The Bioterrorism Training and Emergency Response Curriculum



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The Bioterrorism Training and Emergency Response Curriculum

The Bioterrorism Training and Emergency Response Curriculum was developed to educate students and the public on information regarding bioterrorism preparedness and emergency response. Through the Bioterrorism Training Curriculum Development Project funded by the Health Resources Services Administration (HRSA), 12 modules were selected to be utilized in classes at the Departments of Health Science, Health Care Administration, Nursing, and Professional Studies in the College of Health and Human Services at California State University, Long Beach. These modules were modified to include local, countywide, and statewide information as well as information from various community agencies and public health departments. Instructors are encouraged to use portions or all of the material freely for its intended purpose.

TERMS OF USE

This material was originally developed by the Northwest Center for Public Health Practice, at the University of Washington, School of Public Health & Community Medicine for educational purposes. Permission has been obtained to copy, adapt, and distribute for non-commercial use only.

Acknowledgements



THE BIOTERRORISM TRAINING AND CURRICULUM DEVELOPMENT PROJECT GROUP



Project Director:
Veronica Acosta-Deprez, PhD, CHES

Department of Health Science

California State University, Long Beach
Project Co-Directors:
Sarath Gunatilake, MD, DrPH

Department of Health Science

California State University, Long Beach
Mohammed Forouzesh, PhD

Department of Health Science

California State University, Long Beach

Project Co-Collaborators:
Robert Friis, PhD, Chair

Mohammed Forouzesh, PhD, Graduate Director

Department of Health Science
Paul Bott, PhD, Chair

Department of Professional Studies


Tony Sinay, PhD, Chair

Health Care Administration Program


Barbara White, PhD

Department of Nursing



The following people provided feedback on the content, material selection and/or technical assistance:
Charles W. Clark, Chief of School Safety and Emergency Preparedness, Long Beach Unified School District
Kathy Crow, RN, St. Mary’s Hospital, Disaster Resource Center, Long Beach
Elizabeth Cross, Orange County Health Care Agency
Sue Donelson, MPH, California State University, Long Beach
Vanessa Garcia, Orange County Health Care Agency
Lisa Grabhorn, MPH California State University, Long Beach
Jee Kim, MPH, County of Los Angeles Public Health Department
Hang Nguyen, MPH Orange County Health Care Agency Bioterrorism Preparedness Unit
Hanan Obeidi, MPH, Long Beach Health Department, coordinator, Bioterrorism Preparedness Coordinator
Phil Falcetti, MPH, Orange County Health Care Agency
Steve Raginold, Captain, Long Beach Fire Department
Ibtisam Sirhan, MPH California State University, Long Beach
John Van Sky, PhD, Director, Orange County Public Health Department, Bioterrorism Preparedness Unit

Consultants:
Palitha Abeykoon, MD, World Health Organization, Sri-Lanka
Ron Arias, MPA, Director, City of Long Beach Health and Human Services
Curt Bonk, PhD, Instructional Systems Technology Department, Indiana University, Bloomington, Indiana
Joseph Carlucci, MD, World Health Organization
Thushara Fernando, MD, World Health Organization, Sri-Lanka
Ravindu Gunatilake, MD, University of Hawaii- Manoa
Indika Karunathilake, MD, Faculty of Medicine, Colombo, Sri Lanka
J. M Peiris, MD, University of Hong Kong
Emelinda Parentela, PhD, Department of Civil Engineering, California State University, Long Beach

Students:
Sherlene Gatdula, BS, Department of Health Science
Cindy Gotz, MPH Candidate, Department of Health Science
Shirley Jensen, MPH Candidate, Department of Health Science
Bow Lee, MPH candidate, Department of Health Science
Kristina Mayuga, BS, Department of Health Science
Kristine Talavera, BS candidate, Department of Health Science
Riza Tamayo, BS, Department of Health Science
Jevie Tomilloso, BS candidate, Department of Health Science

Website design and development:
Yiubun Liu, MS candidate, Civil Engineering Department
Marvin Mayo, University College & Extension Services, California State University, Long Beach
Francisco Romero, University College & Extension Services, California State University, Long Beach

Table of Contents

About This Module ……....7

How to Use This Manual 8

Introduction to Bioterrorism 9

Learning Objectives (Slide 4) 10

What Is Bioterrorism? (Slides 5-8) 11

History of Bioterrorism (Slides 9-11) 13

Recognition of a BT Event (Slides 12-17) 14

Public Health Response to a BT Event (Slides 18-21). 18

Potential Roles for Public Health Workers in

BT Response (Slides 22-28). 20

Summary of Key Points (Slide 29) 21

Resources (Slides 30-32) 22

In Case of an Event (Slides 33-34) 22

Review Questions 23

References 25

Appendix A: Modules. 33


About This Module

This is one of a series of modules in a curriculum developed to provide a basic understanding about bioterrorism preparedness and response, and how public health fits into the overall purpose. The target audience for this module includes students in the four collaborating departments: Health Science, Health Care Administration, Nursing, and Professional Studies at California State University, Long Beach. Instructors are encouraged to use portions or all of the material freely for its intended purpose.
This module was originally developed by the Northwest Center for Public Health Practice in Seattle, Washington. However, modifications have been made in the format as well as in the addition of other information from local (Greater Long Beach), countywide (Los Angeles and Orange counties), and state (California) resources in order to be more relevant to our target audience and applicable to the local setting. This module incorporates information from a wide variety of sources including the Centers for Disease Control and Prevention, the Federal Emergency Management Agency, the Working Group on Civil Biodefense, the United States Army Medical Research Institute in Infectious Disease (USAMRIID), and public health departments including Long Beach Department of Health Services, Los Angeles County Public Health Department, Orange County Health Care Agency, and the California Department of Health Services, among others.
This module is not copyrighted and may be used freely for the education of students and public health employees, and other partners working within bioterrorism and emergency response.

How to Use This Manual

This manual provides the instructor with additional useful information related to the accompanying MS PowerPointÒ slides. The manual and slides are divided into twelve topic areas: Introduction to Bioterrorism, Planning for Emergency Response, Overview of Diseases, Bioterrorism Surveillance and Epidemiologic Response Plan, Consequence Management: Public Health Leaders, Consequence Management: Public Health Staff, Consequence Management: Other Public Health Staff, Risk Communication, Public Health and the Law, Incident Command System and The Anarchist: Tabletop Exercise. Links to Web sites of interest are included in the lower right-hand corner of some slides and can be accessed by clicking the link while in the “Slide Show” view. Blocks of material in the manual are periodically summarized in the “Key Point” sections, to assist the instructor in deciding what material to include in a particular presentation. A

Introduction to Bioterrorism



Summary of Key Points (Slide 29)

  1. A bioterrorist attack is likely to be covert.

  2. First responders in a covert attack are likely to be health care providers.

  3. Public health workers will use many of the same skills in response to a bioterrorism incident as they do in a routine workday.

  4. The manner in which job skills are implemented will potentially differ from a routine workday.

Slide 3: Module Title

Learning Objectives (Slide 4)



The learning objectives for this module are:

    1. Define bioterrorism (BT)

    2. Describe the potential characteristics of a BT event

    3. Describe the general public health response to a BT event

    4. Identify and describe your potential roles and responsibilities in a BT event



What Is Bioterrorism (Slides 5-8)
KEY POINTS

    1. Biological agents producing either high mortality or low mortality, but moderate-high morbidity, are capable of creating significant terror and disruption in society.

    2. A bioterrorist attack may be announced, but is more likely to be unannounced (covert).



  1. Health care providers may be the first to recognize victims of a covert attack.





      Bioterrorism (BT) is terrorism involving the use of biological weapons, i.e., microbes or biologically derived toxins to inflict disease on humans. Terrorists seek to create fear and consequent disruption in society. The number of cases and deaths may be large, although terrorism achieves fear and societal disruption out of proportion to the actual damage done by the attack, as illustrated in the 2001 anthrax outbreak on the East Coast of the United States. Biological agents producing both high mortality and low mortality with moderate-high morbidity are included among the CDC-identified “critical agents” of concern (to be discussed in the module on diseases of BT potential). Although terrorists ultimately seek to create terror in other humans, their activities may produce death or disease in plants and animals





      Animals and humans may both become infected through the intentional release of a biological agent in the environment, or animals and plants may be infected or contaminated for the purpose of infecting humans via the food supply.



      A bioterrorist attack can be either announced (overt, slide 7), or unannounced (covert, slide 8). The first scenario may result in a response similar to that of other overt emergencies, such as chemical spills and fires. The second scenario (covert) is thought to be the more likely scenario in a bioterrorist incident. The first casualties are likely to be discovered by health care providers, as opposed to traditional emergency first-responders such as fire and HAZMAT teams.






History of Bioterrorism (Slides 9-11)

 

KEY POINTS



    1. Biological agents have been used in the past for offensive purposes.

    2. Biological weapons programs existed in many countries prior to 1972 and most likely continued to exist in some countries beyond that time.

    3. Although the United States no longer has an offensive biological weapons program, a defensive program has been active since 1953.





      Bioterrorism is not a new concept. The use of biological agents for offensive purposes has been documented as far back as the 6th century BC. Historical examples of biological warfare are noted in slide 9, and more recent examples of their use in terrorist activity in slide 10. Many of the biological agents considered to have potential for use in terrorist activity are agents that have been used before in biological warfare or were known to have been studied for that purpose prior to the Biological Weapons Convention in 1972







 

The United States actively studied biological agents for their use in warfare, from 1943 to 1969, when President Nixon ended the offensive arm of the program by executive order. By May 1972, all stockpiles of biological agents and munitions from the U.S. program had been destroyed. A treaty was signed that year by over 140 countries, agreeing not to stockpile or conduct research on biological weapons for offensive purposes. The USSR signed, but did not adhere to, this treaty; and their offensive program continued until the dissolution of the Soviet Union in 1992. It is suspected that other countries also did not adhere to the provisions of the treaty.

The U.S. defensive biological weapons program to develop prophylactic and treatment interventions began in 1953 and continues today at the U.S. Army Medical Research Institute of Infectious Disease (USAMRIID), in Fort Detrick, Maryland.







Recognition of a BT Event (Slides 12-19)
KEY POINTS

    1. According to California State law (Title 17, CCR 2505), all suspected cases of illness caused by potential bioterrorism agents are immediately reportable to the local health jurisdiction.

    2. Most diseases caused by potential bioterrorism agents present initially with a non-specific or flu-like illness.

    3. Being alert to unusual clusters of illness and familiar with epidemiological clues suggesting a potential bioterrorism event are important to allow early recognition of a bioterrorist event.

Surveillance/Detection (Slide 12):





Surveillance systems play an important role in BT recognition by documenting baseline levels of disease and illness in a community and detecting case numbers and patterns that differ from typical. BT events are most likely to be covert, and lag times between exposure and disease development in the index case (i.e., incubation period), transmission to others (if person-person transmission exists), and laboratory diagnosis present a challenge in source identification and response. Health care providers also play an important role in recognizing a BT event by being alert to, and reporting to public health, suspicious cases or clusters of illness in their clinical practice.

General Characteristics (Slide 13):



Most of the identified agents with bioterrorist potential produce an initial non-specific (slide 13 (e.g., fever, malaise, GI distress) and/or “influenza-like” illness—a common presentation that might not be recognized as atypical until the illness has progressed further. Because an effective mode of intentional dissemination for a biological agent is the aerosol route, pneumonia is another likely presentation.



Aerosol dissemination is “ideal” because it has the potential to expose a large number of people in a short period of time when released in a densely populated area. Aerosols can be imperceptible to the senses, and thus individuals unaware of the presence of danger would not know they had been infected until symptoms began. A certain degree of sophistication, however, is required for aerosol production (the degree differing by agent); particles need to be between 1-5 microns to settle in the lungs.

Contamination of the food supply is another potential mode of biological agent dissemination. It is thought that a biological attack involving a community water supply would be unlikely because of dilution effects in reservoirs and the use of chlorination and filtration. Infiltrating smaller water distribution systems with infectious agents or toxins may be a more likely scenario


Epidemiologic Clues (Slides 14-15)






Single case of disease due to an uncommon agent. For example, anthrax cases do occur spontaneously among humans in the United States, but infrequently, and typically as an occupational exposure in those working with infected animals or animal products. A single case of anthrax in someone without a known animal exposure would, therefore, warrant investigation.
Unexpected geographic or seasonal distribution of disease

For example, plague occurs mainly in the Southwestern US, but is extremely rare in Oregon State.


Unusual age distribution

(e.g., adults with a chickenpox-like rash illness)


Illness in persons sharing a common ventilation system or other exposure

(i.e., an aerosol release indoors would create an exposure for all using the same ventilation system)

Atypical route of transmission

For example, botulism occurs when C. Botulinum spores release toxin under anaerobic conditions, such as improperly canned food or in wounds. Aerosol botulism does not occur naturally, and a botulism-like illness with no apparent food vehicle would suggest a deliberate source of infection.








Slides 16-17 summarize disease reporting requirements in California.



Public Health Response to a BT Event (Slides 18-27)


Key Points

    1. Public health workers will use many of the same skills in response to a bioterrorism incident that they use in a routine workday.

    2. Potential differences between a routine public health workday and the response to a bioterrorism event include the coordination of activities with different agencies such as law enforcement and the size and scope of response efforts.







      For the most part, the response of public health to a bioterrorism incident is similar to the response to other public health emergencies. Workers will use the same job-related skills required of them on a daily basis, but the size and scope, time frame, involved partners, and security precautions may differ from that of a typical day. The criminal nature, the potentially covert presentation, and the potentially large

      numbers of casualties each present a challenge to the public health response in a bioterrorism incident. Public health workers may be called upon to address the needs of the public for information and education, resource referral, medications and immunizations in larger numbers than typical, within a more concentrated time period, and in a higher state of stress.







Law enforcement has chain of custody procedures (i.e., to preserve evidence) that may influence when and where public health workers can gather information for their investigation (i.e., epidemiologists conducting surveys, environmental health workers conducting site investigations, etc.). The need to preserve evidence and security may also influence what information is released and when.
Public health workers may need security clearance to enter the crime scene or, at the very least, identification. Agents used in BT may have engineered resistance to the usual treatment (i.e., antibiotics); the population exposed and the time of year may differ than that typically seen.

Key Preparedness Elements (Slides 20-21)



The key preparedness elements listed in slides 20 and 21 come from the Center for Disease Control’s Interim Planning Guidance for State Public Health Officials. Although the guide was written for state public health officials, each of the elements has applicability at the local level. The preparedness elements, with the exception of laboratory diagnosis and characterization, are discussed in varying levels of detail (depending on the target audience) in the other modules included in this curriculum.





Potential Roles for Public Health Workers in BT Response (Slides 22-28)































A variety of activities are required to ensure the health and safety of the public. In routine public health practice, workers perform different tasks, depending on their specific job category; and for the most part, tasks performed in a bioterrorism event can also be expected to reflect specific job categories. Workers may be called upon to assist in areas outside of their usual “job description” (e.g., answering phones, making deliveries), but not outside their scope of training (i.e., non-medically trained individuals would not be expected to give medical advice). Slides 22-28 list potential roles for epidemiologists, public health nurses, managers/administrators, assessment coordinators, administrative staff, health educators, and environmental health workers in the public health response to a biological terrorism incident. Note that these are potential roles. The scope of responsibility for any one worker will vary depending on the size, organization, and location of the department.




Summary of Key Points (Slide 29)


General Resources (Slides 30-32)











State of California Emergency Preparedness Office http://www.dhs.ca.gov/epo/EPOIndex.htm

Los Angeles County Department of Public Health 800-397-3993 (communicable disease reporting system) http://lapublichealth.org/acd/cdrs.htm or To report a possible bioterrorist incident contact ACDC Bioterrorism and Response at 213-240-7941








In Case of an Event (Slides 33-34)






Module 1-Introduction to Bioterrorism

Review Questions




  1. A bioterrorist attack is most likely to be overt. True or False?




  1. Public health workers will use many of the same skills in response to a bioterror incident as they would in the normal course of their day. True or False?




  1. According to the FBI bioterrorism is defined as




  1. A Bioterror attack affects

    1. People

    2. Animals

    3. Plants

    4. All of the above\




  1. Casualties in a covert bioterrorist event are most likely to be discovered by?

    1. Police/Fire

    2. HAZMAT

    3. Health Care Worker

    4. All of the above




  1. The development of bioterrorism as a method of intimidation is a relatively (last 25 years) new concept. True or False?




  1. List 3 things that present a challenge in source identification and response to a bioterror agent exposure.



  1. List epidemiological clues which might suggest a bioterror event.

Answer Key




  1. False

  2. True

  3. Unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population or any segment of it, in furtherance of political or social objectives.

  4. D

  5. C

  6. False

  7. Lag times between exposure and disease development in the index case (i.e., incubation period), transmission to others (if person-person transmission exists), and laboratory diagnosis.

  8. Single case of disease due to an uncommon agent, unexpected geographical or seasonal distribution of disease, unusual age distribution, illness in persons sharing a common ventilation system or other exposure, atypical route of transmission, unusual illness among animals preceding or accompanying human illness.

References
General Bioterrorism Information and Web Sites
American College of Occupational and Environmental Medicine. Emergency Preparedness/Disaster Response. January 2007. http://www.acoem.org/emergencyohden.aspx

California Department of Health Services. Division of Disease Control Bioterrorism Epidemiology Section. Home Page. http://www.dhs.ca.gov/ps/dcdc/bt/index.htm

California Department of Health Services. California Bioterrorism Surveillance and Epidemiologic Resource Plan, January 2002. http://www.dhs.ca.gov/ps/dcdc/bt/pdf/CA_BT_Surv_Epi_Plan-2002b.pdf

Centers for Disease Control and Prevention. Public Health Emergency Preparedness and Response. January 2007. http://www.bt.cdc.gov

Center for the Study of Bioterrorism and Emerging Infections at Saint Louis University School of Public Health. Home Page. January 2007. http://www.bioterrorism.slu.edu

County of Los Angeles Department of Health Services. Emergency Preparedness & Response. Home Page. http://www.labt.org

Historical perspective of bioterrorism. Wyoming Epidemiology Bulletin;5(5):1-2, Sept-Oct 2000.

Journal of the American Medical Association. Bioterrorism articles. January 2007. http://pubs.ama-assn.org/cgi/search?fulltext=bioterror

Johns Hopkins Center for Public Health Preparedness. Home Page. January 2007. http://www.jhsph.edu/preparedness/

Los Angeles County Department of Health Services. Bioterrorism Readiness Report, November 2005. http://www.labt.org/pdf/BT_Readiness_Report_2005.pdf

Los Angeles County Department of Public Health. Communicable disease reporting system January 2007 http://lapublichealth.org/acd/cdrs.htm

Pavlin JA. Epidemiology of bioterrorism. Emerging Infect Disease [serial online] 1999 Jul-Aug; 5(4). http://www.cdc.gov/ncidod/eid/index.htm

Phillips, M.B. (2005) Bioterrorism, a Brief History. North East Florida Medicine: Focus on Bioterrorism February 2007 http://www.dcmsonline.org/jax-medicine/2005journals/bioterrorism/bioterrorism_history.pdf

State of California Emergency Preparedness Office http://www.dhs.ca.gov/epo/EPOIndex.htm

Tucker JB. Historical trends related to bioterrorism: an empirical analysis. Emerging Infect Disease [serial online] 1999 Jul-Aug; 5(4). http://www.cdc.gov/ncidod/eid/index.htm

U.S. Department of Homeland Security. National Response Plan. Home Page. http://www.dhs.gov/xprepresp/committees/editorial_0566.shtm

Washington State Department of Health. Home Page. January 2007. http://www.doh.wa.gov

Emergency Response Planning


Auf der Heide, E (2003), Disaster response: Principles of Preparation and Coordination http://orgmail2.coe-dmha.org/dr/Static.htm

Butler JC, Mitchell LC, Friedman CR, Scripp RM, Watz CG. Collaboration between public health and law enforcement: new paradigms and partnerships for bioterrorism planning and response. Emerging Infect Dis [serial online] 2002 Oct; 8(10):1152-55. http://www.cdc.gov/ncidod/eid/index.htm

California Department of Health Services Emergency Response Plan February 2007 www.dhs.ca.gov/epo/pdf/chds_EmergencyResponsePlan.PDF

CDC. Biological and chemical terrorism: strategic plan for preparedness and response. MMWR Recommendations and Reports 2000 April 21;49(RR-4):1-14.

CDC. Cooperative agreement U90/CCUXXXXXX-03-X public health preparedness and response for bioterrorism. http://www.bt.cdc.gov/Planning/CoopAgreementAward/index.asp

Center for Health Policy, Columbia University School of Nursing. Bioterrorism and emergency preparedness home page February 2007 http://www.nursing.columbia.edu/chphsr/btcomps.html

City of Long Beach Disaster Management Home page. February 2007 http://www.ci.long-beach.ca.us/fire/emergency_prep/default.asp

Environmental Protection Agency. Emergency planning and community right-to-know act overview. http://yosemite.epa.gov/oswer/ceppoweb.nsf/content/epcraOverview.htm

Federal Emergency Management Agency. Emergency management guide for business & industry. Home Page February 2007 http://www.fema.gov/business/guide/index.shtm

Federal Emergency Management Agency & United States Fire Administration-National Fire Academy. Emergency response to terrorism: self-study (ERT:SS) (Q534), February 2003. http://www.usfa.fema.gov/pdf/ertss.pdf

Federal Emergency Management Agency. Independent study course on the incident command system. http://www.fema.gov/emergency/nims/nims_training.shtm

Medical response in emergencies: HHS role. http://www.hhs.gov/news/press/2001pres/01fsemergencyresponse.html

University California Los Angeles Center for Public Health and Disasters home page. February 2007 http://www.cphd.ucla.edu/

U.S. Department of Homeland Security. Ready America Home page. Information for all types of emergencies as well as state contact information. February 2007 http://www.ready.gov/america/local/ca.html

Washington state comprehensive emergency management plan. http://emd.wa.gov/3-pet/pal/cemp/01-cemp-idx.htm

Health Surveillance and Epidemiologic Investigation

CDC. Case definitions under public health surveillance. MMWR; 1997:46(RR-10):1-55.

CDC. Updated guidelines for evaluating public health surveillance systems: recommendations from the Guidelines Working Group. MMWR. 2001; 50(RR13):1-35. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm

CDC Epidemiology Program Office. Excellence in curriculum integration through teaching epidemiology (Web-based curriculum). http://www.cdc.gov/excite/index.htm

Friis, R.H. & Sellers, T.A. (1999) Epidemiology for Public Health Practice. Jones & Bartlett: Massachuetts

Koehler J, Communicable Disease Control, Epidemiology & Immunization Section, Public Health – Seattle & King County. Surveillance and Preparedness for Agents of Biological Terrorism (presentation). 2001.

Koo, D. Public health surveillance (slide set). http://www.cdc.gov/epo/dphsi/phs/overview.htm

List of nationally notifiable infectious diseases. http://www.cdc.gov/epo/dphsi/phs/infdis.htm

Lober WB, Karras BT, Wagner MM, Overhage JM, Davidson AJ, Fraser H, et al. Roundtable on bioterrorism detection: information system–based surveillance. JAMIA 2002;9:105-115. http://www.jamia.org/cgi/content/full/9/2/105
Diseases of Bioterrorist Potential

Advisory Committee on Immunization Practices (ACIP). Use of smallpox (vaccinia vaccine), June 2002: supplemental recommendation of the ACIP.

Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deithman SD. HICPAC. Guideline for infection control in health care personnel, 1998. Am J Infect Control 1998;26:289-354. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/InfectControl98.pdf

Breman JG & Henderson DA. Diagnosis and management of smallpox. N Engl J Med 2002;346(17):1300-1308.

CDC. CDC Responds: Smallpox: What Every Clinician Should Know, Dec. 13th, 2001.
Webcast: http://www.sph.unc.edu/academics/webcasts.html?webcast=event

CDC. CDC Responds: Update on Options for Preventive Treatment for Persons at Risk for Inhalational Anthrax, Dec 21, 2001.


Webcast: http://www.sph.unc.edu/academics/webcasts.html?webcast=event

CDC. Considerations for distinguishing influenza-like illness from inhalational anthrax. MMWR 2001;50(44):984-986.

CDC. Notice to readers update: management of patients with suspected viral hemorrhagic fever – United States. MMWR. 1995;44(25):475-79.

CDC. The use of anthrax vaccine in the United States. MMWR 2000;49(RR-15):1-20.

CDC. Update: investigation of bioterrorism-related anthrax --- Connecticut, 2001. MMWR 2001;50(48):1077-9.

CDC. Vaccinia (smallpox) vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2001;50(RR-10):1-25.

Centers for Disease Control and Prevention. Smallpox response plan and guidelines (version 3.0). Sep 21, 2002.

Centers for Disease Control and Prevention. Smallpox vaccination and adverse events training module, 2002. http://www.bt.cdc.gov/training/smallpoxvaccine/reactions/default.htm

Centers for Disease Control and Prevention, American Society for Microbiology & American Public Health Laboratories. Basic diagnostic testing protocols for level A laboratories. http://www.bt.cdc.gov/labissues/

Chin J, ed. Control of Communicable Diseases Manual (17th ed), 2000: Washington DC.

Duchin JS, Communicable Disease Control, Epidemiology & Immunization Section Public Health – Seattle & King County. Bioterrorism: Recognition and Clinical Management of Anthrax and Smallpox (presentation). 2001.

Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and its eradication, 1988:Geneva.

Franz DR, Jarhling PB, Friedlander AM, McClain DJ, Hoover DL, Bryne R et al. Clinical recognition and management of patients exposed to biological warfare agents. JAMA 1997;278:399-411.

Frey SE, Newman FK, Cruz J, Shelton WB, Tennant JM, Polach T et al. Dose-related effects of smallpox vaccine. N Engl J Med 2002;346(17):1265-74.

Fulco CE, Liverman CT, Sox HC, eds. Gulf War and Health: Volume 1. Depleted Uranium, Pyridostigmine Bromide, Sarin, and Vaccines, 2000: Washington DC. URL: http://www.nap.edu.

Jernigan JA, Stephens DS, Ashford DA, Omenaca C, Topiel MS, Galbraith M et al. Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States. Emerging Infect Dis [serial online] 2001 Jul-Aug; 7(6): 933-44. http://www.cdc.gov/ncidod/eid/index.htm

Mandel GL, Bennett JE, Dolin R, eds. Principles and practice of infectious diseases (5th ed), 2000: Philadelphia.

New England Journal of Medicine. Smallpox Issue. April 25, 2002; 346(17).

Plotkin SA & Orenstein WA, eds. Vaccines (3rd ed), 1999: Philadelphia.

Rosen P, Barkin R, Danzl DF, et al, eds. Emergency medicine: concepts and clinical practice (4th ed), 1998: St. Louis, MO.

Rotz LD, Khan AS, Lillebridge SR. Public health assessment of potential biological terrorism agents. Emerging Infect Dis [serial online] 2002;8(2):225-230. http://www.cdc.gov/ncidod/eid/pastcon.htm

US Army Medical Research Institute of Infectious Diseases. USAMRIID’s medical management of biological casualties handbook (4th ed). Fort Detrick, MD: 2001.

Zajtchuk R, Bellamy RF, eds. Textbook of military medicine: medical aspects of chemical and biological warfare. Office of The Surgeon General Department of the Army, United States of America. http://ccc.apgea.army.mil/

reference_materials/textbook/HTML_Restricted/index.htm


Working Group on Civilian Biodefense Consensus
Recommendations:

Arnon SS, Schechter R, Inglesby TV, Henderson DA, Bartlett JG, Ascher MS, et al. Botulinum toxin as a biological weapon: medical and public health management. JAMA 2001;285:1059-1070.

Borio L, Inglesby T, Peters CJ, Schmalijohn AL, Hughes JM, Jarhling PB et al. Hemorrhagic fever viruses as biological weapons: medical and public health management. JAMA. 2002;287:2391-2405.

Dennis DT, Inglesby TV, Henderson DA, MD, Bartlett JG, Ascher MS, Eitzen E, et al. Tularemia as a biological weapon: medical and public health management. JAMA 2001;285:2763-73.

Henderson DA, Inglesby TV, Bartlett JG, Ascher MS, Eitzen E, Jahrling PB, et al. Smallpox as a biological weapon: medical and public health management. JAMA 1999;281(22): 2127-2137.

Inglesby TV, Dennis DT, Henderson DA, MD, Bartlett JG, Ascher MS, Eitzen E, et al. Plague as a biological weapon: medical and public health management. JAMA 2000;283:2281-90.

Inglesby TV, Henderson DA, Bartlett JG, Ascher MS, Eitzen E, Friedlander AM, et al. Anthrax as a biological weapon: medical and public health management. JAMA 1999;281:1735-45.

Inglesby TV, O’Toole T, Henderson DA, Bartlett JG, Ascher MS, Eitzen E et al. Anthrax as a biological weapon, 2002: updated recommendations for management. JAMA 2002;287:2236-2252.


Environmental Sampling and Decontamination

Alexander L. Decontaminating civilian facilities: biological agents and toxins. Institute for Defense Analysis, January 1998.

CDC. Comprehensive procedures for collecting environmental samples for culturing Bacillus anthracis, revised April 2002. http://www.bt.cdc.gov/Agent/Anthrax/environmental-sampling-apr2002.doc

CDC. Protecting investigators performing environmental sampling for Bacillus anthracis: personal protective equipment. http://www.bt.cdc.gov/agent/anthrax/

CDC. Packaging critical biological agents. http://www.bt.cdc.gov/

CDC. Use of onsite technologies for rapidly assessing environmental Bacillus anthracis contamination on surfaces in buildings. MMWR. 2001;50(48):1087.

Centers for Disease Control, Office of Health and Safety & National Institutes of Health. Biosafety in microbiological and biomedical laboratories (4th Ed), 1999: Washington DC. http://www.cdc.gov/od/ohs/biosfty/bmbl4/b4acf1.htm

Centers for Disease Control and Prevention & World Health Organization. Infection control for viral haemorrhagic fevers in the African health care setting. http://www.cdc.gov/ncidod/dvrd/spb/mnpages/vhfmanual.htm

Environmental Protection Agency. EPA’s Strategic Plan for Homeland Security. http://www.epa.gov/epahome/downloads/epa_homeland_security_strategic_plan.pdf.

Environmental Protection Agency. EPA’s Emergency response organizational structure (slide set). http://fl1.findlaw.com/news.findlaw.com/hdocs/docs/epa/epactrolerspns61598.pdf

Friis, R.H. (2007) Essentials of Environmental Health. Jones & Bartlett: Massachuetts

Wilhemi, J. & Kremer, F. (2003) Environmental Protection Agency. Report on the Homeland Security Workshop on Transport and Disposal of Wastes From Facilities Contaminated With Chemical or Biological Agents http://www.epa.gov/NHSRC/pubs/reportFacilityWaste110104.pdf

Consequence Management

Albert M. R., Ostheimer K. G., Breman J. G. The last smallpox epidemic in boston and the vaccination controversy, 1901–1903. N Engl J Med 2001; 344:375-379.

Barbera J, Macintyre A, Gostin L, Inglesbury T, O’Toole T, DeAtley C et al. Large-scale quarantine following biological terrorism in the United States: scientific examination, logistic and legal limits, and possible consequences. JAMA 2001;286(21):2711-2717.

Bardi J. Aftermath of a hypothetical smallpox disaster. Emerging Infect


Dis [serial online] 1999 Jul-Aug; 5(4): 547-51http://www.cdc.gov/ncidod/eid/index.htm

CDC. Interim recommendations for the selection and use of protective clothing and respirators against biological agents http://www.bt.cdc.gov/DocumentsApp/Anthrax/Protective/10242001Protect.asp

Geberding JL, Hughes JM, Koplan JP. Bioterrorism preparedness and response: clinicians and public health agencies as essential partners. JAMA 2002;287(7):898-900.

Glass TA & Schoch-Spana M. Bioterrorism and the people: how to vaccinate a city against panic. Clinical Infectious Diseases 2002;34:217-223.

Rowitz, L. Public Health for the 21st Century: The Prepared Leader. Jones & Bartlett: Massachusetts

Psychological Aftermath of Trauma

American Psychiatric Association: Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC, American Psychiatric Association, 2000.

American Psychiatric Association. Home Page. January 2002. http://www.psych.org

Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Center for Mental Health Services. Disaster manual for mental health and human services workers in major disasters. http://www.mentalhealth.org/cmhs/EmergencyServices/fpubs.asp

Communication and Informatics

Agency for Toxic Substances and Disease Registry. A primer on health risk communication principles and practices. http://www.atsdr.cdc.gov/HEC/primer.html

CDC. CDC Responds: Risk Communication and Bioterrorism, Thursday, December 6, 2001. Webcast. http://www.sph.unc.edu/about/webcasts.html?webcast=2001-12-06_risk&action=view

Covello T, Peters RG, Wojtecki JG, Hyde RC. Risk communication, the West Nile Virus epidemic, and bioterrorism: responding to the communication challenges posed by the intentional or unintentional release of a pathogen in an urban setting. J Urban Health: Bulletin of the NY Academy of Medicine 2001;78(2):382-391.

O’Carroll PW, Halverson P, Jones DL, Baker EL. The health alert network in action. Northwest Public Health 2002;19(1):14-15.


Qureshi K, Gebbie KM, Gebbie EN. Public Health Incident Command System: A Guide for the Management of Emergencies or Other Unusual Incidents within Public Health Agencies, Volume I. October 27, 2006; First edition.

Public Health and the Law

101 Session of Congress Biological Weapons Anti-Terrorism Act of 1989. February 2007 http://www.au.af.mil/au/awc/awcgate/congress/bwat1989.htm


California Department of Health Services, Title 17, California Code of Regulations (CCR), Section 2505 - REPORTABLE CONDITIONS: NOTIFICATION BY LABORATORIES

http://www.dhs.ca.gov/dcdc/disb/pdf/Title%2017%20lab%20reportable%20conditions.pdf
Doyle, C. (1996) Antiterrorism and Effective Death Penalty Act of 1996: A Summary Retrieved on February 14, 2007 from http://www.fas.org/irp/crs/96-499.htm
State of California, Government Code. Reportable Deaths (Coroner's Cases) Section 27491. February 2007 http://www.acgov.org/ems/Resource/Coroners_cases.PDF
Galvin, J.E., Atchison & C., Levey, S. (2005) Public Health Strategy and the Police Powers of the State. Public Health Reports. 120;sup1: 20-27. http://www.publichealthreports.org/userfiles/120_SUP1/120020sup.pdf

Gostin, L.O.& Hodge, J.G. (n.d.) Reforming Alaska Public Health Law. http://www.publichealthlaw.net/Resources/ResourcesPDFs/Alaska.pdf


Kuzler, P. (2005) Public Health Law in the Age of Terrorism. February 2007 http://www.nwcphp.org/docs/edu/iphl/module/
The Library of Congress. 107 Session of Congress U.S. Patriot Act of 2001. February 2007 http://thomas.loc.gov/cgi-bin/bdquery/z?d107:h.r.03162

Appendix A: Glossary



Bulbar: Referring to the cranial nerves

Coagulopathy: A disease affecting the coagulability (clotting) of the blood

Confluent: Joining, running together

Conjunctivitis: Inflammation of the conjunctiva; “red eye”

Depigmentation: Loss of pigmentation (color)

Diplopia: Double vision

Dyspnea: Shortness of breath

Edema: An accumulation of an excessive amount of watery fluid in cells or tissues

Enanthem: A mucous membrane eruption (rash)

Epistaxis: Nose bleed

Erythema: Redness

Eschar: A thick, coagulated crust or slough

Exanthem: A skin eruption (rash) occurring as a symptom of an acute viral or coccal disease

HAZMAT: Hazardous materials management; HAZMAT workers respond to discharges and/or releases of oil, chemical, biological, radiological, or other hazardous substances .



Hematemesis: Vomiting of blood

Hemoptysis: Coughing up blood

Hemorrhagic mediastinitis: Bloody inflammation in the chest cavity

Hypotension: Low blood pressure

Indolent ulcer: Chronic ulcer, showing no tendency to heal

Leukocytosis: Elevated white blood cell count

Lymphadenitis: Inflammation of a lymph node or lymph nodes

Lymphadenopathy: A disease process (e.g., swelling) affecting a lymph node or nodes

Macule: A small, discolored patch or spot on the skin, neither elevated above nor depressed below the skin's surface

Malaise: General ill feeling

Myalgia: Muscle aches

Papule: A small, circumscribed solid elevation on the skin

Percutaneous: Denoting the passage of substances through unbroken skin; passage through the skin by needle puncture

Petechiae: Pin-head sized hemorrhagic spots in the skin

Pharyngitis: Inflammation of the tissues of the pharynx; “Sore throat”

Pleuropulmonary: Relating to the pleura and the lungs

Preauricular: Anterior to the auricle of the ear

Prodrome: An early or premonitory symptom of a disease

Prophylaxis: Prevention of a disease, or of a process that can lead to disease

Prostration: A marked loss of strength, as in exhaustion

Pustule: A small circumscribed elevation of the skin, containing purulent material

Sepsis: The presence of various pus-forming and other pathogenic organisms, or their toxins, in the blood or tissues

Stomatitis: Inflammation of the mucous membrane of the mouth

Vesicle: A small, circumscribed elevation on the skin containing fluid (I.e., blister)

*Reference: Stedman’s Medical Dictionary, 26th Ed.





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