
be followed. However, a large number
of patients may not allow routine
triage and isolation strategies. In
that case, it will be necessary to
apply practical alternatives. These
may include grouping affected
patients with similar symptoms into
a designated section of a clinic or
emergency department, or a
designated ward or floor of a
facility, or even setting up a
response center at a separate
building (APHL, 2006).
Many states have implemented the use
of the START triage system
categorizing the patient into four
categories based on the acuity of
their symptoms. This method of
triage works well with field triage
and can be implemented into the
hospital initial triage system. With
a surge of patients to triage from a
large scale event, security will be
required to either man the doors or
go into a lock down and direct the
patients to the central triage
location. The best method of triage
in a large scale event is to have a
doctor-nurse-tagger team established
to triage and track the patient as
they present to triage. Radio
communication with the incident
command center is essential to
follow the patient through the
system.
The need for decontamination depends
on the suspected exposure and in
most cases will not be necessary.
The goal of decontamination after a
potential exposure to a bioterrorism
agent is to reduce the extent of
external contamination of the
patient and contain the
contamination to prevent further
spread. Decontamination should only
be considered in instances of gross
contamination. Decisions regarding
the need for decontamination should
be made in consultation with state
and local health departments.
Decontamination of exposed
individuals prior to receiving them
in the healthcare facility may be
necessary to ensure the safety of
patients and staff while providing
care (CDC, 2006).
Decontamination will be done
depending on the agent, the
likelihood for re-aerosolization, or
a risk associated with cutaneous
exposure via clothing of exposed
persons. After removal of
contaminated clothing, patients
should immediately shower with soap
and water. Bathing patients with
bleach solutions are unnecessary and
should be avoided because of the
potential harm to the patient. Clean
water, saline solution, or
commercial ophthalmic solutions are
recommended for rinsing eyes. If
indicated, after removal at the
decontamination site, patient
clothing should be handled only by
personnel wearing appropriate
personal protective equipment, and
placed in an impervious bag to
prevent further environmental
contamination (CDC, 2006).
After a bioterrorism-related event,
fear and panic can be expected from
both patients and healthcare
providers. Psychological responses
following a bioterrorism event may
include horror, anger, and panic,
unrealistic concerns about
infection, fear of contagion,
paranoia, social isolation, or
demoralization. Healthcare workers
should be provided with bioterrorism
readiness education, including
discussions of potential risks and
plans for protecting healthcare
providers. Bioterrorism readiness
was a necessity and required
disaster drills on an ongoing basis
(CDC, 2006), (APHL, 2006).
A comprehensive public health
response to a biological or chemical
terrorist event involves
epidemiologic investigation, medical
treatment and prophylaxis for
affected persons, and the initiation
of disease prevention or
environmental decontamination
measures. CDC will assist state and
local health agencies in developing
resources and expertise for
investigating unusual events and
unexplained illnesses (CDC, 2006).
CDC maintains a national
pharmaceutical stockpile to ensure
the availability, procurement, and
delivery of medical supplies and
devices needed to respond to
terrorist-caused illness or injury.
If requested by a state health
agency, CDC will deploy response
teams to investigate unexplained or
suspicious illnesses or unusual
etiologic agents. CDC will also
provide on-site consultation
regarding medical management and
disease control.
In the event of a confirmed
terrorist attack, CDC will
coordinate with other federal
agencies in accord with Presidential
Decision Directive (PDD) 39. This
directive designates the Federal
Bureau of Investigation as the lead
agency for the crisis plan and
charges the Federal Emergency
Management Agency with ensuring that
the federal response management is
adequate to respond to the
consequences of terrorism (APHL,
2006).
The following are descriptions and
recommendations for care of the most
common biological agents that may be
used in bioterrorist attacks. Theses
recommendation come from APIC's
publication Bioterrorism readiness
plan: A template for healthcare
facilities available at
http://www.cdc.gov/ncidod/hip/Bio/13apr99APIC-CDCBioterrorism.PDF).
Additional information can be
obtained from emergency Number at
the CDC Emergency Response Office,
770/488-7100.
Anthrax
Anthrax is an acute infectious
disease caused by Bacillus
anthracis, a spore forming, and
gram-positive bacillus. Associated
disease occurs most frequently in
sheep, goats, and cattle, which
acquire spores through ingestion of
contaminated soil. Humans can become
infected through skin contact,
ingestion, or inhalation of B.
anthracis spores from infected
animals. Person-to-person
transmission of inhalational disease
does not occur. Direct exposure to
vesicle secretions of cutaneous
anthrax lesions may result in
secondary cutaneous infection.
Human anthrax infection occurs in
three forms: pulmonary, cutaneous,
or gastrointestinal, depending on
the route of exposure. Of these
forms, pulmonary anthrax is
associated with bioterrorism
exposure to aerosolized spores.
Clinical features for each form of
anthrax include:
Pulmonary
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non-specific prodrome of
flu-like symptoms follows
inhalation of infectious
spores, |
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possible brief interim
improvement, two to four
days after initial symptoms,
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abrupt onset of respiratory
failure and hemodynamic
collapse, possibly
accompanied by thoracic
edema and a widened
mediastinum on chest
radiograph suggestive of
mediastinal lymphadenopathy
and hemorrhagic
mediastinitis |
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gram-positive bacilli on
blood culture, usually after
the first two or three days
of illness, and |
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treatable in early prodromal
stage (mortality remains
extremely high despite
antibiotic treatment if it
is initiated after onset of
respiratory symptoms). |
Cutaneous
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local skin involvement after
direct contact with spores
or bacilli, commonly seen on
the head, forearms or hands,
localized itching, |
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followed by a papular lesion
that turns vesicular that
within 2-6 days develops
into a depressed black
eschar, and |
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usually non-fatal if treated
with antibiotics. |
Gastro-intestinal
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abdominal pain, nausea,
vomiting, and fever
following ingestion of
contaminated food, usually
meat, |
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bloody diarrhea, |
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hematemesis, |
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gram-positive bacilli on
blood culture, usually after
the first two or three days
of illness, and |
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usually fatal after
progression to toxemia and
sepsis. |
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The incubation period following
exposure to B. anthracis ranges from
1day to 8 weeks (average 5days),
depending on the exposure route and
dose:
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2-60 days following
pulmonary exposure, |
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1-7 days following cutaneous
exposure, and |
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1-7 days following
ingestion. |
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There is an inactivated, cell-free
anthrax vaccine, but availability is
limited.
Standard Precautions are used for
the care of patients with infections
associated with B anthracis.
Placement in a private room is not
necessary. Airborne transmission of
anthrax does not occur. Skin lesions
may be infectious, but requires
direct skin contact only.
The risk for re-aerosolization of B.
anthracis spores appears to be
extremely low in settings where
spores were released intentionally
or were present at low or high
levels. In situations where the
threat of gross exposure to B.
anthracis spores exists, cleansing
of skin and potentially contaminated
fomites (e.g. clothing or
environmental surfaces) may be
considered to reduce the risk for
cutaneous and gastrointestinal forms
of disease. The plan for
decontaminating patients exposed to
anthrax may include the following:
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instructing patients to
remove contaminated clothing
and store in labeled,
plastic bags, |
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handling clothing minimally
to avoid agitation, |
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instructing patients to
shower thoroughly with soap
and water (providing
assistance if necessary),
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decontaminating
environmental surfaces using
an EPA-registered,
facility-approved
sporicidal/germicidal agent
or 0.5% hypochlorite
solution (one part household
bleach added to nine parts
water). |
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Botulism
Clostridium botulinum is an
anaerobic gram-positive bacillus
that produces a potent neurotoxin,
botulinum toxin. In humans,
botulinum toxin inhibits the release
of acetylcholine, resulting in
characteristic flaccid paralysis. C.
botulinum produces spores that are
present in soil and marine sediment
throughout the world. Food borne
botulism is the most common form of
disease in adults. An inhalational
form of botulism is also possible.
Botulinum toxin exposure may occur
in both forms as agents of
bioterrorism.
Food borne botulism is accompanied
by gastrointestinal symptoms.
Inhalational botulism and foodborne
botulism are likely to share other
symptoms including:
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responsive patient with
absence of fever. |
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symmetric cranial
neuropathies (drooping
eyelids, weakened jaw
clench, difficulty
swallowing or speaking),
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blurred vision and diplopia
due to extra-ocular muscle
palsies, |
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symmetric descending
weakness in a proximal to
distal pattern (paralysis of
arms first, followed by
respiratory muscles, then
legs), |
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respiratory dysfunction from
respiratory muscle paralysis
or upper airway obstruction
due to weakened glottis, and
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no sensory deficits. |
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Botulinum toxin is generally
transmitted by ingestion of
toxin-contaminated food.
Aerosolization of botulinum toxin
has been described and may be a
mechanism for bioterrorism exposure.
Neurologic symptoms of foodborne
botulism begin 12– 36 hours after
ingestion. Neurologic symptoms of
inhalational botulism begin 24- 72
hours after aerosol exposure.
A pentavalent toxoid vaccine has
been developed by the Department of
Defense. This vaccine is available
as an investigational new drug.
Completion of a recommended schedule
(0, 2, 12 weeks) has been shown to
induce protective antitoxin levels
detectable at 1-year post
vaccination. Routine immunization of
the public, including healthcare
workers, is not recommended.
Standard Precautions are used for
the care of patients with botulism.
Patient-to-patient transmission of
botulism does not occur. Patient
room selection and care should be
consistent with facility policy.
Principles of Standard Precautions
should be generally applied to the
management of patient-care equipment
and environmental control
Suspicion of even single cases of
botulism should immediately raise
concerns of an outbreak potentially
associated with shared contaminated
food. In collaboration with CDC and
local /state health departments,
attempts should be made to locate
the contaminated food source and
identify other persons who may have
been exposed. Any individuals
suspected to have been exposed to
botulinum toxin should be carefully
monitored for evidence of
respiratory compromise.
Contamination with botulinum toxin
does not place persons at risk for
dermal exposure or risk associated
with re-aerosolization. Therefore,
decontamination of patients is not
required.
Plague
Plague is an acute bacterial disease
caused by the gram-negative bacillus
Yersinia pestis, resulting in
lymphatic and blood infections
(bubonic and septicemia plague). A
bioterrorism-related outbreak may be
expected to be airborne, causing a
pulmonary variant, pneumonic plague.
Clinical features of pneumonic
plague include:
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fever, cough, chest pain,
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hemoptysis, |
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muco-purulent or watery
sputum with gram-negative
rods on gram stain, and
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radiographic evidence of
bronchopneumonia. |
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Plague is normally transmitted from
an infected rodent to man by
infected fleas. Bioterrorism-related
outbreaks are likely to be
transmitted through dispersion of an
aerosol. Person-to-person
transmission of pneumonic plague is
possible via large aerosol droplets.
The incubation period for plague is
normally 2 – 8 days if due to
fleaborne transmission. The
incubation period may be shorter for
pulmonary exposure (1-3 days).
Formalin-killed vaccine exists for
bubonic plague, but has not been
proven to be effective for pneumonic
plague. It is not currently
available in the United States.
Routine vaccination requires
multiple doses given over several
weeks and is not recommended for the
general population. Post-exposure
immunization has no utility.
For pneumonic plague, Droplet
Precautions should be used in
addition to Standard Precautions.
Droplet Precautions should be
maintained until patient has
completed 72 hours of antimicrobial
therapy. Minimize dispersal of
droplets by placing a surgical-type
mask on the patient when transport
is necessary. Principles of Standard
Precautions should be generally
applied to the management of
patient-care equipment and for
environmental control.
The risk for re-aerosolization of Y.
pestis from the contaminated
clothing of exposed persons is low.
In situations where there may have
been gross exposure to Y. pestis,
decontamination of skin and
potentially contaminated fomites
(e.g. clothing or environmental
surfaces) may be considered to
reduce the risk for cutaneous or
bubonic forms of the disease. The
plan for decontaminating patients
may include:
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instructing patients to
remove contaminated clothing
and storing in labeled,
plastic bags, |
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handling clothing minimally
to avoid agitation, and
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instructing to patients to
shower thoroughly with soap
and water (providing
assistance if necessary). |
Smallpox
Smallpox is an acute viral illness
caused by the variola virus.
Smallpox is a bioterrorism threat
due to its potential to cause severe
morbidity in a nonimmune population
and because it can be transmitted
via the airborne route. A single
case is considered a public health
emergency.
Acute clinical symptoms of smallpox
resemble other acute viral
illnesses, such as influenza. Skin
lesions appear, quickly progressing
from macules to papules to vesicles.
Other clinical symptoms to aid in
identification of smallpox include:
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2-4 day, non-specific
prodrome of fever, myalgias,
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rash most prominent on face
and extremities (including
palms and soles) in contrast
to the truncal distribution
of varicella, |
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rash scabs over in 1-2
weeks, and |
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In contrast to the rash of
varicella, which arises in
crops, variola rash has a
synchronous onset. |
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Smallpox is transmitted via both
large and small respiratory
droplets. Patient-to-patient
transmission is likely from airborne
and droplet exposure, and by contact
with skin lesions or secretions.
Patients are considered more
infectious if coughing or if they
have a hemorrhagic form of smallpox.
The incubation period for smallpox
is 7-17 days; the average is 12
days. Unlike varicella, which is
contagious before the rash is
apparent; patients with smallpox
become infectious at the onset of
the rash and remain infectious until
their scabs separate (approximately
3 weeks).
A live-virus intra-dermal
vaccination is available for the
prevention of smallpox. Since the
last naturally acquired case of
smallpox in the world occurred more
than 20 years ago, routine public
vaccination has not been
recommended. Vaccination against
smallpox does not reliably confer
lifelong immunity. Even previously
vaccinated persons should be
considered susceptible to smallpox.
Vaccination is generally
contraindicated in pregnant women,
and persons with immunosuppression,
HIV–infection, and eczema, who are
at risk for disseminated vaccinia.
The last known case of smallpox in
the world was reported in Somalia in
1977 and has since been eradicated.
Therefore, vaccinations have ceased
worldwide.
For patients with suspected or
confirmed smallpox, Airborne
Precautions. Airborne Precautions
are used for patients known or
suspected to be infected with
microorganisms transmitted by
airborne droplet nuclei of
evaporated droplets containing
microorganisms that can remain
suspended in air and can be widely
dispersed by air currents. Airborne
Precautions require healthcare
providers and others to wear
respiratory protection when entering
the patient room. Appropriate
respiratory protection is based on
facility selection policy; but, must
meet the minimal NIOSH standard for
particulate respirators, N95.
Patients suspected or confirmed with
smallpox require placement in rooms
that meet the ventilation and
engineering requirements for
Airborne Precautions, which include:
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monitored negative air
pressure in relation to the
corridor and surrounding
areas, |
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6 - 12 air exchanges per
hour, |
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appropriate discharge of air
to the outdoors, or
monitored high efficiency
filtration of air prior to
circulation to other areas
in the healthcare facility,
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the door that must remain
closed. |
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A key to the success of a
bioterrorism preparation plan is
communication. Healthcare facilities
without patient rooms appropriate
for the isolation and care required
for Airborne Precautions should have
a plan for transfer of suspected or
confirmed smallpox patients to
neighboring facilities with
appropriate isolation rooms.
Limit the movement and transport of
patients with suspected or confirmed
smallpox to essential medical
purposes only. When transport is
necessary, minimize the dispersal of
respiratory droplets by placing a
mask on the patient, if possible.
Patient decontamination after
exposure to smallpox is not
indicated.
Investment in national defense
ensures preparedness and acts as a
deterrent against hostile acts.
Likewise, investment in the public
health system provides the best
civil defense against bioterrorism.
Healthcare facilities, Fire
departments, and emergency
organizations nationwide are working
together practicing for emergencies
and developing ways to provide
emergency care when acts of violence
affect our most precious gifts, the
lives of our people.
The CDC's plan includes the
development of a public health
communication infrastructure, a
multilevel network of diagnostic
laboratories, and an integrated
disease surveillance system. These
components will improve our ability
to investigate rapidly and control
public health threats that emerge.
Tools developed in response to
terrorist threats serve a dual
purpose. They help detect rare or
unusual disease outbreaks and
respond to health emergencies,
including naturally occurring
outbreaks or industrial injuries
that might resemble terrorist events
in their unpredictability and
ability to cause mass casualties.
Hospitals are forming communication
networks to share information, and
practice community emergency drills
utilizing strategies which are
designed to help our citizens
survive.
The goal is to improve our
preparedness and communication, our
surveillance and detection and
become more responsive and skillful
in containment of hazardous
materials of mass destruction.
Listed below are resources that one
can use to reach the goals.
Bioterrorism Guides:
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AAMC Legislative and
Regulatory Updates, June
2007 |
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Arizona Department of Health
Services Zebra Manual 2007.
A Reference
Handbook for Bioterrorism
Agents |
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APIC and CDC. Bioterrorism
Readiness Plan. A Template
for Healthcare Facilities |
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California Department of
Health Services. California
Hospital Bioterrorism
Response Planning Guide 2005 |
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CDC. Influenza Pandemic
Preparedness |
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HHS and CDC. Pan Flu
Business Checklist |
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HHS and CDC. Pan Flu
Business Checklist. Spanish
version |
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Homeland Security Council.
National Strategy for
Pandemic Influenza |
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Homeland Security. National
Incident Management System
guide. (NIMS) 2006 |
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Pandemic Flu Guides 2006
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APHA. (2007). Resource Guide:
Federal Assistance Programs for
Terrorism retrieved June 20, 2007
from
http://www.apha.org/advocacy/priorities/issues/rebuilding/legislativebuildresourceguide.htm.
APIC Bioterrorism Task Force and CDC
Hospital Infections Program
Bioterrorism Working Group (1999).
Bioterrorism readiness plan: A
template for healthcare facilities.
Retrieved May 5, 2007 from
http://www.cdc.gov/ncidod/hip/Bio/13apr99APIC-CDCBioterrorism.PDF.
Arizona Department of Health
Services Zebra Manual. (2007). A
Reference Handbook for Bioterrorism
Agents, retrieved June 20, 2007 from
www.azdhs.gov/phs/edc/edrp/index.htm.
CDC. (n.d.). Bioterrorism
agents/diseases. Retrieved September
6, 2009, from
http://emergency.cdc.gov/agent/agentlist-category.asp
CDC. (2006). Preparation & Planning,
Public Health Emergency
Preparedness, retrieved June 20,
2007 from
www.bt.cdc.gov/planning.
CDC. (2007). Morbidity and Mortality
Weekly Report. Retrieved May 10,
2007 from
http://www.bt.cdc.gov/agent/agentlist.asp.
CDC. (2007). Training for
Terrorism-Related Conditions in
Hospitals: United States, 2003-2004.
Retrieved June 20, 2007 from
www.cdc.gov/nchswww.cdc.gov/nchs.
Federal Emergency Management Agency.
(1999). Federal response plan.
Washington, DC: Government Printing
Office. Retrieved May 10, 2007 from
http://www.fema.gov/r-n-r/frp.
FEMA. (2006). Resource Guide:
Federal Assistance Programs for
Terrorism Preparedness 2006.
Retrieved June 20, 2007 from
http://training.fema.gov/EMIWeb/
Homeland Security. (n.d.). Homeland
Security Presidential Directive 10:
Biodefense for the 21st Century.
Homeland Security Presidential
Directive 10: Biodefense for the
21st Century. Retrieved September 6,
2009, from DHS: Homeland Security
Presidential Directive 10:
Biodefense for the 21st Century
database.
Kahn, C., Levitt, A., & Sage, M.
(2000). Biological and chemical
terrorism: strategic plan for
preparedness and response:
Recommendations of the CDC strategic
planning workgroup, April 21, 2000 /
MMWR, 49(RR04); 1-14 Retrieved May
10, 2007 from
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4904a1.htm
.
McIsaac, J. H. (2008). Hospital
preparation for disasters. ASA
Refresher Courses in Anesthesiology,
36(1), 99-108.
NIMS and Homeland Security Field
Guides. (2006). retrieved June 20,
2007 from
www.bepress.com/cgi/viewcontent.cgi?article=1321&context=jhsem
OPHEPR; Office of Emergency
Preparedness & Response. (2007).
Zebra Manual. ADHS Reference
Handbook for Bioterrorism Agents:
About the Bureau: Personal
Preparedness. Copyright 2007 Arizona
Department of Health Services.
Retrieved June 20, 2007 from
http://www.azdhs.gov/phs/edc/edrp/index.htm.
OSHA. (2007). Safety and Health
Topics: Emergency Preparedness and
Response. Retrieved June 20, 2007
from
http://www.osha.gov/SLTC/emergencypreparedness/index.html.
OSHA. (2007). Federal Register
Notice 70:4027-4030, 2006 retrieved
June 20, 2007 from
www.osha.gov/SLTC/emergencypreparedness/index.html
Preleg, K., Kellermann, A. L., &
Golub, R. M. (2009). Enhancing
hospital surge capacity for mass
casualty events. The Journal of the
American Medical Association,
302(5), 565-567. |
