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Bioterrorism for Nevada Nurses

This course has been awarded four (4.0) contact hours.

This course expires on April 30, 2020.

Copyright © 2005 by RN.com. All Rights Reserved. Reproduction and distribution of

these materials are prohibited without the express written authorization of RN.com.

First Published: January 3, 2005 Revised: January 3, 2007 Revised: January 3, 2009 Revised January 18, 2013 Revised January 17, 2016

AcknowledgementsRN.com acknowledges the valuable contributions of…

…The Centers for Disease Control (CDC) (www.cdc.gov), the key government agency responsible for disseminating knowledge about various biological agents.

…U.S. Army Medical Research Institute of Infectious Diseases (USAMRRID). USAMRRID spearheads efforts to protect service members from biological threats. Its efforts are well known and utilized by the civilian population. USAMRRID is located at Fort Detrick, Maryland.

….

Suzan Miller-Hoover, DNP, RN, CCNS, CCRN

RN.com strives to keep its content fair and unbiased.

The author(s), planning committee, and reviewers have no conflicts of interest in relation to this course. Conflict of Interest is defined as circumstances a conflict of interest that an individual may have, which could possibly affect Education content about products or services of a commercial interest with which he/she has a financial relationship.

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There is no commercial support being used for this course. Participants are advised that the accredited status of RN.com does not imply endorsement by the provider or ANCC of any commercial products mentioned in this course. There is no "off label" usage of drugs or products discussed in this course. You may find that both generic and trade names are used in courses produced by RN.com. The use of trade names does not indicate any preference of one trade named agent or company over another. Trade names are provided to enhance recognition of agents described in the course. Note: All dosages given are for adults unless otherwise stated. The information on medications contained in this course is not meant to be prescriptive or all-encompassing. You are encouraged to consult with physicians and pharmacists about all medication issues for your patients. Purpose and Objectives The purpose of this course is to provide the learner with information regarding preparation for and response to bioterrorism. Although this course is designed to meet the Nevada state requirements, healthcare workers everywhere may benefit from the information provided in this module. For the purposes of this course, bioterrorism will include more than just biological agents. Discussion will include biological, chemical, radiological, and nuclear weapons. After successful completion of this course, you will be able to:

1. Define terrorism 2. Define bioterrorism 3. Delineate the categories of bioterrorism agents 4. Delineate the categories of personal protective equipment 5. Define Syndromic Surveillance and reporting procedures for acts of terrorism that involve

biological agents 6. Delineate information available on the Health Alert Network

Introduction The field of bioterrorism in the United States came to the forefront in the months following September 11th 2001. Bioterrorism is a unique threat that combines the fields of public health and national security. Bioterrorism is a national security issue. Numerous state and federal agencies are dedicated to prevention, reporting, and management of any potential terrorist act (Porter, 2012). After the 911 attack in 2011, several anthrax letters were sent across the nation, infecting 22 people and killing 5. This incident became “the worst biological attack in U.S. history” resulting in bioterrorism preparedness becoming a top security priority of the Bush administration. The U.S. Government Civilian Biodefense Funding was subsequently increased from $414 million,2001 to $3.65 billion, 2002 (Porter, 2012). Did you know?

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• Bioterrorism, biodefense, biological warfare can be traced back to the Assyrians before

600BC? • Modern day biological warfare began in World War I when the German’s attempted to infect

livestock being transported to France • The US started a bioweapons program in 1943 and discontinued it in 1969 • The Biological and Toxin Weapons Convention (BTWC) was signed in Washington, London,

and Moscow in 1972 and entered into force in 1975? • The first case of U.S. bioterrorism occurred in 1984 when a religious sect in Oregon

contaminated food with salmonella? What is Terrorism The Federal Emergency Management Agency (FEMA) defines terrorism as the use of force or violence against persons or property in violation of the criminal laws of the United States for purposes of intimidation, coercion, or ransom. Terrorists often use threats to create fear among the public, to try to convince citizens that their government is powerless to prevent terrorism, and to obtain immediate publicity for their causes. Terrorists usually select targets that will produce large numbers of casualties, so most acts of terrorism will also be Mass Casualty Incidents (MCI). This means that healthcare providers and facilities will have to change the way they normally practice to appropriately respond to an act of terrorism. What is Bioterrorism The Centers for Disease Control and Prevention (CDC) defines bioterrorism as “intentional release of viruses, bacteria, or other germs that can sicken or kill people, livestock, or crops” (Centers for Disease Control (CDC), 2016). The White House adds another sentence to this definition, “the act is intended to create fear and/or intimidate governments or societies in the pursuit of political, religious, or ideological goals” (Porter, 2012). The CDC focuses on the physical and medical damage while the White House focuses on the intention to commit an act of terrorism. Weapons of Mass Destruction Weapons of Mass Destruction (WMD) encompass a broad number of weapons, including: • Conventional weapons • Biological weapons • Chemical weapons • Nuclear weapons • Other advanced weapons These weapons are characterized by their broad-sweeping intended effects, such as inflicting mass casualties and/or physical destruction (Virginia Tech office of the Vice President for Research, 2005).

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Biological and Chemical Weapons Biological agents are infectious microbes or toxins used to produce illness or death in people, animals, or plants. Biological agents can be dispersed as aerosols or airborne particles. Terrorists may use biological agents to contaminate food or water because they are extremely difficult to detect. Chemical agents kill or incapacitate people, destroy livestock, or ravage crops. They can have an immediate effect (a few seconds to a few minutes) or a delayed effect (several hours to several days). Test your Knowledge: Terrorists may use biological agents to contaminate food or water because they are extremely difficult to detect.

A. True B. False

Rationale: Biological agents can be dispersed as aerosols or airborne particles. Terrorists may use biological agents to contaminate food or water because they are extremely difficult to detect. Indications of Biologic Warfare or Terrorist Attack There can be epidemiologic indications to a bioterrorist attack. The U.S Army Medical Research Institute of Infectious Diseases (USAMRIID) located at Fort Derick, Maryland lists the following as possible indications of a biologic related terrorist attack:

• The presence of a large epidemic with a similar disease or syndrome, especially in a discrete population

• Many cases of unexplained diseases or deaths • More severe disease than is usually expected for a specific pathogen, or failure to respond to

standard therapy • Unusual routes of exposure for a pathogen, such as the inhalational route for diseases that

normally occur through other exposures • A disease that is unusual for a given geographic area or transmission season • Disease normally transmitted by a vector that is not present in the local area • Multiple simultaneous or serial epidemics of different diseases in the same population • A single case of disease by an uncommon agent (smallpox, some viral hemorrhagic fevers) • A disease that is unusual for an age group • Unusual strains or variants of organisms or antimicrobial resistance patterns different from

those circulating • Similar genetic type among agents isolated from distinct sources at different times or locations • Higher disease rates in those exposed in certain areas, such as inside a building if released

indoors, or lower rates in those inside a sealed building if released outside • Disease outbreaks of the same illness occurring in noncontiguous areas • A disease outbreak with zoonotic (animal diseases that are transmitted to humans, e.g. rabies,

Ebola) impact • Intelligence of a potential attack, claims by a terrorist or aggressor of a release, and discovery

of munitions or tampering (USAMRIID, 2005) Test Your Knowledge: Which of the following may be an epidemiologic indication?

A. A disease that is usual for a specific gender

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B. Common routes of exposure for the pathogen C. Many cases of unexplained diseases and deaths D. Less severe disease than is usually expected for a specific pathogen

Rationale:

• The presence of a large epidemic with a similar disease or syndrome, especially in a discrete population

• Many cases of unexplained diseases or deaths • More severe disease than is usually expected for a specific pathogen, or failure to respond to

standard therapy • Unusual routes of exposure for a pathogen, such as the inhalational route for diseases that

normally occur through other exposures • A disease that is unusual for a given geographic area or transmission season • Disease normally transmitted by a vector that is not present in the local area • Multiple simultaneous or serial epidemics of different diseases in the same population • A single case of disease by an uncommon agent (smallpox, some viral hemorrhagic fevers) • A disease that is unusual for an age group • Unusual strains or variants of organisms or antimicrobial resistance patterns different from

those circulating • Similar genetic type among agents isolated from distinct sources at different times or locations • Higher disease rates in those exposed in certain areas, such as inside a building if released

indoors, or lower rates in those inside a sealed building if released outside • Disease outbreaks of the same illness occurring in noncontiguous areas • A disease outbreak with zoonotic (animal diseases that are transmitted to humans, e.g. rabies,

Ebola) impact • Intelligence of a potential attack, claims by a terrorist or aggressor of a release, and discovery

of munitions or tampering (USAMRIID, 2005) Syndromic Surveillance Syndromic surveillance is used for early detection of outbreaks; tracking the size, spread, and tempo of outbreaks, monitoring disease trends, and providing reassurance that an outbreak has not occurred. Syndromic surveillance systems seek to use existing health data in real time to provide immediate analysis and feedback to those charged with investigation and follow-up of potential outbreaks. Optimal syndrome definitions for continuous monitoring and specific data sources best suited to outbreak surveillance for specific diseases have not been determined. Broadly applicable signal-detection methodologies and response protocols that would maximize detection while preserving scant resources are being sought. There are advantages and disadvantages to syndromic surveillance systems. Syndromic surveillance systems might enhance collaboration among public health agencies, healthcare providers, information-system professionals, academic investigators, and industry. However, syndromic surveillance does not replace traditional public health surveillance, nor does it substitute for direct physician reporting of unusual or suspect cases of public health importance. Categories of Biological Agents Potential agents of bioterrorism are classified into 3 categories, depending on how easily they can be spread and the severity of illness or death they cause: Category A agents: • Pathogens, organisms/biologic agents that pose the highest risk because they:

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o Can be easily disseminated or transmitted from person to person o Result in high mortality rates and have the potential for major public health impact o Might cause public panic and social disruption o Require special action for public health preparedness

• Category A Priority Pathogens o Bacillus anthracis (anthrax) o Clostridium botulinum toxin (botulism) o Yersinia pestis (plague) o Variola major (smallpox) and other related pox viruses o Francisella tularensis (tularemia) o Viral hemorrhagic fevers

▪ Arenaviruses Junin, Machupo, Guanarito, Chapare (new in fiscal year (FY) 14), Lassa,

Lujo (new in FY 14) ▪ Bunyaviruses

Hantaviruses causing Hanta Pulmonary syndrome, Rift Valley Fever, Crimean Congo Hemorrhagic Fever

▪ Flaviruses Dengue

▪ Filoviruses Ebola Marburg

Category B agents: • Pathogens, organisms/biologic agents that pose the second highest risk because they:

o Are moderately easy to disseminate o Result in moderate morbidity rates and low mortality rates o Require specific enhancements for diagnostic capacity and enhanced disease surveillance

• Category B Priority Pathogens o Urkholderia pseudomallei (melioidosis) o Coxiella burnetii (Q fever) o Brucella species (brucellosis) o Burkholderia mallei (glanders) o Chlamydia psittaci (Psittacosis) o Ricin toxin (Ricinus communis) o Epsilon toxin (Clostridium perfringens) o Staphylococcus enterotoxin B (SEB) o Typhus fever (Rickettsia prowazekii) o Food- and waterborne pathogens o Bacteria

▪ Diarrheagenic E. coli ▪ Pathogenic Vibrios ▪ Shigella species ▪ Salmonella ▪ Listeria monocytogenes ▪ Campylobacter jejuni

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▪ Yersinia enterocolitica o Viruses

▪ Caliciviruses ▪ Hepatitis A

o Protozoa ▪ Cryptosporidium parvum ▪ Cyclospora cayatanensis ▪ Giardia lamblia ▪ Entamoeba histolytica ▪ Toxoplasma gondii ▪ Naegleria fowleri (new in FY 14) ▪ Balamuthia mandrillaris (new in FY 14)

o Fungi Microsporidia

o Mosquito-borne encephalitis viruses West Nile virus (WNV) LaCrosse encephalitis (LACV) California encephalitis Venezuelan equine encephalitis (VEE) Eastern equine encephalitis (EEE) Western equine encephalitis (WEE) Japanese encephalitis virus (JE) St. Louis encephalitis virus (SLEV)

Category C agents: • Pathogens, organisms/biologic agents that pose the third highest risk because they:

o Are emerging pathogens that could be engineered for mass dissemination ▪ Availability ▪ Ease of production and dissemination ▪ Potential for high morbidity and mortality rates and major health impact

• Category C Priority Pathogens o ipah and Hendra viruses o Additional hantaviruses o Tickborne hemorrhagic fever viruses o Bunyaviruses o Severe Fever with Thrombocytopenia Syndrome virus (SFTSV), Heartland virus o Flaviruses o Omsk Hemorrhagic Fever virus, Alkhurma virus, Kyasanur Forest virus o Tickborne encephalitis complex flaviviruses o Tickborne encephalitis viruses o European subtype o Far Eastern subtype o Siberian subtype o Powassan/Deer Tick virus o Yellow fever virus o Tuberculosis, including drug-resistant TB o Influenza virus o Other Rickettsias

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o Rabies virus o Prions o Chikungunya virus o Coccidioides spp o Severe acute respiratory syndrome associated coronavirus (SARS-CoV), MERS-CoV,

and other highly pathogenic human coronaviruses (new in FY 14) The above list of biological agents is not meant to be inclusive. Healthcare providers must be prepared to address various biological agents. The following link will enable the learner to access the most up-to-date information regarding biological agents, exposure, symptoms, and treatment. https://www.niaid.nih.gov/topics/biodefenserelated/biodefense/pages/cata.aspx Category A Biological Agents For each agent in Category A described in this course, we present an overview, symptoms, treatments, vaccines, and decontamination issues. At the end of this section there is a discussion on decontamination in general. U.S Army Medical Research Institute of Infectious Diseases (USAMRIID) (www.usamriid.army.mil/education/), located at Fort Derick, MD is the source of the critical information on the various Category A potential agents of bioterrorism. This course details those diseases in Category A and includes the following Category A bioterrorism agents: • Anthrax • Botulism • Pneumonic Plague • Smallpox • Tularemia • Viral Hemorrhagic Fevers (VHF) Bacterial Agents: Anthrax Bacillus anthracis, the causative agent of Anthrax, is a gram-positive, sporulation rod. The spores are the usual infective form. Anthrax is primarily a zoonotic disease of herbivores, with cattle, sheep, goats, and horses being the usual domesticated animal hosts, but other animals may be infected. Humans generally contract the disease when handling contaminated hair, wool, hides, flesh, blood, and excreta of infected animals, and from manufactured products such as bone meal. Infection is introduced through scratches or abrasions of the skin, wounds, inhalation of spores, eating insufficiently cooked infected meat, or by being bitten by fleas. The primary concern for intentional infection by this organism is through inhalation after aerosol dissemination of spores. All human populations are susceptible. The spores are very stable and may remain viable for many years in soil and water. They resist sunlight for varying periods. Test Your Knowledge:

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Many biologic agents are zoonotic diseases (animal sources), Anthrax is a zoonotic disease primarily from (choose all that apply)

A. Herbivores such as cattle and sheep B. Carnivores such as dogs and cats C. Domesticated animals D. Undomesticated animals

Rationale: Anthrax is primarily a zoonotic disease of herbivores, with cattle, sheep, goats, and horses being the usual domesticated animal hosts, but other animals may be infected. Humans generally contract the disease when handling contaminated hair, wool, hides, flesh, blood, and excreta of infected animals, and from manufactured products such as bone meal. Presentation of Anthrax Signs and Symptoms Incubation period is generally 1–6 days, although longer periods have been noted. Fever, malaise, fatigue, cough, and mild chest discomfort progresses to severe respiratory distress with dyspnea, diaphoresis, stridor, cyanosis, and shock. Death typically occurs within 24–36 hours after onset of severe symptoms. Diagnosis Physical findings are non-specific. A widened mediastinum may be seen on CXR in later stages of illness. The organism is detectable by Gram stain of the blood and by blood culture late in the course of illness. Treatment Although effectiveness may be limited after symptoms are present, high dose antibiotic treatment with penicillin, ciprofloxacin, or doxycycline should be undertaken. Supportive therapy may be necessary. Decontamination of clothing with antimicrobial soap and water is also recommended. Bacterial Agents: Anthrax Prophylaxis Oral ciprofloxacin (Cipro) or doxycycline (Vibramycin) for known or imminent exposure. An FDA licensed vaccine is available. Vaccine schedule is 0.5 ml SC at 0, 4 weeks, then 6, 12, and 18 months (primary series), followed by annual boosters. Isolation and Decontamination Standard precautions for healthcare workers. After an invasive procedure or autopsy is performed, the instruments and area used should be thoroughly disinfected with a sporicidal agent (hypochlorite).

Contagious?

NO! Biological Toxins: Botulism Botulinum The botulinum toxins are a group of seven related neurotoxins produced by the spore-forming bacillus Clostridium botulinum and two other Clostridia species. These toxins, types A through G, are the

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most potent neurotoxins known; paradoxically, they have been used therapeutically to treat spastic conditions (such as strabismus, torticollis & tetanus) and cosmetically to treat wrinkles. The spores are ubiquitous; they germinate into vegetative bacteria that produce toxins during anaerobic incubation. Industrial-scale fermentation can produce large quantities of toxin for use as a BW agent. There are three epidemiologic forms of naturally occurring botulism—food borne, infantile, and wound. Botulinum could be delivered by aerosol or used to contaminate food or water supplies. When inhaled, these toxins produce a clinical picture very similar to food borne intoxication, although the time to onset of paralytic symptoms after inhalation may actually be longer than for food borne cases, and may vary by type and dose of toxin. The clinical syndrome produced by these toxins is known as "botulism." Test Your Knowledge: Which of the following are epidemiologic forms of naturally occurring botulism?

A. Food borne B. Infantile C. Wound D. All of the above

Rationale: There are three epidemiologic forms of naturally occurring botulism—food borne, infantile, and wound. Biological Toxins: Botulism Signs and Symptoms Usually begins with cranial nerve palsies, including ptosis, blurred vision, diplopia, dry mouth and throat, dysphagia, and dysphonia. This is followed by symmetrical descending flaccid paralysis, with generalized weakness and progression to respiratory failure. Symptoms begin as early as 12–36 hours after inhalation, but may take several days after exposure to low doses of toxin. Diagnosis Diagnosis is primarily a clinical one. Biowarfare attack should be suspected if multiple casualties simultaneously present with progressive descending flaccid paralysis. Lab confirmation can be obtained by bioassay (mouse neutralization) of the patient’s serum. Other helpful labs include: ELISA or ECL for antigen in environmental samples, PCR for bacterial DNA in environmental samples, or nerve conduction studies and electromyography. Treatment Early administration of trivalent licensed antitoxin or heptavalent antitoxin (IND product) may prevent or decrease progression to respiratory failure and hasten recovery. Intubation and ventilatory assistance for respiratory failure. Tracheostomy may be required. Prophylaxis Pentavalent toxoid vaccine (types A, B, C, D, and E) is available for those at high risk of exposure. Isolation and Decontamination Standard Precautions for healthcare workers. Toxin is not dermally active and secondary aerosols are not a hazard from patients. Decontaminate with soap and water. Botulinum toxin is inactivated by sunlight within 1–3 hours. Heat (80OC for 30 min., 100OC for several minutes) and chlorine (>99.7% inactivation by 3 mg/L FAC in 20 min.) also destroy the toxin.

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Contagious?

NO! Bacterial Agents: Plague Yersinia pestis is a rod-shaped, non-motile, non-sporulating, gram-negative bacterium of the family Enterobacteraceae. It causes plague, a zoonotic disease of rodents. Fleas that live on the rodents can transmit the bacteria to humans, who then suffer from the bubonic form of plague. The bubonic form may progress to the septicemic and/or pneumonic forms. Pneumonic plague would be the predominant form after a purposeful aerosol dissemination. All human populations are susceptible. Recovery from the disease is followed by temporary immunity. The organism remains viable in water, moist soil, and grains for several weeks. The bacterium can remain alive from months to years, but are killed by 15 minutes of exposure to 55°C. It also remains viable for some time in dry sputum, flea feces, and buried bodies but is killed within several hours of exposure to sunlight. Signs and Symptoms Pneumonic plague begins after an incubation period of 1–6 days, with high fever, chills, headache, malaise, followed by cough (often with hemoptysis), progressing rapidly to dyspnea, stridor, cyanosis, and death. Gastrointestinal symptoms are often present. Death results from respiratory failure, circulatory collapse, and a bleeding diathesis. Bubonic plague, featuring high fever, malaise, and painful lymph nodes (buboes) may progress spontaneously to the septicemic form (septic shock, thrombosis, DIC) or to the pneumonic form. Bacterial Agents Plague Diagnosis Suspect plague if large numbers of previously healthy individuals develop fulminant Gram negative pneumonia, especially if hemoptysis is present. Presumptive diagnosis can be made by Gram, Wright, Giemsa, or Wayson stain of blood, sputum, CSF, or lymph node aspirates. Definitive diagnosis requires culture of the organism from those sites. Immunodiagnostic is also helpful. Treatment Early administration of antibiotics is critical; as pneumonic plague is invariably fatal if antibiotic therapy is delayed more than 1 day after the onset of symptoms. Choose one of the following: streptomycin, gentamicin (Garamycin), ciprofloxacin (Cipro), or doxycycline (Vibramycin) for 10–14 days. Chloramphenicol (Chloromycetin) is the drug of choice for plague meningitis. Prophylaxis For asymptomatic persons exposed to a plague aerosol or to a patient with suspected pneumonic plague, give doxycycline (Vibramycin) 100 mg orally twice daily for seven days or the duration of risk of exposure plus one week. Alternative antibiotics include ciprofloxacin (Cipro), tetracycline, or chloramphenicol (Chloromycetin). No vaccine is currently available for plague prophylaxis. The previously available licensed, killed vaccine was effective against bubonic plague, but not against aerosol exposure.

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Isolation and Decontamination Use Standard Precautions for bubonic plague and Respiratory Droplet Precautions for suspected pneumonic plague. Y. pestis can survive in the environment for varying periods, but is susceptible to heat, disinfectants, and exposure to sunlight. Soap and water are effective if decontamination is needed. Take measures to prevent local disease cycles if vectors (fleas) and reservoirs (rodents) are present.

Contagious?

YES! Viral Agents: Smallpox Smallpox is caused by the Orthopox virus, variola, which occurs in at least two strains, variola major and the milder disease, variola minor. Despite the global eradication of smallpox and continued availability of a vaccine, the potential weaponization of variola continues to pose a military threat. This threat can be attributed to the aerosol infectivity of the virus, the relative ease of large-scale production, and an increasingly Orthopoxvirus-naive populace. Although the fully developed cutaneous eruption of smallpox is unique, earlier stages of the rash could be mistaken for varicella. Secondary spread of infection constitutes a nosocomial hazard from the time of onset of a smallpox patient's exanthem until scabs have separated. Quarantine with respiratory isolation should be applied to secondary contacts for 17 days post-exposure. Vaccinia vaccination and vaccinia immune globulin each possess some efficacy in post-exposure prophylaxis. Signs and Symptoms Clinical manifestations begin acutely with malaise, fever, rigors, vomiting, headache, and backache. 2–3 days later lesions appear which quickly progress from macules to papules, and eventually to pustular vesicles. They are more abundant on the extremities and face, and develop synchronously. Test Your Knowledge: Which of the following are NOT true about smallpox?

A. Smallpox has been eradicated worldwide, but is a potential biological warfare agent B. Smallpox may be mistaken for varicella in the early stages C. Respiratory isolation should be applied for 17 days to exposed contacts D. Smallpox lesions are more abundant on the trunk

Rationale: Despite the global eradication of smallpox and continued availability of a vaccine, the potential weaponization of variola continues to pose a military threat. Although the fully developed cutaneous eruption of smallpox is unique, earlier stages of the rash could be mistaken for varicella. Secondary spread of infection constitutes a nosocomial hazard from the time of onset of a smallpox patient's exanthem until scabs have separated. Quarantine with respiratory isolation should be applied to secondary contacts for 17 days post-exposure. Two to three days later lesions appear which quickly progress from macules to papules, and eventually to pustular vesicles. They are more abundant on the extremities and face, and develop synchronously.

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Viral Agents: Smallpox Diagnosis Neither electron nor light microscopy are capable of discriminating variola from vaccinia, monkeypox, or cowpox. The new PCR diagnostic techniques may be more accurate in discriminating between variola and other Orthopoxviruses. Treatment At present there is no effective drug therapy, and treatment of a clinical case remains supportive. Prophylaxis Immediate vaccination or re-vaccination should be undertaken for all personnel exposed. Isolation and Decontamination Droplet and Airborne Precautions for a minimum of 17 days following exposure for all contacts. Patients should be considered infectious until all scabs separate and quarantined during this period. In the civilian setting strict quarantine of asymptomatic contacts may prove to be impractical and impossible to enforce. A reasonable alternative would be to require contacts to check their temperatures daily. Any fever above 38° C (101° F) during the 17-day period following exposure to a confirmed case would suggest the development of smallpox. The contact should then be isolated immediately, preferably at home, until smallpox is either confirmed or ruled out and remain in isolation until all scabs separate. (Scabbing is complete and falls off; skin underneath is intact.)

Contagious?

YES! Bacterial Agents: Tularemia Francisella tularensis is a small, aerobic non-motile, gram-negative cocco-bacillus. Tularemia (also known as rabbit fever and deer fly fever) is a zoonotic disease that humans typically acquire after skin or mucous membrane contact with tissues or body fluids of infected animals, or from bites of infected ticks, deerflies, or mosquitoes. Less commonly, inhalation of contaminated dusts or ingestion of contaminated foods or water may produce clinical disease. Respiratory exposure by aerosol would typically cause typhoidal or pneumonic tularemia. F. tularensis can remain viable for weeks in water, soil, carcasses, hides, and for years in frozen rabbit meat. It is resistant for months to temperatures of freezing and below. It is easily killed by heat and disinfectants. Signs and Symptoms Ulceroglandular tularemia presents with a local ulcer and regional lymphadenopathy, fever, chills, headache, and malaise. Typhoidal tularemia presents with fever, headache, malaise, substernal discomfort, prostration, weight loss, and a non-productive cough. Bacterial Agents: Tularemia Diagnosis Clinical diagnosis. Physical findings are usually non-specific. Chest x-ray may reveal a pneumonic process, mediastinal lymphadenopathy, or pleural effusion. Routine culture is possible but difficult. The diagnosis can be established retrospectively by serology.

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Treatment Administration of antibiotics (streptomycin or gentamicin [Garamycin]) with early treatment is very effective. Prophylaxis A live, attenuated vaccine is recommended for prophylaxis. It is administered once by scarification. A two-week course of tetracycline is also effective as prophylaxis when given after exposure. Isolation and Decontamination Standard Precautions for healthcare workers. Organisms are relatively easy to render harmless by mild heat (55 degrees Celsius for 10 minutes) and standard disinfectants.

Contagious?

NO! Viral Agents: Hemorrhagic Fever-Ebola Viral hemorrhagic fevers (VHFs) refer to a diverse group of illnesses that are caused by distinct families of RNA viruses from four viral families. In general, the term VHF is used to describe a severe multi-system syndrome. One of the newest viral agent added to this category is Ebola. Ebola was brought to the fore-front due to the Ebola epidemic in 2015. While some types of hemorrhagic fever viruses can cause relatively mild illnesses, many of these viruses cause severe, life-threatening disease. Examples of VHFs include Ebola, dengue and yellow fever. These viruses are spread in a variety of ways; some may be transmitted to humans through a respiratory portal of entry. Although evidence for weaponization does not exist for many of these viruses, they are included in this course because of their potential for aerosol dissemination or weaponization. Signs and Symptoms VHFs present as febrile illnesses which can feature flushing of the face and chest, petechiae, bleeding, edema, hypotension, and shock. Malaise, myalgia, headache, vomiting, and diarrhea may occur in any of the hemorrhagic fevers. Characteristically, the overall vascular system is damaged, and the body's ability to regulate itself is impaired. These symptoms are often accompanied by hemorrhage; however, the bleeding is itself rarely life-threatening. Viral Agents: Hemorrhagic Fevers Diagnosis Definitive diagnosis rests on specific virologic techniques. Significant numbers of military personnel with a hemorrhagic fever syndrome should suggest the diagnosis of a viral hemorrhagic fever. Treatment Intensive supportive care may be required. Antiviral therapy with ribavirin (Virazole) may be useful in several of these infections. Convalescent plasma may be effective in Argentine hemorrhagic fever.

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Prophylaxis The only licensed VHF vaccine is yellow fever vaccine. Prophylactic ribavirin (Virazole) may be effective for Lassa fever, Rift Valley fever, and possibly HFRS (Hemorrhagic Fever with Renal Syndrome). Isolation and Decontamination Contact isolation, with the addition of a surgical mask and eye protection for those coming within three feet of the patient, is indicated for suspected or proven VHFs. Respiratory protection should be upgraded to airborne isolation, including the use of a fit-tested HEPA filtered respirator, a battery powered air purifying respirator, or a positive pressure supplied air respirator, if patients with the above conditions have prominent cough, vomiting, diarrhea, or hemorrhage. Decontamination is accomplished with hypochlorite or phenolic disinfectants.

Contagious?

YES! (But not always)

Chemical Agents • 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: o Chemical agents already known to be used as weaponry o Availability of chemical agents to potential terrorists o Chemical agents likely to cause major morbidity or mortality o Potential of agents for causing public panic and social disruption o Agents that require special action for public health preparedness

The CDC generally groups chemical agents into a number of categories. Not all categories or agents will be discussed within the scope of this course. Five Specific agents/types of agents will be discussed in detail later in this course.

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Common categories and agents.

Biotoxins Abrin Ricin Strychnine

Blood Agents Arsine (SA) Cyanide Cyanogen chloride (CK) Hydrogen cyanide (AC) Potassium cyanide (KCN) Sodium cyanide (NaCN)

Choking/Lung/Pulmonary Agents Ammonia Bromine (CA) Chlorine (CL) Hydrogen chloride Osmium Tetroxide Phosgene Diphosgene (DP) Phosgene (CG) Phosphine Phosphorus, elemental, white or yellow

Long-Acting Anticoagulants Super warfarin

Nerve Agents G agents Sarin (GB) Soman (GD) Tabun (GA)

V agents VX Blister Agents/Vesicants Mustards

Distilled mustard (HD) Mustard gas (H) (sulfur mustard) Mustard/lewisite (HL) Mustard/T Nitrogen mustard (HN-1, HN-2, HN-3) Sesqui mustard Sulfur mustard (H) (mustard gas) Lewisites/chloroarsine agents Lewisite (L, L-1, L-2, L-3) Mustard/lewisite (HL) Phosgene oxime (CX)

Caustics (Acids) Hydrofluoric acid (hydrogen fluoride) Hydrogen fluoride (hydrofluoric acid)

Incapacitating Agents

BZ Fentanyl and other opioids

Metals Arsenic Mercury Thallium

Organic Solvents Benzene Riot Control Agents/Tear Gas Various agents and combinations of agents

Bromobenzylcyanide (CA) Chloroacetophenone (CN) Chlorobenzylidenemalononitrile (CS) Chloropicrin (PS) Dibenzoxazepine (CR)

Toxic Alcohols Ethylene glycol Vomiting Agents Adamsite (DM)

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Emergency Room Procedures in Chemical Hazard Emergencies The following information and information for medical management of other toxic chemical agents is provided by The Agency for Toxic Substances and Disease Registry Division of Toxicology, part of the CDC (http://www.atsdr.cdc.gov), and from the Environmental Public Health Readiness Branch, Chemical Weapons Elimination team. This course contains emergency guidelines from these agencies for 5 common agents: Nerve Agent, Phosgene, Lewisite, Mustard, and Chlorine. Agent identification is the #1 step in preparing to receive patients from a chemical emergency. Emergency Room Procedures in Chemical Hazard Emergencies Preparations 1. Try to determine agent identity. 2. Break out personal protection equipment, decontamination supplies, antidotes, etc. 3. Is chemical hazard certain or very likely? YES:

• Don personal protective equipment • Set up hot line

4. Clear and secure all areas that could become contaminated 5. Prepare to or secure hospital entrances and grounds 6. Notify local emergency management authorities if needed 7. If chemical is a military agent and Army has not been informed, call them 8. If an organophosphate is involved, notify hospital pharmacy that large amounts of atropine and

2PAM may be needed When victim arrives (Note: A contaminated patient may present at an emergency room without prior warning.)

9. Does chemical hazard exist? * Known release/exposure (including late notification) * Liquid on victim's skin or clothing * Symptoms in victim, EMTs, others * Odor (H, L, phosgene, chlorine) * M-8 paper, if appropriate YES: Go to 10 NO: Handle victim routinely

10. Hold victim outside until preparations are completed (don personal protective equipment to assist EMT’s as necessary)

11. If patient is grossly contaminated (liquid on skin, positive M-8 paper) OR if there is any suspicion of contamination, decontaminate patient before entry into building

M-8 paper tape provides a simple way to check exposed surfaces for the presence of chemical agent contamination. The papers are treated with agent-sensitive dyes that change color in the presence of liquid chemical agents. They can be placed on a person’s skin or clothing and change color depending on the agent that the paper detects. M-8 will change to four possible

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colors: red, yellow, green or blue. If the paper changes to red, it indicates possible blister agent. A yellow, green or blue change indicates possible nerve agent. Emergency Room Procedures in Chemical Hazard Emergencies 1. Establish airway if necessary. 2. Give artificial respiration if not breathing. 3. Control bleeding if hemorrhaging. 4. Symptoms of cholinesterase poisoning?

* Pinpoint pupils * Difficulty breathing (wheezing, gasping, etc.) * Local or generalized sweating * Fasciculation (uncontrollable muscle twitching) * Copious secretions * Nausea, vomiting, diarrhea * Convulsions * Coma YES: Go to NERVE AGENT PROTOCOL (on the following pages)

5. History of chlorine poisoning? YES: Go to CHLORINE PROTOCOL. (on the following pages)

6. Burns that began within minutes of poisoning? YES: Go to 7. NO: Go to 8.

7. Thermal burn? YES: Go to 9. NO: Go to LEWISITE PROTOCOL (on the following pages)

8. Burns or eye irritation beginning 2-12 hours after exposure? YES: Go to MUSTARD PROTOCOL (on the following pages) NO: Go to 9. 9. Is phosgene exposure possible? * Known exposure to phosgene * Known exposure to hot chlorinated hydrocarbons * Respiratory discomfort beginning a few hours after exposure YES: Go to PHOSGENE PROTOCOL (on the following pages) 10.

Check other possible chemical exposures: * Known exposure * Decreased level of consciousness without head trauma. * Odor on clothes or breath * Specific signs or symptoms

Facts About Phosgene What is phosgene?

• Phosgene is a major industrial chemical used to make plastics and pesticides. • At room temperature (70°F), phosgene is a poisonous gas. • With cooling and pressure, phosgene gas is converted into a liquid that can be shipped and

stored. When liquid phosgene is released, it quickly turns into a gas that stays close to the ground and spreads rapidly.

• Phosgene gas may appear colorless or a white to pale yellow cloud. At low concentrations, it has a pleasant odor of newly mown hay or green corn, but its odor may not be noticed by all people exposed. At high concentrations, the odor may be strong and unpleasant.

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• Phosgene itself is nonflammable but it can cause flammable substances around it to burn. • Phosgene is also known by its military designation, “CG.”

Where phosgene is found and how it is used

• Phosgene was used extensively during World War I as a choking (pulmonary) agent. • Phosgene is not found naturally in the environment; it is used in industry to produce many

other chemicals such as pesticides. • Phosgene can be formed when certain compounds are exposed to heat, such as some types

of plastics. • Phosgene gas is heavier than air, so it would be more likely found in low-lying areas.

Exposure to Phosgene The risk for exposure depends on how close an individual is to the place where the phosgene was released. If phosgene gas is released into the air, people may be exposed through skin contact or eye contact. They may also be exposed by breathing air that contains phosgene. If phosgene liquid is released into water, people may be exposed by touching or drinking water that contains phosgene. If phosgene liquid comes into contact with food, people may be exposed by eating the contaminated food. Phosgene gas and liquid are irritants that can damage the skin, eyes, nose, throat, and lungs. The extent of damage caused by phosgene poisoning depends on the amount of phosgene to which a person is exposed, the route of exposure, and the length of time that a person is exposed. Immediate Signs and Symptoms of Phosgene Exposure During or immediately after exposure to dangerous concentrations of phosgene, the following signs and symptoms may develop: • Coughing • Burning sensation in the throat and eyes • Watery eyes • Blurred vision • Difficulty breathing or shortness of breath • Nausea and vomiting • Skin contact can result in lesions similar to those from frostbite or burns • Following exposure to high concentrations of phosgene, a person may develop pulmonary edema

within 2 to 6 hours Later Signs and Symptoms of Phosgene Exposure Exposure to phosgene may cause delayed effects that may not be apparent for up to 48 hours after exposure, even if the person feels better or appears well following removal from exposure. Therefore, people who have been exposed to phosgene should be monitored for 48 hours afterward. Delayed effects that can appear for up to 48 hours include the following: • Difficulty breathing • Coughing up white to pink-tinged fluid • Low blood pressure

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• Heart failure Management of Phosgene Exposure Most people exposed to phosgene make a complete recovery. However, chronic bronchitis and emphysema have been reported as a result of phosgene exposure. If exposed to phosgene: • Leave the area where the phosgene was released and get to fresh air. If outdoors, go to the

highest ground possible, because phosgene is heavier than air and will sink to low-lying areas. • Remove all clothing, rapidly wash the entire body with large amounts of soap and water, and

provide medical care as quickly as possible. Avoid pulling any contaminated clothing over the head. Seal all clothing in double plastic bags.

• Inform the local or state health department or emergency personnel upon their arrival. Do not handle the plastic bags.

• If a person experiences burning eyes or blurred vision, rinse the eyes with plain water for 10 to 15 minutes.

• If phosgene is ingested, do not induce vomiting or drink fluids. Treatment for phosgene exposure consists of removing phosgene from the body as soon as possible and providing supportive medical care in a hospital setting. No antidote exists for phosgene. Exposed people should be observed for up to 48 hours, because it may take that long for symptoms to develop or reoccur. Phosgene Protocol The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET) recommends the following protocol post phosgene exposure: If there is known phosphate poisoning, restrict fluids, perform chest x-ray and draw blood gases ASAP. If results are consistent with phosgene poisoning, admit immediately and provide oxygen under positive end-expiratory pressure and restrict fluids. Observe closely for at least 6 hours. Facts About Sulfur Mustard What is sulfur mustard?

• Sulfur mustard is a type of chemical warfare agent. These kinds of agents are called vesicants or blistering agents, because they cause blistering of the skin and mucous membranes on contact.

• Sulfur mustard is also known as “mustard gas or mustard agent,” or by the military designations H, HD, and HT.

• Sulfur mustard sometimes smells like garlic, onions, or mustard and sometimes has no odor. It can be a vapor, an oily-textured liquid, or a solid.

• Sulfur mustard can be clear to yellow or brown when it is in liquid or solid form. Where sulfur mustard is found and how it is used

• Sulfur mustard is not found naturally in the environment. • Sulfur mustard was introduced in World War I as a chemical warfare agent. Until recently, it

was available for use in the treatment of a skin condition called psoriasis. Currently, it has no medical use.

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Exposure to Sulfur Mustard If sulfur mustard is released into the air as a vapor, people can be exposed through skin contact, eye contact, or breathing. Sulfur mustard vapor can be carried long distances by wind. If sulfur mustard is released into water, people can be exposed by drinking the contaminated water or getting it on their skin. People can be exposed by coming in contact with liquid sulfur mustard. Sulfur mustard can last from 1 to 2 days in the environment under average weather conditions and from weeks to months under very cold conditions. Sulfur mustard breaks down slowly in the body, so repeated exposure may have a cumulative effect. The adverse health effects caused by sulfur mustard depend on the amount people are exposed to, the route of exposure, and the length of time that people are exposed. Sulfur mustard is a powerful irritant and blistering agent that damages the skin, eyes, and respiratory tract. It damages DNA, a vital component of cells in the body. Sulfur mustard vapor is heavier than air, so it will settle in low-lying areas Management of Sulfur Mustard Exposure Exposure to sulfur mustard liquid is more likely to produce second- and third- degree burns and later scarring than is exposure to sulfur mustard vapor. Extensive breathing in of the vapors can cause chronic respiratory disease, repeated respiratory infections, or death. Extensive eye exposure can cause permanent blindness. Exposure to sulfur mustard may increase a person’s risk for lung and respiratory cancer. If exposed to sulfur mustard:

• Immediately leave the area where the sulfur mustard was released. Try to find higher ground, because sulfur mustard is heavier than air and will settle in low-lying areas.

• Rapidly remove the sulfur mustard from the body and any contaminated clothing as soon as possible after exposure, as this is the only effective way to prevent or decrease tissue damage to the body. Seal clothing in a plastic bag, and then seal that bag inside a second plastic bag.

• Immediately wash any exposed part of the body (eyes, skin, etc.) thoroughly with plain, clean water. Eyes need to be flushed with water for 5 to 10 minutes. Do NOT cover eyes with bandages, but do protect them with dark glasses or goggles.

The most important factor is removing sulfur mustard from the body. Exposure to sulfur mustard is treated by giving the victim supportive medical care to minimize the effects of the exposure. Though no antidote exists for sulfur mustard, exposure is usually not fatal.

If someone has ingested sulfur mustard, do NOT induce vomiting. Give the person milk to drink.

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Mustard Protocol The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET) recommends the following protocol post sulfur mustard exposure: If there is known sulfur mustard poisoning, check for airway obstruction. If present, a tracheostomy may need to be performed ASAP. Assess for skin burns. If large burns are present, establish IV lines, but do not push fluids as for thermal burns. Drain vesicles by unroofing large blisters and irrigating the area with topical antibiotics. Treat other symptoms appropriately. This may include the application of antibiotic eye ointment, the use of sterile precautions prn and the administration of morphine prn for pain (generally not needed in emergency treatment; might be appropriate for in-patient treatment). Where lewisite is found and how it is used Lewisite was produced in 1918 to be used in World War I, but its production was too late for it to be used in the war. It has been used only as a chemical warfare agent. It has no medical or other practical use. Lewisite is not found naturally in the environment. Facts About Lewisite What is lewisite? Lewisite is a type of chemical warfare agent. This kind of agent is called a vesicant or blistering agent, because it causes blistering of the skin and mucous membranes on contact. Lewisite is an oily, colorless liquid in its pure form and can appear amber to black in its impure form. It has an odor like geraniums, and contains arsenic, a poisonous element. Lewisite is also known by its military designation, “L.”

Exposure to Lewisite Risk for exposure depends on how close an individual is to the site where the lewisite is released. If lewisite gas is released into the air, people may be exposed through skin contact or eye contact. Lewisite is a powerful irritant and blistering agent that immediately damages the skin, eyes, and respiratory tract. Exposure can also occur by inhaling air that contains lewisite. If lewisite liquid is released into water, people may be exposed by drinking water that contains lewisite or by getting the water on their bodies. If lewisite liquid comes into contact with food, people may be exposed by eating the contaminated food. Lewisite vapor is heavier than air, so it will settle in low-lying areas and will remain a liquid under a wide range of environmental conditions. Thus, it can last for a long time in the environment. Adverse health effects caused by lewisite depend on the amount people are exposed to, the route of exposure, and the length of time that people are exposed. Because it contains arsenic, lewisite has some effects that are similar to arsenic poisoning, including stomach ailments and low blood pressure.

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Signs & Symptoms of Lewisite Exposure Most information on the health effects of lewisite is based on animal studies. Signs and symptoms occur immediately following a lewisite exposure, and may include:

• Skin changes: Pain and irritation within seconds to minutes, redness within 15 to 30 minutes followed by blister formation within several hours. The blister begins as a small blister in the middle of the red areas and then expands to cover the entire reddened area of skin. The lesions (sores) from lewisite heal much faster than lesions caused by the other blistering agents, sulfur mustard and nitrogen mustards, and the discoloring of the skin that occurs later is much less noticeable.

• Eye irritation: Pain, swelling, and tearing may occur on contact. Blindness may result. • Respiratory tract changes: Runny nose, sneezing, hoarseness, bloody nose, sinus pain,

shortness of breath, and cough. • Digestive tract: diarrhea, nausea, and vomiting. • Cardiovascular: “Lewisite shock” or low blood pressure may occur.

Showing these signs and symptoms does not necessarily mean that a person has been exposed to lewisite. Lewisite does not suppress the immune system. Management of Lewisite Exposure If exposure to lewisite occurs, the area should be evacuated as quickly as possible. Moving quickly to an area where fresh air is available is highly effective in reducing the possibility of death from exposure to lewisite. People should move to the highest ground possible, because lewisite is heavier than air and will sink to low-lying areas. If the lewisite release is indoors, get out of the building. If you think you may have been exposed, remove your clothing as quickly as possible. Any clothing that has to be pulled over the head should be cut off the body and sealed in double plastic bags. This will help protect against further exposure to any chemicals remaining on the clothing. The entire body should be rapidly washed with soap and water, and medical attention sought as soon as possible. Treatment for lewisite exposure consists of removing lewisite from the body as soon as possible and providing supportive medical care in a hospital setting. An antidote for lewisite is available and is most useful if given as soon as possible after exposure. Lewisite Protocol The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET) recommends the following protocol post lewisite exposure: • Survey the extent of injury, and treat affected skin with British Anti-Lewisite (BAL, also known as

dimercaprol) ointment (if available). • Treat affected eyes with BAL ophthalmic ointment (if available). • Treat pulmonary effects using BAL in oil, 0.5 ml/25 lbs. body wt. deep IM to max of 4.0 ml. Repeat

q 4 h x 3 (at 4, 8, and 12 hours). Morphine may be given prn for pain. • For severe pulmonary reactions to lewisite, shorten the time interval for BAL injections to q 2 h. Facts about Chlorine What Is Chlorine? Chlorine is an element used in industry and in some household products, but can also be found in the form of a poisonous gas. It can be pressurized and cooled to change into a liquid for shipping and

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storage. When liquid chlorine is released, it turns into a gas that stays close to the ground and spreads rapidly. Chlorine gas can be recognized by its pungent, irritating odor, which is like the odor of bleach. The strong smell may provide a warning to people that they have been exposed. Chlorine gas appears to be yellow-green in color. Chlorine itself is not flammable, but it can react explosively or form explosive compounds with other chemicals such as turpentine and ammonia. Test Your Knowledge: Chlorine is a liquid and when released changes into a flammable gas that stays close to the ground and spreads rapidly. A. True B. False Rationale: When liquid chlorine is released, it turns into a gas that stays close to the ground and spreads rapidly. Chlorine itself is not flammable, but it can react explosively or form explosive compounds with other chemicals such as turpentine and ammonia. Where chlorine is found and how it is used Chlorine was used during World War I as a choking (pulmonary) agent, and is one of the most commonly manufactured chemicals in the United States. Its most important use is as a bleach in the manufacture of paper and cloth, but it is also used to make pesticides, rubber, and solvents. Chlorine is used in drinking water and swimming pool water to kill harmful bacteria. It is also as used as part of the sanitation process for industrial waste and sewage. Household chlorine bleach can release chlorine gas if it is mixed with other cleaning agents. Exposure to Chlorine People’s risk for exposure depends on how close they are to the place where the chlorine was released. If chlorine gas is released into the air, people may be exposed through skin contact or eye contact. They may also be exposed by breathing air that contains chlorine. If chlorine liquid is released into water, people may be exposed by touching or drinking water that contains chlorine. If chlorine liquid comes into contact with food, people may be exposed by eating the contaminated food. Chlorine gas is heavier than air, so it would settle in low-lying areas. The extent of poisoning caused by chlorine depends on the amount of chlorine a person is exposed to, how the person was exposed, and the length of time of the exposure.

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When chlorine gas comes into contact with moist tissues such as the eyes, throat, and lungs, an acid is produced that can damage these tissues. Signs & Symptoms of Chlorine Exposure During or immediately after exposure to dangerous concentrations of chlorine, the following signs and symptoms may develop: • Coughing • Chest tightness • Burning sensation in the nose, throat, and eyes • Watery eyes • Blurred vision • Nausea and vomiting • Burning pain, redness, and blisters on the skin if exposed to gas, skin injury similar to frostbite if

exposed to liquid chlorine • Difficulty breathing or shortness of breath (may appear immediately if high concentrations of

chlorine gas are inhaled, or may be delayed if low concentrations of chlorine gas are inhaled) • Pulmonary edema within 2 to 4 hours Exhibition of these signs or symptoms does not necessarily mean that a person has been exposed to chlorine. Long-term complications from chlorine exposure are not found in people who survive a sudden exposure unless they suffer complications such as pneumonia during therapy. Chronic bronchitis may develop in people who develop pneumonia during therapy. Test Your Knowledge: Patients exposed to chlorine may exhibit which of the following signs or symptoms? (choose all that apply)

A. Chest tightness B. Blurred vision C. Nausea D. Difficulty breathing

Rationale: During or immediately after exposure to dangerous concentrations of chlorine, the following signs and symptoms may develop: • Coughing • Chest tightness • Burning sensation in the nose, throat, and eyes • Watery eyes • Blurred vision • Nausea and vomiting • Burning pain, redness, and blisters on the skin if exposed to gas, skin injury similar to frostbite if

exposed to liquid chlorine • Difficulty breathing or shortness of breath (may appear immediately if high concentrations of

chlorine gas are inhaled, or may be delayed if low concentrations of chlorine gas are inhaled) • Pulmonary edema within 2 to 4 hours

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Exhibition of these signs or symptoms does not necessarily mean that a person has been exposed to chlorine

Management of Chlorine Exposure If exposure to chlorine occurs, the area should be vacated immediately. Quickly moving to an area where fresh air is available is highly effective in reducing exposure to chlorine. If the chlorine release was outdoors, move away from the area where the chlorine was released. Go to the highest ground possible, because chlorine is heavier than air and will sink to low-lying areas. If the chlorine release was indoors, get out of the building. If you think you may have been exposed, remove your clothing as quickly as possible. Any clothing that has to be pulled over the head should be cut off the body and sealed in double plastic bags. This will help protect against further exposure to any chemicals remaining on the clothing. The entire body should be rapidly washed with soap and water, and medical attention sought as soon as possible. Flush eyes with cold water and discard contact lenses with clothing. If chlorine is ingested, do not induce vomiting or drink fluids. Inform either the local or state health department or emergency personnel upon their arrival. Do not handle the plastic bags. If you are helping other people remove their clothing, try to avoid touching any contaminated areas, and remove the clothing as quickly as possible. No antidote exists for chlorine exposure. Treatment consists of removing the chlorine from the body as soon as possible and providing supportive medical care in a hospital setting. Chlorine Protocol The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET) recommends the following protocol post chlorine exposure: • If dyspnea is present, administer oxygen by mask as well as bronchodilators. Admit to hospital for

chest X-ray and further evaluation, as soon as possible. • Treat other problems and reevaluate. • If the respiratory system is stable, provide supportive therapy; treat other problems or discharge. Facts About Sarin (Nerve Agent) What Is Sarin? Sarin is a human-made chemical warfare agent classified as a nerve agent. Nerve agents are the most toxic and rapidly acting of the known chemical warfare agents. They are similar to certain kinds of pesticides called organophosphates in terms of how they work and what kind of harmful effects they cause. However, nerve agents are much more potent than organophosphate pesticides. Sarin originally was developed in 1938 in Germany as a pesticide, and is a clear, colorless, and tasteless liquid that has no odor in its pure form. However, sarin can evaporate into a vapor and spread into the environment. Sarin is also known as GB.

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Where Sarin is Found and How It Is Used Sarin is not found naturally in the environment. It is man-made and was used in chemical warfare during the Iran-Iraq War in the 1980s, and in two terrorist attacks in Japan in 1994 and 1995. Sarin is the most volatile of the nerve agents, which means that it can easily and quickly evaporate from a liquid into a vapor and spread into the environment. People can be exposed to the vapor even if they do not come in contact with the liquid form of sarin. Since sarin evaporates so quickly, it presents an immediate but short-lived threat. Exposure to Sarin Following the release of sarin into the air, people can be exposed through skin contact or eye contact. They can also be exposed by breathing air that contains sarin. Sarin mixes easily with water, so it could be used to poison water. Following release of sarin into water, people can be exposed by touching or drinking water that contains sarin. Following contamination of food with sarin, people can be exposed by eating the contaminated food. A person’s clothing can release sarin for about 30 minutes after it has come in contact with sarin vapor, which can lead to exposure of other people. Because sarin breaks down slowly in the body, people who are repeatedly exposed to sarin may suffer more harmful health effects. Sarin vapor is heavier than air and will sink to low-lying areas and create a greater exposure hazard there. Signs & Symptoms of Sarin Exposure The extent of poisoning caused by sarin depends on the amount of which a person was exposed, how the exposure occurred, and the length of time of the exposure. People may not know that they were exposed because sarin has no odor. People exposed to a low or moderate dose of sarin by breathing contaminated air, eating contaminated food, drinking contaminated water, or touching contaminated surfaces may experience some or all of the following symptoms within seconds to hours of exposure:

• Runny nose • Increased urination • Watery eyes • Confusion • Small, pinpoint pupils • Drowsiness • Eye pain • Weakness • Blurred vision • Headache • Drooling and excessive sweating • Nausea, vomiting, and/or abdominal

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• Cough • Pain • Chest tightness • Slow or fast heart rate • Rapid breathing • Low or high blood pressure • Diarrhea

Exposure to large doses of sarin by any route may result in the following harmful health effects: • Loss of consciousness • Convulsions • Paralysis • Respiratory failure possibly leading to death

Note! Even a small drop of sarin on the skin can cause sweating and muscle twitching where sarin touched the skin. Nerve agents inhibit the function of chemical that acts as the body’s “off switch” for glands and muscles. Without an “off switch,” the glands and muscles are constantly being stimulated. They may tire and no longer be able to sustain breathing function. Management of Sarin Exposure Recovery from sarin exposure is possible with treatment, but the antidotes available must be used quickly to be effective. Therefore, the best thing to do is avoid exposure. Evacuate the area where the sarin was released and get to fresh air. Quickly moving to an area where fresh air is available is highly effective in reducing the possibility of death from exposure to sarin vapor. If the sarin release was outdoors, move away from the area where the sarin was released. Go to the highest ground possible, because sarin is heavier than air and will sink to low lying areas. If the sarin release was indoors, get out of the building. If exposure occurs, remove all clothing, rapidly wash the entire body with soap and water, and get medical care as quickly as possible. Any clothing that has to be pulled over the head should be cut off the body and sealed in double plastic bags. This will help protect against further exposure to any chemicals remaining on the clothing. Flush eyes with cold water and discard contact lenses with clothing. If sarin is ingested, do not induce vomiting or drink fluids. Inform either the local or state health department or emergency personnel upon their arrival. Do not handle the plastic bags. If you are helping other people remove their clothing, try to avoid touching any contaminated areas, and remove the clothing as quickly as possible. Antidotes are available for sarin, and are most useful if given as soon as possible after exposure. Mild or moderate exposure usually results in a full recovery. Severe exposure results in death. Unlike some organophosphate pesticides, nerve agents have not been associated with neurological problems lasting more than 1 to 2 weeks after exposure.

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Nerve Agent Protocol The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET) recommends the following protocol post nerve agent exposure: • If severe respiratory distress is present: * Intubate and ventilate

o Administer Atropine: Adults: 6 mg IM or IV Infants/pediatrics: 0.05 mg/kg IV

o Administer 2-PAM C1 ▪ Adults: 600-1000 mg IM or slow IV ▪ Infants/pediatrics: 15 mg/kg slow IV

• If major secondary symptoms are present: o Administer Atropine:

▪ Adults: 4 mg IM or IV ▪ Infants/pediatrics: 0.02 - 0.05 mg/kg IV

o Administer 2-PAM C1: ▪ Adults: 600-1000 mg IM or slow IV ▪ Infants/pediatrics: 15 mg/kg

• OPEN IV LINE • Repeat atropine as needed until secretions decrease and breathing easier

o Adults: 2 mg IV or IM o Infants/pediatrics: 0.02 - 0.05 mg/kg IV

• Repeat 2-PAM C1 as needed: o Adults: 1.0 gm IV over 20-30 min and repeat hourly x 3 prn o Infants/pediatrics: 15 mg/kg slow IV

• If convulsions present: o Administer Diazepam

• Adults: 10 mg slow IV • Infants/pediatrics: 0.2 mg/kg IV

• Reevaluate q 3-5 min. If signs worsen, repeat atropine as directed. Note! NOTIFY the hospital pharmacy that unusual amounts of atropine and 2-PAM may be needed. CDC Resources It is more than possible that an unidentified chemical agent may bring patients to your facility. The CDC has extensive guidelines for the treatment of patients with an unidentified chemical exposure. These are too extensive to address in this course, but can be found at http://www.atsdr.cdc.gov/, the website for the Agency for Toxic Substances and Disease Registry, which is part of the CDC. This registry has a wealth of knowledge and management guidelines for a variety of toxic substances. How people can get more information about these agents

• Regional poison control center (1-800-222-1222) • Centers for Disease Control and Prevention • Public Response Hotline (CDC) • English (888) 246-2675 • Español (888) 246-2857

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• TTY (866) 874-2646 • Emergency Preparedness and Response Web site (http://www.bt.cdc.gov/) • E-mail inquiries: cdcresponse@ashastd.org • Agency for Toxic Substances and Disease Registry (ATSDR) (1-770-488-7100; 24 hours a

day) • E-mail inquiries: cdcinfo@cdc.gov

Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH), Pocket Guide to Chemical Hazards (www.cdc.gov/niosh/npg/npgd0504.html) Case Study #1 Your emergency department has been notified of an external disaster. There has been an increase in the number of GI disturbances, severe cramping, vomiting, and diarrhea over the past few days and an acute rise in symptomology in the past few hours since lunch time. You are told to prepare for the arrival of 30 adults from the outlying town of Idyllwild. Based on this information, can you determine if this is bioterrorism or if this might be related to something within the town? There is not enough information. Who would you notify? The Centers for Disease Control, your Public Health Department would be a great starting point. As the patients begin to arrive, you become aware that all of these patients work for the same company and they all attended a company sponsored and catered event for lunch. Where would you continue to look for clues to this GI outbreak? 1. The lunch room 2. The caterers 3. The food source company 4. Food preparation surfaces As you are researching this GI outbreak, you remember that you recently attended an in-service on bioterrorism and the example that was discussed was a similar case. In the discussed case, the President of company #1 was in the midst of a stock dispute with company #2 and a member of the company #2 work force decided to “poison” the food being served at a company #1 event in order to influence the shareholder’s vote. Could this be the case here? Or is your imagination on overload??? You won’t know unless you investigate further. Fortunately, you discover that the caterers had purchased salad greens which had been contaminated with e. coli. All of the patients had consumed this salad. However, bioterrorism was not out of the question. It is better to have a heighten awareness than to miss an overt attempt to harm others.

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Nuclear and Radiologic Weapons This module is primarily focused on biologic agents. However, to be thorough, it is prudent to discuss nuclear and radiologic weapons as well. Radiation is a form of energy that is present all around us. Different types of radiation exist, some of which have more energy than others. Radiation released into the environment is measured in units called curies. However, the dose of radiation that a person receives is measured in units called rem. Possible terrorist events could involve introducing radioactive material into the food or water supply, using explosives to scatter radioactive materials, bombing or destroying a nuclear facility, or exploding a small nuclear device. Nuclear and Radiologic Weapons

Nuclear explosion (bomb, nuclear reactor explosion, etc.): radioactive fallout would extend over a large region far from the point of impact, potentially increasing people's risk of developing cancer over time. “Dirty bomb” (an explosive device containing radioactive material): large scale contamination is possible.

The CDC has outlined for physicians and other healthcare workers the following protocol to follow in the event of radiation exposure. Acute Radiation Syndrome Acute Radiation Syndrome (ARS), also known as radiation toxicity or radiation sickness, is an acute illness caused by irradiation of the body by a high dose of penetrating radiation in a very short period of time (usually a matter of minutes). The major cause of this syndrome is depletion of immature parenchymal stem cells in specific tissues. This can occur when the radiation exposure is greater than 0.7 Gray (Gy), or 70 rads. Mild symptoms may be observed as low as 0.3 Gy or 30 rads. The dose is usually external, and is penetrating (i.e., able to reach the internal organs). The entire body (or a significant portion of it) must have received the dose. Most radiation injuries are local, frequently involving the hands, and these local injuries seldom cause classical signs of ARS. The dose must have been delivered in a short time (usually a matter of minutes). Fractionated doses are often used in radiation therapy. These are large total doses delivered in small daily amounts over a period of time. Fractionated doses are less effective at inducing ARS than a single dose of the same magnitude.

The Emergency Management Pocket Guide for Clinicians, a product of the CDC, offers a quick review of information related to radiation exposure:

http://www.bt.cdc.gov/radiation/pdf/clinicianpocketguide.pdf Classis Radiation Syndromes There are three classic ARS Syndromes that occur:

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Bone Marrow Syndrome (Hematopoietic Syndrome) • The full syndrome will usually occur with a dose between 0.7 and 10 Gy (70 – 1000 rads)

though mild symptoms may occur as low as 0.3 Gy or 30 rads. • The survival rate of patients with this syndrome decreases with increasing dose. • The primary cause of death is the destruction of the bone marrow, resulting in infection and

hemorrhage. Gastrointestinal (GI) syndrome

• The full syndrome will usually occur with a dose between 10 and 100 Gy (1000 – 10,000 rads) though some symptoms may occur as low as 6 Gy or 600 rads.

• Survival is extremely unlikely with this syndrome. Destructive and irreparable changes in the GI tract and bone marrow usually cause infection, dehydration, and electrolyte imbalance.

• Death usually occurs within 2 weeks. Cardiovascular (CV)/ Central Nervous System (CNS) Syndrome

• The full syndrome will usually occur with a dose greater than 50 Gy (5000 rads) though some symptoms may occur as low as 20 Gy or 2000 rads.

• Death occurs within 3 days. Death is likely due to collapse of the circulatory system as well as increased pressure in the confining cranial vault as the result of increased fluid content caused by edema, vasculitis, and meningitis.

Stages of Acute Radiation Syndrome With any of the three above named syndromes, there are four stages of ARS that occur:

• Prodromal stage (N-V-D stage): The classic symptoms for this stage are nausea, vomiting, and possibly diarrhea (depending on dose) that occur from minutes to days following exposure. The symptoms may last (episodically) for minutes up to several days.

• Latent stage: The patient looks and feels generally healthy for a few hours or even up to a few weeks.

• Manifest illness stage: The symptoms depend on the specific syndrome (see Table 1) and last from hours up to several months.

• Recovery or death: Most patients who do not recover will die within several months of exposure. The recovery process lasts from several weeks up to two years.

Acute Radiation Syndromes

Syndrome Dose Prodromal Stage Latent Stage Manifest Illness stage

Recovery

Hematopoietic (Bone Marrow)

>0.7 GY or > 70 rads Mild symptoms may occur with as low as 0.3 GY or 30 rads

Anorexia Nausea Vomiting Onset: 1 hour to 2 days post exposure Duration: minutes to days

Stem cells in bone marrow die Patient may look and feel well Duration: 1-6 weeks

Anorexia Fever Malaise Drop in blood cell counts for several weeks Cause of death: infection/bleeding Survival decreases with increasing dose Death occurs within a few months of exposure

Bone marrow regenerates Full recovery for high percentage of patients within weeks to 2 years Death can occur at very low GY doses The LD50/60+ is about 2.5 to 5 GY or 250 to 500 rads

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Gastrointestinal >10 GY or >1000 rads Some symptoms may occur with as low as 6 GY or 600 rads

Anorexia Severe nausea Vomiting Cramping Diarrhea Onset: within a few hours Duration: about 2 days

Stem cells in bone marrow and lining the GI tract die Patient may look and feel well Duration: less than 1 week

Malaise Anorexia Severe diarrhea Fever Dehydration Electrolyte imbalance Cause of death: infection/bleeding Survival decreases with increasing dose Death occurs within a few months of exposure

The LD100+ is about 10 GY or 1000 rads

Cardiovascular Central Nervous System

>50 GY or >5000 rads Some symptoms may occur with as low as 20 GY or 2000 rads

Extreme nervousness and confusion Severe nausea Vomiting Watery diarrhea Loss of consciousness Burning sensations on skin Onset: within a few minutes Duration: minutes to hours

Patient may return to partial functionality Duration: hours or less

Return of watery diarrhea Convulsions Coma Onset: 5-6 hours after exposure Death occurs within 3 days of exposure

No recovery is expected

The absorbed doses quoted here are “gamma equivalent” values. Neutrons or protons generally produce the same effects as gamma, beta, or X-rays but at lower doses. If the patient has been exposed to neutrons or protons, consult radiation experts on how to interpret the dose. The LD50/60+ is the dose necessary to kill 50% of the exposed population in 60 days The LD100+ is the dose necessary to kill 100% of the exposed population

Test Your Knowledge: The LD50/60 radiation dose is the dose necessary to kill 100% of the exposed population.

A. True B. False

Rationale: The LD50/60+ is the dose necessary to kill 50% of the exposed population in 60 days The LD100+ is the dose necessary to kill 100% of the exposed population

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Cutaneous Radiation Syndrome (CRS) The concept of cutaneous radiation syndrome (CRS) was introduced in recent years to describe the complex pathological syndrome resulting from acute radiation exposure to the skin. ARS will usually be accompanied by some skin damage. It is also possible to receive a damaging dose to the skin without symptoms of ARS, especially with acute exposures to beta radiation or x-rays. Sometimes this occurs when radioactive materials contaminate a patient’s skin or clothes. When the basal cell layer of the skin is damaged by radiation, inflammation, erythema, and dry or moist desquamation can occur. Also, hair follicles may be damaged causing epilation. Within a few hours after irradiation a transient and inconsistent erythema (associated with itching) can occur. Then, there may be a latent phase that lasts from a few days up to several weeks, when intense reddening, blistering and ulceration of the irradiated site is visible. Patient Management of Radiation Exposure If radiation exposure is suspected:

• Secure ABCs (airway, breathing, circulation) and physiologic monitoring (blood pressure, blood gases, electrolyte and urine output) as appropriate.

• Treat major trauma, burns and respiratory injury if evident. • In addition to the blood samples required to address the trauma, obtain blood samples for

CBC, with attention to lymphocyte count, and HLA (human leukocyte antigen) typing prior to any initial transfusion and at periodic intervals following transfusion.

• Treat contamination as needed. • If exposure occurred within 8 to 12 hours, repeat CBC, with attention to lymphocyte count, 2 or

3 more times (approximately every 2 to 3 hours) to assess lymphocyte depletion. Diagnosis The diagnosis of ARS can be difficult to make because it causes no unique disease. Also; depending on dose, the prodromal stage may not occur for hours or days after exposure, or, the patient may already be in the latent stage by the time they receive treatment, in which case the patient may appear and feel well when first assessed. If a patient received more than 0.05 Gy (5 rads) and 3 or 4 CBCs are taken within 8–12 hours of the exposure, a quick estimate of the dose can be made. If these initial blood counts are not taken, the dose can still be estimated using CBC results over the first few days. It would be best to have radiation dosimetrists conduct the dose assessment, if possible. If a patient is known or suspected of having been exposed to a large radiation dose draw blood for CBC analysis with special attention to the lymphocyte count every 2–3 hours for the first 8 hours following exposure (and every 4–6 hours for the following 2 days). Observe the patient during this time for symptoms and consult with radiation experts before ruling out ARS. If no radiation exposure is initially suspected, you may consider ARS in the differential diagnosis if there is a history of nausea and vomiting that is unexplained by other causes. Other indications are bleeding or epilation or WBC (white blood count) and platelet counts abnormally low a few days or weeks following unexplained nausea and vomiting. Again, consider CBC and chromosome analysis and consultation with radiation experts to confirm diagnosis.

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Initial Treatment and Diagnostic Evaluation Treat vomiting, and repeat CBC analysis, with special attention to the lymphocyte count, every 2–3 hours for the first 8–12 hours following exposure (and every 4–6 hours for the following 2 or 3 days). Precisely record all clinical symptoms, particularly nausea, vomiting, diarrhea, and itching, reddening or blistering of the skin. (Be sure to include time of onset.) Note and record areas of erythema. If possible, take color photographs of suspected radiation skin damage. Consider tissue, blood typing, and initiating viral prophylaxis. Promptly consult with radiation, hematology, and radiotherapy experts in regards to dosimetry, prognosis, and treatment options. Call the Radiation Emergency Assistance Center/Training Site (REAC/TS) at (865) 576-3131 (MF, 8 am to 4:30 am EST) or (865) 576-1005 (after hours) to record the incident in the Radiation Accident Registry System.

For More Help Note that the Radiation Emergency Assistance Center/Training Site (REAC/TS) can also be reached online at http://www.orau.gov/reacts/, and the Medical Radiobiology Advisory Team (MRAT) at (301)

295-0316. Also, more information can be obtained from the CDC Health Alert Network at http://www.bt.cdc.gov. Initial Treatment and Diagnostic Evaluation After consultation, begin the following (as indicated):

• Supportive care in a clean environment (if available, the use of a burn unit may be quite effective).

• Prevention and treatment of infections. • Stimulation of hematopoiesis by use of growth factors. • Stem cell transfusions or platelet transfusions (if platelet count is too low). • Psychological support. • Careful observation for erythema (document locations), hair loss, skin injury, mucositis,

parotitis, weight loss, or fever. • Confirmation of initial dose estimate using chromosome aberration cytogenetic bioassay when

possible. Though resource intensive, this is the “gold standard” for dose assessment following acute exposures.

• Consultation with experts in radiation accident management (Ricks, et al., 2002).

Personal Protective Equipment (PPE) The development and use of proven PPE is essential to the health and safety of workers. PPE (equipment designed to protect persons from the risk of injury by creating a barrier against workplace hazards) is of particular importance to terrorism preparedness and response to ensure worker health

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and safety. PPE has always played an important role in public health and must continue to be customized to mitigate the risks associated with chemical, biological, radiological/ nuclear and mass trauma hazards. Of equal importance is training to ensure workers can properly assess an environment’s hazards and select the appropriate PPE. The type of PPE used varies with each situation. The following discussion of types of PPE is general in nature. If an act of terrorism occurs the type of PPE needed will be determined and action should be taken to follow guidelines that are issued. Levels of Personal Protective Equipment (PPE) There are basically four levels of personal protective equipment:

• Level A protection is required when the greatest potential for exposure to hazards exists, and when the greatest level of skin, respiratory, and eye protection is required. Examples of Level A clothing and equipment include positive-pressure, full face-piece self-contained breathing apparatus (SCBA) or positive pressure supplied air respirator with escape SCBA, totally encapsulated chemical- and vapor-protective suit, inner and outer chemical-resistant gloves, and disposable protective suit, gloves, and boots.

• Level B protection is required under circumstances requiring the highest level of respiratory protection, with lesser level of skin protection. Examples of Level B protection include positive pressure, full face-piece self-contained breathing apparatus (SCBA) or positive pressure supplied air respirator with escape SCBA, inner and outer chemical-resistant gloves, face shield, hooded chemical resistant clothing, coveralls, and outer chemical-resistant boots.

• Level C protection is required when the concentration and type of airborne substances is known and the criterion for using air purifying respirators is met. Typical Level C equipment includes full-face air purifying respirators, inner and outer chemical-resistant gloves, hard hat, escape mask, and disposable chemical-resistant outer boots. The difference between Level C and Level B protection is the type of equipment used to protect the respiratory system, assuming the same type of chemical-resistant clothing is used. The main criterion for Level C is that atmospheric concentrations and other selection criteria permit wearing an air-purifying respirator.

• Level D protection is the minimum protection required. Level D protection may be sufficient when no contaminants are present or work operations preclude splashes, immersion, or the potential for unexpected inhalation or contact with hazardous levels of chemicals. Appropriate Level D protective equipment may include gloves, coveralls, safety glasses, face shield, and chemical-resistant, steel-toe boots or shoes.

While these are general guidelines for typical equipment to be used in certain circumstances, other combinations of protective equipment may be more appropriate, depending upon specific site characteristics. One of the lessons learned from the Ebola incident in 2015 was that healthcare facilities must be prepared to safely care for patients of all types. It was very evident that we were NOT adequately prepared to deal with a disease such as Ebola. Many facilities did not have units that could be used for caring for highly contagious diseases, there was no plan in place to safely transport body fluids to the laboratory, how would you meet the needs of the family without placing them at unnecessary risk/exposure? What about the healthcare workers themselves? How would we protect their families?

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One gap that was acknowledged was healthcare workers in general are not adept at donning and removing PPE without contaminating themselves. Ongoing training and practice is needed to help ensure the safety of our healthcare workforce. Does your facility have ongoing training for donning and removing PPE? This might just be our greatest defense against bioterrorism. Health Alert Network The Health Alert Network (HAN) is a nationwide communications system that was established by the Centers for Disease Control and Prevention, and is implemented by each state. It is designed to enable a two-way, 24/7 flow of critical health information among the Nevada State Health Division and local and rural health care professionals throughout the state, including physicians, nurses, hospitals, laboratories, clinicians, public health workers, emergency management and others. The Nevada Health Alert Network has the ability to:

• Provide ongoing surveillance activities to quickly identify potential health threats • Offer laboratory capabilities to perform testing to determine the threat agent • Conduct disease investigations • Effectively report incidents and share information • Efficiently transmit emergency communications among all involved parties

(Nevada State Health Division, 2012) Contact Information for HAN The Nevada Health Alert Network (HAN) contains up to date information and links to “Hot Topics” in Disaster Preparedness. Since these are constantly changing, the reader can obtain current information on key health topics through one resource. Relief agencies are outlined and links provided, so that in the case of an emergency, they can be easily accessed. Additionally, the HAN contains links to county specific emergency management and public health departments and Federal contacts. The CDC Bioterrorism Hotline Phone Number is the best contact to use when concerned about any types of suspected terrorism activities that could affect the public health. By using this number, you will be connected with one of the key government agencies with information about bioterrorism, and they can provide you with appropriate information and direction.

24 Hour CDC Bioterrorism Hotline – 770.488.7100

Federal Links Ready.gov (www.ready.gov) This website provides information for individuals, families and businesses, to take action to prepare themselves for all types of emergencies, including chemical and bioterrorism. U.S. Department of Health and Human Services (www.dhhs.gov) HHS is the U.S. government's principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves.

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Centers for Disease Control (www.cdc.gov) The CDC is the principal agency in the United States government for protecting the health and safety of all Americans and for providing essential human services, especially for those people who are least able to help themselves. CDC and American Red Cross: Readiness Today (http://www.redcross.org/preparedness/cdc_english/CDC.asp) The CDC and the American Red Cross have combined to create this informative website with information about what types of emergency supplies, including food and water, you should maintain, information about quarantine and isolation, and tools for coping. Health Resources and Services Administration (www.hrsa.gov) The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, is the primary Federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable. Department of Homeland Security (www.dhs.gov) The National Strategy for Homeland Security and the Homeland Security Act of 2002 served to mobilize and organize our nation to secure the homeland from terrorist attacks. Federal Emergency Management Agency (www.fema.gov) The Federal Emergency Management Agency (FEMA) describes its role as follows: FEMA's role in managing terrorism includes both antiterrorism and counterterrorism activities (FEMA, 2006). Nevada is part of Region IX of FEMA, with its regional office located in Oakland, CA. Federal Bureau of Investigation (www.fbi.gov) The Federal Bureau of Investigation (FBI) is part of the U.S. Department of Justice. FBI priorities outlined in 2003 include protecting the United States from terrorist attack (FBI, n.d.). State Links There are three key links in the State Section: Nevada Office of Homeland Security (http://www.dhs.gov/), Nevada Division of Emergency Management (http://www.nemaweb.org/), and Nevada Department of Agriculture (http://agri.nv.gov/). The Nevada Office of Homeland Security is the state section of the national department. The Nevada Division of Emergency Management is part of the Nevada Department of Public Safety. It contains information and communication about issues that affect the public safety of the citizens of Nevada. The Nevada Department of Agriculture is also included due to threats to water and wildlife.

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County Links There are a number of helpful links to differing health services agencies in Nevada. Many of the links include information specific to individuals and families as they make their plans for disaster management. (http://dem.nv.gov/links/) Conclusion Much work was done after 2001 to put plans and resources in place to protect the world from bioterrorism and chemical warfare. However, the level of fear that was present after the bombings and the anthrax mailings has or is diminishing. Stronger more focuses legislation is tantamount to a safer future for all. The information contained in this module empowers healthcare workers to support changes in the healthcare environments so that safe practices are developed and maintained to deal with biological agents, whether they are accidental or part of a well laid out plan. Remember, 2015, and the Ebola epidemic! What is next? Resources Knowing what resources to use is critical in the event of a biological attack. The following list of resources is one that provides both federal and state specific information on bioterrorism, response, and treatment issues. Centers for Disease Control (www.cdc.gov). The central federal government agency with information about infectious diseases Department of Homeland Security (www.dhs.gov). The federal agency tasked with making sure the nation is secure. Federal Emergency Management Agency (www.fema.gov). The federal agency within DHS whose responsibility is emergency response at the federal level to all types of emergencies, including bioterrorist attacks. U.S Army Medical Research Institute of Infectious Diseases (USAMRIID) (www.usamriid.army.mil/education). A key source of critical information on various potential biological weapons. References Agency for Toxic Substances and Disease Registry Division (2012). Retrieved from www.atsdr.cdc.gov Virginia Tech Office of the Vice President for Research. (2005). Opportunity Update. Retrieved from www.research.vt.edu/funding/ou/prev/ou041505.html . Centers for Disease Control and Prevention (CDC). (2016). Bioterrorism Agents/Disease. Retrieved from http://www.bt.cdc.gov/agent/agentlist-category.asp#b

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National Institute Allergy and Infectious Disease (NIAH). (2015). NIAID Emerging Infectious Diseases/Pathogens. Retrieved from: https://www.niaid.nih.gov/topics/biodefenserelated/biodefense/pages/cata.aspx National Institute for Occupational Safety & Health [NIOSH] (2012). Respirators. Workplace Safety & Health Topic. Retrieved from: http://www.cdc.gov/niosh/topics/respirators/ Nevada State Health Division. (2012). Nevada Health Alert Network. Retrieved from http://health.nv.gov/PHP_HealthAlertNetwork.htm . Porter, L. (2012). Bioterrorism Legislation in the U.S. Retrieved from: http://macaulay.cuny.edu/eportfolios/laraporter/2012/04/10/bioterrorism-legislation-in-the-us/ U.S Army Medical Research Institute of Infectious Diseases (USAMRIID) (2005). USAMRIID’s medical management of biological casualties handbook. At the time this course was constructed all URL's in the reference list were current and accessible. rn.com. is committed to providing healthcare professionals with the most up to date information available. © Copyright 2005, AMN Healthcare, Inc. Please Read: This publication is intended solely for the use of healthcare professionals taking this course, for credit, from RN.com. It is designed to assist healthcare professionals, including nurses, in addressing many issues associated with healthcare. The guidance provided in this publication is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold RN.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication. The contents of this publication may not be reproduced without written permission from RN.com.