Disaster Nursing Lecture (Midterms)
TOPIC 1: Essential Emergency Supplies
Build A Kit
– After an emergency, you may need to survive on
your own for several days. Being prepared means
having your own food, water, and other supplies to
last for several days. A disaster supplies kit is a
collection of basic items your household may need in
the event of an emergency.
Basic Disaster Supplies Kit
– To assemble your kit, store items in airtight plastic
bags and put your entire disaster supplies kit in one
or two easy-to-carry containers such as plastic bins
or a duffel bag.
– A basic emergency supply kit could include the
following recommendation Items
● Water (one gallon per person per day for
several days), for drinking and sanitation.
● Food (at least a several-day supply of
non-perishable food)
● Battery-powered or hand crank radio and a
NOAA Weather Radio with tone alert
● Flashlight
● First Aid Kit
● Extra batteries
● Whistle (to signal for help)
● Dust Mask
● Plastic Sheeting and Duct tape (to shelter in
place)
● Moist towelette, garbage bags nad plastic ties
(for personal sanitation)
● Wrench or Pliers
● Local Maps
● Cell phone with chargers and a backup
battery
Consider adding the following items to your
emergency supply kit based on you individual
needs.
● Mask (for everyone ages 2 and above), soap,
hand sanitizer, disinfecting wipes to disinfect
surfaces.
● Prescription medications ABout half of all
Americans take a prescription medicine every
day. An emergency can make it difficult for
them to refill their prescription or to find an
open pharmacy. Organize and protect your
prescriptions, over-the-counter drugs, and
vitamins to prepare for an emergency.
● Non-prescription medications such as pain
relievers, anti-diarrhea medication, antacids
or laxatives
● Prescription eyeglasses and contact lens
solution
● Infant formula, bottles, diapers, wipes, and
diaper rash cream
● Pet food and extra water for pet
● Cash or traveler’s checks
● Important family documents Such as copies
of insurance policies, identification and bank
account records saved electronically or in a
waterproof, portable container
● Sleeping bag or warm blanket for each
person
● Complete change clothing appropriate for
your climate and sturdy shoes
● FIre extinguisher
● Matches in a waterproof container
● Feminine supplies and personal hygiene
items
● Paper and Pencil
● Books, games, puzzle, or other activities for
children
Additional Items to consider adding to an
Emergency Supply Kit:
● Prescription medications and glasses
● Infant Formula and diapers
● Pet food, water and supplies for your pet
● Important family documents such as copies of
insurance policies, identification and bank
account records in a portable waterproof
container
● Cash and Change
● Emergency reference material such as first
aid book of information from www.ready.gov
● Sleeping bag or warm blanket for each person
Recommended Items to include in a Basic
Emergency Supply Kit:
● Water and non perishable food for several
days
● Extra cell phone battery or charger
● Battery-powered or hand crank radio that can
receive NOAA Weather Radio tone alerts and
extra batteries
● Flashlights and extra batteries
● First aid Kit
● Whistle to signal for help
● Dusk mask, to help filter contaminated air
and plastic sheeting and duct tape to
shelter-in-place
 ● Moist towelette, garbage bags and plastic ties
for personal sanitation
● Non-sparking wrench or pliers to turn off
utilities
● Can opener (if kit contains canned food)
● Local maps

Maintaining Your Kit

After assembling your kit remember to maintain it so
it's ready when needed:
● Keep canned food in a cool, dry place.
● Store boxed food in tightly closed plastic or
metal containers.
● Replace expired items as needed.
● Re-think your needs every year and update
your kit as your family’s needs change.

Kit Storage Locations

Since you do not know where you will be when an
emergency occurs, prepare supplies for home, work,
and cars.
● Home : Keep this kit in a designated place
and have it ready in case you have to leave
your home quickly. Make sure all family
members know where the kit is kept.
● Work: Be prepared to shelter at work for at
least 24 hours. Your work kit should include
food, water, and other necessities like
medicines, as well as comfortable walking
shoes, stored in a “grab and go” case.
● Car: In case you are stranded, keep a kit of
emergency supplies in your car.
Disaster Nursing Lecture (Midterms)
TOPIC 2: Hazardous Materials
Hazardous Materials
– Hazardous materials can be silet killers. Almost
every household and workplace has varying amounts
of chemicals that, if spilled or combined, will cause
great harm and even death. It is important that you
have a basic knowledge of how to recognize these
chemicals, where they may be found, and what to do,
about hazardous material spills.
Ways that hazardous materials can enter the
body:
● Inhalation - Through breathing, most rapid
way
● Absorption - Through skin or eyes
● Ingestion - Swallowing
● Injection - penetrating skin
The key to dealing with hazardous material spills
is to remember S.I.N. (Safety, Isolation,
Notification)
SAFETY:
● Always assume that spilled chemicals are
extremely toxic
● Do not approach; stay at a safe distance
● Mixtures of chemicals can be very dangerous
– Bleach mixed with ammonia creates poisonous
gas(es)
ISOLATION
● Close off room and/or building
● Mark outside of building
NOTIFICATION:
● Notify Incident Commander & local
emergency personal
Hazardous Materials are an ever-present danger:
● In the home or workplace
● On roadways
● In industrial or commercial areas
In the home or workplace
INVENTORY:
● Make a list hazardous materials
● Read the labels on all products you purchase
● Segregate and store or dispose of properly
● Know what steps to take if chemicals are
spilled
● Secure and segregate all containers at work
Typical Places Hazardous Materials Are Found In
the Home:
Kitchen:
● Oven cleaners, drain cleaners, ammonia,
bleach
Laundry:
● Bleach, spot removers, cleaners
Garage
● Gasoline, solvents, pesticides, paints, pain
removers, thinners
Asbestos:
– Asbestos is one of the potential hazards that you
may encounter in a damaged building. Asbestos is a
human carcinogen, which can be found in a number
of different building materials throughout city and
campus buildings. The hazard presented by asbestos
varies considerably based upon the nature of
materials and the likelihood of causing an airborne
release of asbestos fibers.
–If left un-disturbed, a release is unlikely.
On Roadways
– Hazardous materials transported on roadways must
carry a Department of Transportation (DOT) warning
label on the package, vehicles transporting quantities
of hazardous materials must have DOT placards
affixed to all sides of the vehicle. Bulk shipments,
such as in gasoline tanker trucks, will have a four
digit numeric code instead of the hazard class in the
center of the placard. This number can be referenced
in the DOT s “Emergency Response Guide Book” to
determine the identity and the emergency handling
for the chemical involved.
DOT HAZARDOUS MATERIALS WARNING LABELS:
Color Coding of Labels and Placards:
● Orange
– Explosives
● Red
– Flammable Gas and Liquid
● White
– Poison
● Black/White
– Corrosive
● Yellow
– Oxidizer
● Green
– Non-flammable gas
● Yellow/White
– Radio Active

Hazardous Materials by Class Numbers:
● Class 1: Explosives
● Class 2 : Gasses (Compressed, liquified or
dissolved under pressure)
● Class 3 : Flammable Liquids
● Class 4: Flammable Solids
● Class 5: Oxidizers
● Class 6: Poisonous or infectious Substances
● Class 7: Radioactive Substances
● Class 8: Corrosives
● Class 9: Miscellaneous Dangerous Substances
The class number is the number located on the
bottom corner of the label or placard
In Industrial and Commercial Fixed Sites
– Most buildings that contain hazardous materials
are identified by the National Fire Protection
Association 704 Diamond system, which is usually
located at the building entrance or in the storage
area.
– The 704 Diamond is divided into four quadrants.
Each quadrant of the diamond has a special meaning
and is color-coded. The top quadrant is coded red for
fire hazard, the right quadrant is coded yellow for
reactivity, the left quadrant is coded blue for health
hazards, and the bottom quadrant is white and
contains information about special hazards of the
particular chemical. Each colored quadrant is also
numbered for the degree of hazard from zero to four,
four being the greatest hazard.
RED (FIRE HAZARD)
4 - Materials that burn readily
3 - Materials that can ignite at room
temperature
2 - Materials that ignite if moderately heated
1 - Materials that ignite after considerable
preheating
0 - will not burn
YELLOW (REACTIVITY)
4 - May detonate
3 - Shock and heat may detonate
2 - Violent chemical change
1 - Unstable if heated
0 - Stable
BLUE (HEALTH INFORMATION)
4 - Deadly
3 - Extreme Hazard
2 - Hazardous
1 - Slightly Hazardous
0 - Normal Material
SPECIAL INFORMATION
W: Water
COR: Corrosive
OXY: Oxidizer
ACID: Acid
Common Hazardous Material Locations:
● Industrial or manufacturing plants
● Shopping centers, supermarkets
● Dry cleaners
● Hardware stores
● Auto repair shops
Signs of Hazardous Material SPills:
● Overturned containers with DOT label
especially on roadways
● Pungent or noxious odor you should never
intentionally get close enough to smell it
● Bubbling liquid
● Vapr anything that is letting off a vapor is
having a reaction and should be avoided
– If you see one or more of these signs of a hazardous
materials spill on roadway or at a fixed facility, take
the following actions
● Get uphill, and upwind, and a safe distance
away from the spill
● Evacuate the surroundings areas if possible,
but do not put yourself in danger of exposure
to the spill
● Notify authorities as quickly as possible
“Hazardous Materials” is a very comprehensive
subject. The important concept to understand is
recognition. DOT placards are placed on vehicles,
DOT labels are placed on packages, and the 704
diamonds are placed on buildings or storage areas
containing hazardous materials. Being able to
recognize warning signs and being able to recognize
that there is a hazardous condition present may save
your life and the lives of others.
Remember, “Hazardous Materials” in the home and
workplace should be segregated and stored in
well-marked, unbreakable containers. They should
also be stored in a low cabinet with an
earthquake-proof latch. Dispose of any hazardous
materials that are no longer need,
 ● Gasoline
DOT HAZARD CLASSES EXPLAINED ● Acetone
● Ethanol
HAZARD CLASS 1 - EXPLOSIVES ● Xylene
– The explosives hazard class is divided into six ● Many paints and common solvents
categories based on the kind of explosive hazard:
● Mass Explosion
● Projection
● Fire
● Level of sensitivity
– Explosives that most people are familiar with
include dynamite, gun powder, and fireworks.

HAZARD CLASS 4 - FLAMMABLE SOLIDS

–These are the three divisions of flammable solids
along with a common example for each:
HAZARD CLASS 2 - GASES ● Flammable solid (4.1)
– Gases have three divisions: - Match sticks
● Flammable gases (2.1) ● Spontaneously combustible material (4.2)
- Burn readily in air and are in a - Oily rags
gaseous state at 68*F (e.g. ● Dangerous when wet (4.3)
propane and spray paints) - Magnesium fire starter
● Non-flammable gases (2.2)
- May include liquefied gases or
cryogenic liquids (e.g. helium
and asthma inhalers)
● Poisonous gases (2.3)
- Are toxic or presumed toxic to
humans (e.g. carbon
monoxide)

HAZARD CLASS 5 - OXIDIZING SUBSTANCE &

ORGANIC PEROXIDE
– Oxidizers (5.1) may contribute to the combustion
of other materials. Concentrated hydrogen peroxide
and silver nitrate are both examples of oxidizers.
– Organic Peroxides (5.2) Contain both an oxidizer
and an organic fuel. They are sometimes used to
initiate polymerization of epoxy resins.

HAZARD CLASS 3 - FLAMMABLE LIQUIDS

–Flammable liquids have a “flashpoint” of 140*F or
less. A flash point is the temperature when an
ignition source near the liquid can ignite the vapor

Examples of flammable liquids include the following:

 HAZARD CLASS 8 - CORROSIVE MATERIALS
– Acids (low pH) and bases (high pH) are corrosive
materials that can eat away at skin and steel. Sources
for corrosive materials include battery acid and
degreasers.

HAZARD CLASS 6 - TOXIC & INFECTIOUS

SUBSTANCES
– Toxic or poisonous material (6.1) can be solids or
liquids known or presumed to be toxic to humans.
Classification is based on oral, dermal, and inhalation
exposure. In high doses, some medications are toxic,
such as coumadin.
– Infectious Substances (6.2) are materials that are
known or reasonably expected to contain a pathogen.

HAZARD CLASS 9 - MISCELLANEOUS HAZARDOUS

MATERIAL
– Class 9 materials pose a hazard during
transportation, so they are regulated when shipped,
but they do not meet the definition of the previously
listed hazard classes. Formalin sample containers and
liquids fall under this category.

HAZARD CLASS 7 - RADIOACTIVE

– Uranium and Plutonium are not the only
radioactive materials. Exit signs, smoke detectors,
and x-rays equipment are a few common sources of
radioactive material in our day-to-day lives.

Remember that small and large quantity generators

of hazardous wastes must notify the EPA of their
generation activities and receive an EPA
identification number.

Some states have stricter regulations.If you need help

identifying your hazardous waste, contact sharps
compliance. We offer comprehensive solutions for the
management of regulated medical waste, hazardous
waste, and unused medications
HAZMAT PLACARDS AND UN NUMBERS; WHAT
YOU NEED TO KNOW
What are UN Numbers?
– Located on the back or sides of trailers or other
containers, UN numbers (or UN IDs) are four-digit
numbers ranging from 0004-3534 that identify
dangerous goods or hazardous substances – such as
explosives, flammable liquids, or toxic substances – in
the framework of international transport.
– These numbers are assigned by the United Nation
(UN) committee of experts on the transport of
dangerous Goods, and must be listed on the Material
Safety Data Sheet (MSDS) of each shipment. (Goods
that aren’t classified or regulated by the UN are given
four-digit North designated by the United States
Department of Transportation(DOT))
What are Hazmat Placards?
– In addition to a UN number, the DOT requires cargo
carry Hazmat placards that helps shippers determine
its class, division, and compatibility group.
– Similar to road or construction sign these diamond
shaped hazmat placards alert the public that
potentially hazardous materials are being hauled, as
well as inform emergency responders which
chemicals are present in case of an accident. Even if
members of the public of first responders are
unaware of exactly which materials are on board, the
presence of hazmat placards lets them know what
they should proceed with caution.
– With rare exceptions, companies that transport
hazardous materials without the use of DOT hazmat
placards are at risk for stiff fines and other penalties.
‘’
Each Hazmat sign has up to six main parts:
● Hazard classification number
- See Below
● UN/NA number
- See above
● Compatibility letters
- Some placards include the letters A-S,
which let shippers and carriers know
which explosive materials can be
loaded together onto a trailer.
● Color
- Other than classification numbers,
hazmat placards are most identified
by their different colors
- ORANGE - represents explosive
materials, including products like
dynamite, ammunition, or fireworks
- RED - represents flammable goods
like gasoline, rubbing alcohol, paint,
or acetone
- GREEN - signs signify non-flammable
substances like compressed or
liquified gases.
- YELLOW - indicates the transport of
oxidizers - like ammonium nitrate,
potassium nitrate, or nitric acid - that
are likely to combust when mixed
with oxygen.
- WHITE - represents poisonous and
bio-hazardous substances like dyes,
aerosols, acids, and medical waste.
- BLUE - signifies materials that can
become flammable when combined
with water, like sodium, calcium, and
potassium.
- HALF RED AND WHITE - sign
indicates the presence of substances
that can ignite when exposed to air,
like aluminum and lithium alkyls or
white phosphorus.
- RED AND YELLOW - indicates
organic peroxides that can ignite or
explode, including methyl ethyl
ketone peroxide and benzoyl
peroxide.
- YELLOW AND WHITE - represent
radioactive substances often found in
medical equipment
- HALF WHITE AND HALF BLACK -
indicates corrosive materials that can
irritate and harm the skin, including
batteries, hydrochloric acid, sulfuric
acid, and sodium hydroxide.
 - WHITE WITH BLACK VERTICAL
STRIPES - denote various dangerous
goods, including non-classified,
environmentally hazardous
substances like asbestos and dry ice.
● Words
- Depending on the contents of each
container, its hazmat placard is
labeled with various terms like
“Spontaneously COmbustible”,
“Explosive”, “Non Flammable gas”,
“Oxygen”, ”poison”, ”flammable”, and
others.
● Graphics
- Different hazmat placards feature
illustrations to reinforce the danger of
their contents. For example, placards
for toxic materials include an image of
a skull and crossbones, while signs for
radioactive materials include a
radiation symbol consisting of three
blades surrounding a small circle.
Class 2 - Gases
● 2.1 Flammable gases
● 2.2 Non Flammable gases
● 2.3 Toxic gases
Class 3 - Flammable and Combustible Liquids
Class 4 - Flammable Materials
● 4.1 Flammable solids
● 4.2 Spontaneously combustible
● 4.3: Dangerous when wet
Class 5 - Oxidizer and Organic Peroxide
● 5.1 Oxidizing substances
● 5.2 Organic Peroxides
Class 6 - Poisons
● 6.1 Toxic substances
● 6.2 Infectious substances
Class 7 - Radioactive Materials
Class 8 - Corrosive Materials

Class 9 - Miscellaneous Materials

Rules for Hazmat Placards Placements

– According to federal regulations, each freight
container, railcar, transport vehicle, or other vessel
carrying hazardous materials must display placards
on each side and each end. Regulations also state that
Classifications
placards on railcars and transport vehicles must be
– Hazmat warning placards are broken down into
clearly visible from the direction they face unless
none different classifications, along with their
they are obscured when coupled with another railcar
divisions. Each class number is found at the bottom of
or transport vehicle.
the sign, while the division number can be found in
the middle.
– In all, carriers must display at least flour placards in
areas where the view isn’t obstructed. Some carriers
Class 1 - Explosive Materials
add extra signs on each side of the truck cab for
● 1.1 Products with the potential to create a
additional visibility.
mass explosion
● 1.2 Products with the potential to create a
projectile hazard
● 1.3 Products with the potential to create a fire
or minor blast
● 1.4 Products with no significant risk of
creating a blast
● 1.5 Products considered very insensitive that
are used as blasting agents
● 1.6 Products considered extremely insensitive
with no risk to create a mass explosion
Disaster Nursing Lecture (Midterms)
TOPIC 3: Decontamination
DECONTAMINATION
– Is a process or treatment that renders a device,
instrument, or work surface safe to handle. A
decontamination procedure can range from
sterilization by autoclave or ethylene oxide to simple
cleaning with soap and water. Sterilization.
Disinfection, and antisepsis are all forms of
decontamination.
STERILIZATION
– is the use of a physical or chemical procedure to
destroy all microbial life including highly resistant
bacterial endospores.
(primarily through person-to-person transmission).
Decontamination of media, work surfaces, and
equipment is also necessary to prevent
contamination of cultured organisms.
– Infectious wastes such as contaminated liquid and
solid will be handled. Treated and disposed of
according to biological waste policies and
procedures. Liquid wastes such as bacterial or viral
culture media from labs will be treated with
appropriate disinfectant prior to sink disposal. Solid
wastes from the laboratories will be segregated and
placed in biohazard containers lined with
biohazardous waste bags and disposed of as
biological wastes. This waste is sealed by the
laboratory and shipped off site for sterilization.

DISINFECTION – All wastes from the laboratories will be inactivated

– Eliminates virtually all pathogenic, before disposal from the laboratory
non-spore-forming microorganisms but not
– A disinfectant should be chosen that is appropriate
necessarily all microbial forms on inanimate objects
for the organism in use.
(work surfaces, equipment, etc). Effectiveness is
influenced by the types and extent of organisms, the – All solid biological cultures should be disposed of in
amount of organic matter, and the surface type (i.e. biohazard waste containers.
porous or smooth) of the object to be disinfected and
– Waste created in laboratories is required to be
chemical exposure time, temperature, and
autoclaved prior to removal from the laboratory.
concentration.

METHODS OF DECONTAMINATION
ANTISEPSIS
— The three main categories of physical and
– Is the application of a liquid antimicrobial
chemical decontamination are heat, liquid
chemical to skin or living tissue to inhibit or destroy
disinfection, and vapors and gases.
microorganism. It includes using germicidal solutions
for swabbing an injection site on a person or animal
● Heat
and or handwashing. Although some chemicals may
● Liquid Disinfection
be utilized as either a disinfectant or an antiseptic,
● Gas and Vapor
adequacy for one application does not guarantee
● Autoclaving
adequacy for another. Manufacturers’
● Dry Heat
recommendations for appropriate use of germicides
● CHemical Disinfection
should always be followed.

HEAT
– Prevents sepsis (growth of microbes in blood and
– Wet heat is the most dependable method of
other tissues)
sterilization. Autoclaving (saturated steam under
● Examples: iodine, hydrogen peroxide, soap
pressure of approximately 15 psi to achieve a
chamber temperature of at least 250° F for a
General Procedures
prescribed time) is the best method of rapidly
– Decontamination of cultures and objects
achieving destruction of all forms of microbial life.
contaminated by biological agents is routinely
performed in microbiological laboratories.
– In addition to proper temperature and time,
Decontamination is a vital component of
prevention of entrapped air is critical to achieving
microbiological safety practice and serves to protect
sterility because of air’s poor heat transfer
laboratory personnel (as well as others) from
properties.
contamination and potential infection and the release
of infectious organisms to the outside environment
– Material to be sterilized must come into contact
with steam and heat. Indicators of proper autoclave
operation (e.g., autoclave tape or autoclave-sensitive
labels) must be used with each load to visually
indicate successful processing.
– Use of autoclave tape alone is not an adequate
monitor of the sterilization’s success.
Wet Heat
Liquid Disinfection
– A liquid disinfectant (e.g., 1:10 solution of
household bleach yielding a final hypochlorite
concentration of 0.5%) is used to wipe or soak
potentially contaminated materials for a period of
time to kill all pathogenic agents present. Each
disinfectant requires varying amounts of contact
time.
Gas and Vapor
– Potentially contaminated articles are exposed to a
sterilizing gas (e.g., ethylene oxide, or ETO) or vapors
from a chemical (e.g., formaldehyde, vaporized
hydrogen peroxide). Because of the hazardous nature
of the gases and vapors used, this requires specially
designed equipment and facilities.
Autoclaving
– Autoclaving uses saturated steam under pressure
(approximately 15 psi) to achieve a temperature in
the autoclave of at least 121°C (250°F). Autoclaving
can be used to destroy vegetative bacteria, bacterial
spores, and viruses. When decontaminating
biohazardous waste, it is recommended that the
temperature in the waste reach a minimum of 115°C
for a minimum of 20 minutes. The total processing
time required to meet these conditions depends on
several loading factors (see below); however, it is
recommended that a minimum autoclave cycle of one
hour be used when decontaminating waste. Please
note that waste that has been designated for
autoclave treatment must be treated by autoclaving
prior to disposal in biohazardous waste boxes and
shipped off as regulated biohazardous wastes. The
autoclaving process makes them safer for handling
and transport, it does not change the disposal
endpoint.
When using an autoclave, the following guidelines
should be taken into consideration:
– Biohazardous materials should not be left inside
the autoclaves overnight in anticipation of
autoclaving the next day.
– Autoclaves should not be operated by untrained
personnel.
– Special precautions should be taken to prevent
accidental removal of material from an autoclave
before it has been sterilized or the simultaneous
opening of both doors on a double door autoclave.
– Always use the appropriate PPE when operating the
autoclave including lab coat, disposable gloves, heat
resistant gloves and face protection.
– Dry hypochlorite, or any other strong oxidizing
material, must not be autoclaved with organic
materials such as paper, cloth, or oil: WARNING!
OXIDIZER + ORGANIC MATERIAL + HEAT =
POSSIBLE EXPLOSION
Three factors in combination determine the
effectiveness of autoclaving:
● Temperature
– An autoclave uses steam under a pressure of
approximately 15 psi to achieve a chamber
temperature of at least 121°C. Although the autoclave
chamber may reach 121°C, this does not necessarily
mean that the interior of the load will reach this
temperature.
● Time
– A minimum autoclave cycle time of 20 minutes at a
chamber temperature of 121°C (time does not begin
as soon as the autoclave cycle is initiated) is
commonly recommended for sterilization of clean
items. However, the total processing time required to
achieve decontamination depends on several loading
factors , including the load container (heat transfer
properties); the amount of water added to the load;
and the weight of the load. For increased loads, an
increased cycle time will be required to ensure
effective decontamination
● Contact
— steam saturation is essential for maximum heat
transfer. Steam must contact all areas of the load.
Autoclave bags and other containers should be left
partially open (or otherwise permit entry of steam)
to ensure adequate contact. Studies have shown that
adding water to the interior of the bag improves the
time-temperature profile of the autoclave cycle,
thereby increasing the autoclave’s sterilization
efficiency
Dry Heat
– Dry heat method requires a higher temperature and
longer contact time. It is less effective than moist
heat (autoclaving). Nevertheless, dry heat is
preferable to moist heat for decontamination of
anhydrous materials and closed containers because
the moisture component of the steam used in an
autoclave will not effectively penetrate anhydrous
materials and closed containers.
– The highest dry heat equivalent temperature that
these materials will reach in an autoclave is 121°C.
The highest temperature that material will reach in a
dry heat oven will be the actual temperature inside
the oven. A temperature of 160°-180°C for three to
four hours is recommended for decontamination of
waste using a dry heat oven.
Chemical Disinfection
– Disinfection is the decontamination of work
surfaces, equipment, biological safety cabinets, and
other inanimate objects using antimicrobial agents.
Several chemical agents are used as disinfectants.
Laboratory workers should remember that there are
hazards associated with all of these chemical
disinfectants.
– Inhalation and skin contact should be minimized,
and contact with eyes avoided.
– Appropriate gloves and safety eyewear should
always be worn when handling these chemicals.
Summary of Chemical Disinfectant
Use Parameters:
- 85%; contact time: 10-30 min
Effective Against:
- Vegetative cells: very positive response
- Lipophilic viruses: very positive response
- Tubercle bacilli: very positive response
- Hydrophilic viruses: less positive response
Important Characteristics:
- Eye irritant, toxic, flammable, inactivated by
organic matter
Potential Application:
- Surfaces: work and equipment
Chlorine Compounds
Use Parameters:
- : conc.: 0.05-0.5% (commercial bleach 0.5%);
contact time: 10-30 min
Effective Against:
- Vegetative cells: very positive response
- Lipophilic viruses: very positive response
- Tubercle bacilli: very positive response
- Hydrophilic viruses: very positive response
- Bacterial spores: less positive response
Important Characteristics:
- May leave residue; corrosive; skin, eye and
respiratory irritant; inactivated by organic
matter; make up at least weekly
Potential Application:
- Spills, equipment surfaces, instruments,
glassware, water baths.
Quaternary Ammonium Compounds
Use Parameters:
- conc.: 0.1-2%; contact time: 10-30 min.
- Effective Against:
- Vegetative cells: very positive response
- Lipophilic viruses: very positive response
Important Characteristics:
- Toxic, inactivated by organic matter
Potential Application:
- Surfaces (work and equipment), BSCs, floor
maintenance, glassware, instruments
Phenolic Compounds
Use Parameters:
- conc.: 0.2-3%; contact time: 10-30 min.
- Effective Against:
- Vegetative cells: very positive response
- Lipophilic viruses: very positive response
- Tubercle bacilli: very positive response
- Hydrophilic viruses: less positive response
Important Characteristics
- : Leaves residue; corrosive; skin, eye and
respiratory irritant; toxic; inactivated by
organic matter
Potential Application:
- Surfaces (work and equipment), BSCs, floors,
spills, glassware, instruments, water baths
Iodophor Compounds
– These compounds have been incorporated in time
release formulation and its soaps (surgical scrubs).
Simple iodine tinctures (dissolved in alcohol) have
limited cleaning ability. These compounds are
bactericidal, sporicidal, virucidal and fungicidal but
require a prolonged contact time.
Formaldehyde (Formalin)
Use Parameters:
- conc.: 4-8%; contact time: 10-30 min.
- Effective Against:
- Vegetative cells: very positive response
- Lipophilic viruses: very positive response
- Tubercle bacilli: very positive response
- Hydrophilic viruses: very positive response
- Bacterial spores: less positive response
Important Characteristics:
- Leaves residue; skin, eye and respiratory
irritant; toxic (carcinogen)
Potential Application:
- Less effective than other disinfectants but
can be used for equipment surfaces,
glassware, instruments
Note: Due to its irritating characteristics and status
as a carcinogen, formaldehyde should not be used
without good local exhaust ventilation.
Glutaraldehyde
Use Parameters
- Conc: : 2%; contact time: 10-60 min.
- Effective Against:
- Vegetative cells: very positive response
- Lipophilic viruses: very positive response
- Tubercle bacilli: very positive response
- Hydrophilic viruses: very positive response
- Bacterial spores: very positive response
Important Characteristics:
- Leaves residue; skin, eye and respiratory
irritant; toxic
Potential Application:
- Equipment surfaces, glassware, instruments
DECONTAMINATION FOR HAZMAT & TERRORISM
– Decontamination is essential when faced with the
contamination of civilians, military personnel or
emergency responders as the result of an accidental
or intentional contamination by hazardous materials
or weapons of mass destruction. But different
agencies have different ways of defining
decontamination beyond the basics:
– Occupational Safety and Health Organization
(OSHA): “Decontamination is the process of removing
or neutralizing contaminants that have accumulated
on personnel and equipment.” (Note: This is
sometimes referred to as technical decontamination.)
– Department of Homeland Security (DHS): “Any
process, method or action that leads to a reduction,
removal, neutralization—by partitioning or binding
(as opposed to chemical neutralization, which is not
recommended)— or inactivation of contamination on
or in the patient in order to prevent or mitigate
adverse health effects to the patient; protect
emergency first responders, healthcare facility first
receivers, and other patients from secondary
contamination; and reduce the potential for
secondary contamination of response and health care
infrastructure.”
– Centers for Disease Control (CDC): “The reduction
or removal of radioactive contamination from a
structure, object or person. Decontamination is a part
of hazmat response team operations.” Further,
according to National Fire Protection Association
(NFPA) Standard 472, a hazmat response team is an
“organized group of trained personnel operating
under an emergency response plan and appropriate
standard operating procedures who handle and
control actual or potential leaks or spills of hazardous
materials requiring possible close approach to the
material. The team members respond to releases or
potential releases of hazardous materials for the
purpose of control or stabilization of the incident.”
– Further, according to National Fire Protection
Association (NFPA) Standard 472, a hazmat response
team is an “organized group of trained personnel
operating under an emergency response plan and
appropriate standard operating procedures who
handle and control actual or potential leaks or spills
of hazardous materials requiring possible close
approach to the material. The team members
respond to releases or potential releases of
hazardous materials for the purpose of control or
stabilization of the incident.”
– Decontamination is an important step in protecting
emergency personnel and the public during a hazmat
or terrorist incident. Decon provides protection for
victims, including emergency responders, who have
become contaminated without the benefit of proper
protective clothing. It also protects responders who
have entered an incident scene with proper
protective clothing by removing any harmful
materials that they may have contacted during
operations. The longer harmful materials contact the
body, the more damage that is done. Therefore, the
quicker decontamination can be performed, the
quicker the damage can be limited or stopped. There
are three basic types of decontamination: technical,
emergency and mass.
Technical Decontamination
– Technical decon is established by hazmat team
members or operations-level responders who have
been trained for decontamination of the hazmat team
exiting the hot zone. It may also include equipment
decontamination as well. If there are not mass
numbers of victims, additional technical
decontamination lines can be set up for just the
victims. Technical decontamination is set up before
hazmat team members make an entry.
– The Center for Domestic Preparedness at Fort
McClellan, AL, uses the “good, better, best” concept
for decontamination solutions. Water is good, soap
and water is better, and chlorine bleach solutions are
best when dealing with chemical or biological agents.
Chlorine bleach is widely accepted in military and
civilian sectors for decontamination of chemical and
biological agents, although it is not without dangers
when used on people. Chlorine can cause damage to
the skin and blindness if splashed in the eyes
– Technical decontamination generally involves the
use of a “corridor” (sometimes referred to as a
“contamination reduction corridor”) with a gross
contaminant reduction section followed by a series of
wash-and-rinse stations, an undressing area and a
rehabilitation area.
– Technical decon operations take time to set up. If a
community must wait for a hazmat team to respond
from a remote location, the setup is delayed even
longer. While the response and setup of technical
decon is taking place, chemicals are continuing to
harm victims. While the concept of emergency decon
for terrorism is well established, I am not sure all first
responders realize that the same tactics can be used
for other hazardous materials. Many training
programs for first responders do not even mention
emergency decon as an option. In fact, I think many
times we instill so much fear into first responders
that they do not want to do anything with victims. It
makes no sense to force people who have been
splashed with an acid or other harmful chemical to
wait for a hazmat team to set up technical decon
before the materials can be removed from their
bodies.
Emergency Decontamination
– • Response protocols for hazmat incidents have
identified the duties of first responders as isolation,
notification, protection and identification. Protection
includes PPE for responders and evacuation or
sheltering in place for the public. Protection should
also include emergency decon for contaminated
victims. Emergency decon should be conducted as a
defensive operation. Personnel conducting
emergency decon, regardless of the circumstances,
should be wearing full firefighter turnouts and SCBA.
Decon operations should be located upwind and
uphill from the contamination, and personnel should
avoid contact with the persons contaminated and
runoff from the decon operation.
– Emergency decon can be accomplished without the
purchase of any additional equipment for first
responders. Equipment used for emergency decon is
already available on most fire apparatus. Typical fire
apparatus carry rope, tarps and various types of
nozzles and hose lines as standard equipment. Some
additional inexpensive supplies to carry include soap,
chlorine bleach solutions and some type of garment
for victims once emergency decon takes place. Many
of the supplies needed to complete decontamination
can be purchased locally at hardware and discount
stores. Fire departments usually have access to SCBA
for respiratory protection. OSHA regulations permit
decon teams to wear one level of protective clothing
less than the entry team is wearing. Hazmat teams
generally use Level A (total encapsulation) for vapor
atmospheres or Level B (splash protection) for
non-vapor atmospheres. As a result, the
decontamination team will almost always be in Level
B.
Emergency decon involves several steps:
– Wash down the victim with water while outer
cloths are still on.
– Remove the victim’s outer clothing, leaving
underwear in place. Clothing may contain the most
contaminant, and keeping it on will prolong the
contact of the harmful materials with the body.
– Wash down the victim again. With the second wash
down, soap and water can be applied if soap is
available. Liquid soap should be used because it
dissolves better in cold water and dry soap can be
abrasive.
– Provide victims with replacement clothing or
coverings. This can be as simple as large plastic trash
bags with holes cut in them, disposable sheets or
blankets, hospital gowns or scrubs, used clothing
from Goodwill or the Salvation Army, or commercially
available paper clothing.
– When outer clothing is removed, actions should be
taken to protect the privacy of victims. Tarps used for
salvage and ropes used in rescue operations can be
employed to provide privacy curtains for decon.
Ropes can be strung between the hose beds of
apparatus placed back to back with spacing for the
protected decon corridors. Tarps can then be placed
over the ropes to provide privacy corridors for
victims and can be used to segregate sexes. Nozzles
can be placed on discharge ports of two engines side
by side to provide a wide-angle fog for
decontamination. The area between the engines can
be used as a privacy protected corridor.
– While there are important environmental concerns
for the runoff from any type of decontamination, life
safety of victims should be the first priority when
conducting emergency decon. Runoff may contain
contaminants that could harm the environment and
every effort should be made to control it; however,
the life safety of victims and responders takes
precedence. First responders should not take time to
worry about runoff at the expense of the victims’
well-being.
EMERGENCY DECONTAMINATION
Mass Decontamination
– Mass decon is required when large numbers of
victims have been exposed to contamination, which
needs to be removed as quickly as possible. Mass
decontamination can be performed in conjunction
with emergency decontamination if a technical decon
has yet to be established. Once resources have
arrived on scene, a more organized mass
decontamination can be performed on victims. This
may involve mass decontamination trailers or large
mass decontamination tents with roller assemblies to
take care of nonambulatory patients.
– With large numbers of people, decontamination
may be accomplished with a combination of systems.
Large numbers of victims are going to be difficult to
handle at best. Do not become overwhelmed. Take
care of victims one at a time. Training with
equipment and conducting realistic drills will help
make an actual incident run smoother.
– Technical decon may also be set up to deal with
decontamination of response personnel. All three
types of decon may be in operation at one time
depending on the circumstances of an incident.
Training and Resources
– The process of decontamination is not overly
technical, nor does it require the purchase of lots of
expensive equipment or training personnel to the
technician level. While traditionally technician-level
personnel from hazmat teams have conducted decon,
many fire departments train and equip specialized
decon teams with personnel who have
operations-level hazmat training and provide them
with training for decontamination. This is an
acceptable procedure under OSHA regulations.
OSHA's basic regulatory philosophy is to train and
equip employees to do the job they are asked to do. A
decon team should have a response plan and
standard operating procedures (SOPs) to establish
protocols for decon operations, including emergency
decon. Jurisdictions that choose to operate with first
responder emergency decon should also have written
procedures in place guiding the operations.
– Many jurisdictions do not have their own hazmat
teams; they require the use of mutual aid or private
contractors for hazmat responses. Mutual-aid teams
and private contractors generally do not respond
with large numbers of people, but a simple entry into
a hazmat hot zone and resulting decon can easily
require 20 to 30 personnel. So the idea of a local
designated decon team can provide additional
personnel to assist the mutual-aid hazmat team. This
concept can also work well in departments that have
hazmat teams because in both cases, decon teams
will free technician-level personnel on the hazmat
team to concentrate on entry operations. A local
decon team can provide ambulatory victim
decontamination while waiting for the hazmat team
to arrive. A local decon team can then provide
technical decontamination for hazmat team
members, thus freeing technicians for entry tactics
and rescue of non-ambulatory victims.
– Decon teams also must be trained. Training has a
monetary value in terms of the cost of the training
and in the cost of the time spent on the training.
Decon training would require 16–24 hours, including
theory and hands-on. Training should include
elementary toxicology, decontamination solutions,
decontamination setup, protective equipment and
decontamination procedures. Toxicology is covered
because the primary reason for decontamination is to
remove toxic materials from victims and personnel.
Being flexible and creative in establishing
decontamination procedures can streamline
operations, make better use of personnel, and
provide better protection for responders and the
public
disaster on the community will only be compounded
by the medical system. Once plans are developed,
they must be practiced and personnel trained to
follow them. Being flexible and creative in
establishing decontamination procedures can
streamline operations, make better use of personnel,
and provide better protection for responders and the
public.

– Some hospital emergency departments are not even

prepared to deal with victims of accidental hazmat
incidents. (Because agents used in terrorist attacks
are hazardous materials, no differentiation is made in
this column when referring to them when discussing
procedures unless they are unique to a particular
material.) Patients could contaminate a hospital
emergency department and close it to other types of
emergencies until it can be decontaminated. Much of
the attention at a hazmat or terrorist scene is focused
on treating victims and mitigating the incident.
Response personnel also need to take into
consideration treatment beyond the scene (i.e., the
hospital and, in particular, the emergency room).

– Many hospitals, particularly smaller ones, are not

prepared to accept potentially contaminated victims
from a hazmat or terrorist incident. While it is not
necessary that every hospital emergency department
have the capability of receiving contaminated victims,
response personnel should know which hospitals do
have that ability. The successful outcome of a hazmat
or terrorist incident will depend on good
preplanning, which must include the local medical
system. In addition to decontamination ability,
hospitals should be identified that have the expertise
to handle poison exposures, including stocks of
antidotes. When a community has more than one
hospital, certain ones may be designated as hazmat
facilities for the purpose of receiving patients from
the emergency medical system. All other hospitals
should at least have the ability to provide basic
decontamination and care for people exposed to
hazardous materials.

In summary:
– Mass-casualty incidents involving hazardous
materials may overwhelm all hospitals in a
community. There may not be enough doctors and
nurses, supplies, equipment or bed space to treat
victims. Without a pre plan that makes contingencies
for mass-exposure incidents, the impact of the
Disaster Nursing Lecture (Midterms)
TOPIC 4: Biological Warfare
What is the History of Biological Warfare?
– Biological weapons include any microorganism
(such as bacteria, viruses, or fungi) or toxin
(poisonous compounds produced by
microorganisms) found in nature that can be used to
kill or injure people.
– The act of bioterrorism can range from a simple
hoax to the actual use of these biological weapons,
also referred to as agents.
– Several nations have or are seeking to acquire
biological warfare agents, and there are concerns that
terrorist groups or individuals may acquire the
technologies and expertise to use these destructive
agents.
– Biological agents may be used for an isolated
assassination, as well as to cause incapacitation or
death to thousands. If the environment is
contaminated, a long-term threat to the population
could be created
History: The use of biological agents is not a new
concept, and history is filled with examples of
their use.
– Attempts to use biological warfare agents date back
to antiquity. Scythian archers infected their arrows by
dipping them in decomposing bodies or blood mixed
with manure as far back as 400 BC. Persian, Greek,
and Roman literature from 300 BC quote examples of
dead animals used to contaminate wells and other
sources of water. In the Battle of Eurymedon in 190
BC, Hannibal won a naval victory over King Eumenes
II of Pergamon by firing earthen vessels full of
venomous snakes into the enemy ships.
– During the battle of Tortona in the 12th century AD,
Barbarossa used the bodies of dead and decomposing
soldiers to poison wells. During the siege of Kaffa in
the 14th century AD, the attacking Tatar forces
hurled plague-infected corpses into the city in an
attempt to cause an epidemic within enemy forces.
This was repeated in 1710 when the Russians
besieging Swedish forces at Reval in Estonia
catapulted bodies of people who had died from the
plague.
– During the French and Indian War in the 18th
century AD, British forces under the direction of Sir
Jeffrey Amherst gave blankets that had been used by
smallpox victims to the Native Americans in a plan to
spread the disease.
– Allegations were made during the American Civil
War by both sides, but especially against the
Confederate Army, of the attempted use of smallpox
to cause disease among enemy forces
Modern times: Biological warfare reached
sophistication during the 1900s
– During World War I, the German Army developed
anthrax, glanders, cholera, and a wheat fungus
specifically for use as biological weapons. They
allegedly spread plague in St. Petersburg, Russia,
infected mules with glanders in Mesopotamia, and
attempted to do the same with the horses of the
French Cavalry.
– The Geneva Protocol of 1925 was signed by 108
nations. This was the first multilateral agreement
that extended the prohibition of chemical agents to
biological agents. Unfortunately, no method for
verification of compliance was addressed.
– During World War II, Japanese forces operated a
secret biological warfare research facility (Unit 731)
in Manchuria that carried out human experiments on
prisoners. They exposed more than 3,000 victims to
plague, anthrax, syphilis, and other agents in an
attempt to develop and observe the disease. Some
victims were executed or died from their infections.
Autopsies were also performed for a greater
understanding of the effects on the human body
– In 1942, the United States formed the War Research
Service. Anthrax and botulinum toxin initially were
investigated for use as weapons. Sufficient quantities
of botulinum toxin and anthrax were stockpiled by
June 1944 to allow unlimited retaliation if the
German forces first used biological agents. The
British also tested anthrax bombs on Gruinard Island
off the northwest coast of Scotland in 1942 and 1943
and then prepared and stockpiled anthrax-laced
cattle cakes for the same reason.
– The United States continued research on various
offensive biological weapons during the 1950s and
1960s. From 1951-1954, harmless organisms were
released off both coasts of the United States to
demonstrate the vulnerability of American cities to
biological attacks. This weakness was tested again in
1966 when a test substance was released in the New
York City subway system.
–During the Vietnam War, Viet Cong guerrillas used
needle-sharp punji sticks dipped in feces to cause
severe infections after an enemy soldier had been
stabbed.
– In 1979, an accidental release of anthrax from a
weapons facility in Sverdlovsk, USSR, killed at least
66 people. The Russian government claimed these
deaths were due to infected meat and maintained this
position until 1992 when Russian President Boris
Yeltsin finally admitted to the accident.
Facts on Bioterrorism and Bio- warfare Today
Bioterrorism and bio - warfare today: A number of
countries have continued offensive biological weapons
research and use. Additionally, since the 1980s,
terrorist organizations have become users of biological
agents. Usually, these cases amount only to hoaxes.
– In 1985, Iraq began an offensive biological
weapons program producing anthrax, botulinum
toxin, and aflatoxin. During Operation Desert Storm,
the coalition of allied forces faced the threat of
chemical and biological agents. Following the Persian
Gulf War, Iraq disclosed that it had bombs, Scud
missiles, 122-mm rockets, and artillery shells armed
with botulinum toxin, anthrax, and aflatoxin. They
also had spray tanks fitted to aircraft that could
distribute agents over a specific target.
– In September and October of 1984, 751 people
were intentionally infected with Salmonella, an agent
that causes food poisoning, when followers of the
Bhagwan Shree Rajneesh contaminated restaurant
salad bars in Oregon.
– In 1994, a Japanese sect of the Aum Shinrikyo cult
attempted an aerosolized (sprayed into the air)
release of anthrax from the tops of buildings in
Tokyo.
– In 1995, two members of a Minnesota militia group
were convicted of possession of ricin, which they had
produced themselves for use in retaliation against
local government officials.
– In 1995, two members of a Minnesota militia group
were convicted of possession of ricin, which they had
produced themselves for use in retaliation against
local government officials. In 1996, an Ohio man
attempted to obtain bubonic plague cultures through
the mail.
– In 2001, anthrax was delivered by mail to U.S.
media and government offices. There were five
deaths as a result.
– In December 2002, six terrorist suspects were
arrested in Manchester, England; their apartment
was serving as a "ricin laboratory." Among them was
a 27-year-old chemist who was producing the toxin.
Later, on Jan. 5, 2003, British police raided two
residences around London and found traces of ricin,
which led to an investigation of a possible Chechen
separatist plan to attack the Russian embassy with
the toxin; several arrests were made.
– On Feb. 3, 2004, three U.S. Senate office buildings
were closed after the toxin ricin was found in a
mailroom that serves Senate Majority Leader Bill
Frist's office.
The threat that biological agents will be used on both
military forces and civilian populations is now more
likely than it was at any other point in history.
How are Biological Agents Delivered and
Detected?
– Although there are more than 1,200 biological
agents that could be used to cause illness or death,
relatively few possess the necessary characteristics to
make them ideal candidates for biological warfare or
terrorism agents. The ideal biological agents are
relatively easy to acquire, process, and use. Only
small amounts (on the order of pounds and often
less) would be needed to kill or incapacitate
hundreds of thousands of people in a metropolitan
area. Biological warfare agents are easy to hide and
difficult to detect or protect against. They are
invisible, odorless, tasteless, and can be spread
silently.
Biological warfare agents can be Disseminated in
various ways.
– Through the air by aerosol sprays: To be an
effective biological weapon, airborne germs must be
dispersed as fine particles. To be infected, a person
must breathe a sufficient quantity of particles into
the lungs to cause illness.
– Used in explosives (artillery, missiles, detonated
bombs): The use of an explosive device to deliver and
spread biological agents is not as effective as the
delivery by aerosol. This is because agents tend to be
destroyed by the blast, typically leaving less than 5%
of the agent capable of causing disease.
– Put into food or water: Contamination of a city's
water supplies requires an unrealistically large
amount of an agent as well as an introduction into the
water after it passes through a regional treatment
facility.
– Absorbed through or injected into the skin: This
method might be ideal for assassination but is not
likely to be used to cause mass casualties.
Detection
– Early detection of a biological agent in the
environment allows for early and specific treatment
and time enough to treat others who were exposed to
protective medications. Currently, the U.S.
Department of Defense is evaluating devices to detect
clouds of biological warfare agents in the air.
– Doctors must be able to identify early victims and
recognize patterns of disease. If unusual symptoms, a
large number of people with symptoms, dead
animals, or other inconsistent medical findings are
noted, a biological warfare attack should be
suspected. Doctors report these patterns to public
health officials.
Protective Measures:
– Masks: Currently, available masks such as the
military gas mask or high-efficiency particulate air
(HEPA) filter masks used for tuberculosis exposure
filter out most biological warfare particles delivered
through the air.
– Clothing: Most biological agents in the air do not
penetrate unbroken skin, and few organisms stick to
skin or clothing. After an aerosol attack, the simple
removal of clothing eliminates a great majority of
surface contamination.
– Medical protection: Health care professionals
treating victims of biological warfare may not need
special suits but should use latex gloves and take
other precautions such as wearing gowns and masks
with protective eye shields. Victims would be isolated
in private rooms while receiving treatment.
– Antibiotics: Victims of biological warfare might be
given antibiotics orally (pills) or through an IV, even
before the specific agent is identified.
– Vaccinations: Currently, protective vaccines (given
as shots) are available for anthrax, Q fever, yellow
fever, and smallpox. The widespread immunization of
nonmilitary personnel has not been recommended by
any governmental agency so far. Immune protection
against ricin and staphylococcal toxins may also be
possible in the near future.
Anthrax Exposure Symptoms, SIgns, and
Diagnosis
– Anthrax bacteria occur worldwide. The United
States Working Group on Civilian Biodefense and the
Centers for Diseases Control and Prevention (CDC)
have identified anthrax as one of a few biological
agents capable of causing death and disease in
sufficient numbers to cripple a developed region or
urban setting.
– The organisms known as Bacillus anthracis may
ordinarily produce disease in domesticated as well as
wild animals such as goats, sheep, cattle, horses, and
swine.
– Humans become infected by contact with infected
animals or contaminated animal products. Infection
occurs mainly through the skin and rarely by
breathing spores or swallowing them.
– Spores exist in the soil and become aerosolized
when the microorganisms are released into the air by
excavation, plowing, or other disruptive actions.
Signs and Symptoms
– Skin anthrax (cutaneous): Infection begins when
the spores enter the skin through small cuts or
abrasions. Spores then become active in the host
(human or animal) and produce poisonous toxins.
Swelling, bleeding, and tissue death may occur at the
site of infection.
– Most of the cases of anthrax involve the skin. After a
person is exposed, the disease first appears in 1-5
days as a small pimple-looking sore that progresses
over the next 1-2 days to contain fluid-filled with
many organisms. The sore is usually painless, and it
may have to swell around it. Sometimes the swelling
affects a person's entire face or limb.
– Victims may have a fever, feel tired, and have a
headache. Once the sore open, it forms a black area of
tissue. The black appearance of the tissue injury gives
anthrax its name from the Greek word anthracosis,
meaning coal. After a period of 2-3 weeks, the black
tissue separates, often leaving a scar. With adequate
treatment, less than 1% of people infected with skin
anthrax die.
– Inhalation anthrax: In inhalation anthrax, the
spores are inhaled into the lungs where they become
active and multiply. There they produce massive
bleeding and swelling inside the chest cavity. The
germs can spread to the blood, leading to shock and
blood poisoning, which may lead to death.
– Historically known as woolsorter's disease
(because it affected people who work around sheep),
inhalation anthrax can appear anywhere within 1-6
days, or as long as 60 days after exposure. Initial
symptoms are general and can include headache,
tiredness, body aches, and fever. The victim may have
a nonproductive cough and mild chest pain. These
symptoms usually last for 2-3 days.
– Some people show a short period of improvement.
This is followed by the sudden onset of increased
trouble breathing, shortness of breath, bluish skin
color, increased chest pain, and sweating. Swelling of
the chest and neck may also occur. Shock and death
may follow within 24-36 hours in most people with
this type of infection.
– Anthrax is not spread from person to person.
Inhalation anthrax is the most likely form of the
disease to follow a military or terrorist attack. Such
an attack likely will involve the aerosolized delivery
of anthrax spores.
– Mouth, throat, GI tract (oropharyngeal and
gastrointestinal): These cases result when someone
eats infected meat that has not been cooked
sufficiently. After an incubation period of 2-5 days,
victims with the oropharyngeal disease develop a
severe sore throat or sores in the mouth or on a
tonsil. Fever and neck swelling may occur. The victim
may have trouble breathing. GI anthrax begins with
nonspecific symptoms of nausea, vomiting, and fever.
DIagnosis
– With skin anthrax, a biopsy is taken of the sore
(lesion), and lab tests are performed to look at the
organism under a microscope and confirm the
diagnosis of anthrax.
– The diagnosis of inhalation anthrax is difficult to
make. A chest X-ray may show certain signs in the
chest cavity. A CT scan of the chest may be very
helpful when there is suspected inhalational anthrax.
Early in the process, when the chest X-ray is still
normal, the CT scan may show pleural, pericardial,
and mediastinal fluid collections, enlarged
hemorrhagic mediastinal lymph nodes, and bronchial
airway edema. Cultures (growing the bacteria in a lab
and then examining them under a microscope) are
minimally helpful in making the diagnosis. Blood
tests may also be performed.
– GI anthrax also is difficult to diagnose because the
disease is rare and symptoms are not always obvious.
Diagnosis usually is confirmed only if the victim has a
history of eating contaminated meat in the setting of
an outbreak. Once again, cultures generally are not
helpful in making the diagnosis.
– Meningitis (brain swelling) from anthrax is difficult
to distinguish from meningitis due to other causes. A
spinal tap may be performed to look at the person's
spinal fluid in identifying the organism.
– Rapid diagnostic tests for anthrax and its proteins
include polymerase chain reaction (PCR), enzyme
linked immunosorbent assay (ELISA), and direct
fluorescent antibody (DFA) testing. Currently, these
tests are only available at national reference
laboratories.
Anthrax Exposure Treatment
– Ciprofloxacin (Cipro), doxycycline (Vibramycin),
and penicillin are FDA-approved antibiotics for the
treatment of anthrax. Experts currently recommend
ciprofloxacin or other drugs in the same class for
adults who are assumed to have inhalation anthrax
infection. Penicillin and doxycycline may be used
once organism culture sensitivities are known.
– Traditionally, ciprofloxacin and other antibiotics in
that class are not recommended for use in children
younger than 16-18 years of age because of a weak
theoretical link to permanent joint disorders.
Balancing these small risks against the risk of death
and the possibility of infection with a resistant strain
of anthrax, experts recommend that ciprofloxacin
nonetheless be given to children in appropriate
doses.
– Because there is a risk the infection will recur,
victims are treated with antibiotics for at least 60
days.
– Skin anthrax: Treatment of skin anthrax with
antibiotics generally prevents the disease from
progressing to the entire body although the black
tissue and scar continue to form. Although previous
guidelines have suggested treating skin anthrax with
7-10 days of therapy, recent recommendations
suggest treatment for 60 days in the setting of
bioterrorism, thus assuming the person may also
have been exposed to inhalational anthrax.
– In pregnant women, experts recommend that
ciprofloxacin be given after exposure as a preventive
medication following exposure to an anthrax attack.
Prevention
– A vaccination series to protect against anthrax
consists of five IM doses administered at day 0, week
4, and months 6, 12, and 18, followed by annual
boosters. The CDC does not recommend vaccination
for the general public, health care workers, or even
people working with animals. The only groups that
are recommended to receive routine vaccination are
military personnel and investigators and remediation
workers who are likely to enter an area with B.
anthracis spores.
Post exposure prophylaxis
When unvaccinated people are exposed to anthrax, it
is now recommended that they receive antibiotics for
60 days and be vaccinated. The common antibiotics
used for post exposure prophylaxis are ciprofloxacin
or doxycycline. The vaccine is Anthrax Vaccine
Adsorbed (AVA), and it is given in three subcutaneous
doses (administered at 0, 2, and 4 weeks post
exposure). These recommendations are for everyone
and include pregnant women and children (although
the recommendation for children will be reviewed on
an event-by-event basis). The government has
stockpiles of drugs and vaccines available and can
deliver them to an affected area very quickly.
PLAGUE
– Plague is another infection that can strike humans
and animals. It is caused by the bacteria Yersinia
pestis, which has been the cause of three great
human pandemics in the sixth, 14th, and 20th
centuries. Throughout history, the oriental rat flea
has been largely responsible for spreading bubonic
plague. After the flea bites an infected animal, the
organisms can multiply inside the flea. When an
infected flea attempts to bite again, it vomits clotted
blood and bacteria into the victim's bloodstream and
passes the infection on to the next victim, whether
small mammals (usually rodents) or humans
Signs and Symptoms
– People infected with plague may suddenly develop
high a fever, painful lymph nodes, and have bacteria
in their blood. Some victims with the bubonic form of
the disease may develop secondary pneumonic
plague (a disease similar to pneumonia). Plague is
contagious, and when the victim coughs, plague can
spread. Pneumonic plague is the most severe form of
the disease and if untreated, most people die.
– As few as one to 10 organisms are enough to infect
humans or other animals including rodents. During
the early phase, the germs usually spread to lymph
nodes near the bite, where swelling occurs. The
infection then spreads to other organs such as the
spleen, liver, lungs, skin, mucous membranes, and
later, the brain.
If fleas were used as carriers of disease, bubonic
or septicemic (blood infection) plague would
result.
– Bubonic plague: Swollen lymph nodes (called
buboes) develop 1-8 days after exposure. Their
appearance is associated with the onset of sudden
fever, chills, and headache, which often are followed
by nausea and vomiting several hours later. The
buboes become visible within 24 hours and cause
severe pain. Untreated, septicemia (blood poisoning)
develops in 2-6 days. Up to 15% of bubonic plague
victims develop secondary pneumonic plague and
thus can spread illness from person to person by
coughing.
– Septicemia plague: Septicemia plague may occur
with bubonic plague. The signs and symptoms of
primary septicemic plague include fever, chills,
nausea, vomiting, and diarrhea . Later, bleeding in the
skin may develop, hands and feet may lose
circulation, and tissue may die.
– Pneumonic plague: Pneumonic plague may occur
primarily from inhaling organisms in the air or from
exposure to infected blood. Victims typically have a
productive cough with blood tinged sputum within
24 hours of symptom onset
Diagnosis
– The diagnosis of bubonic plague may be made if
the victim has painful lymph glands and other
common symptoms, especially if the victim has been
exposed to rodents or fleas. But if the victim is not in
an area where plague is present and symptoms are
typical of other illnesses, the diagnosis may be
difficult.
– The doctor may view under a microscope a sample
of sputum from a productive cough or the fluid from a
swollen lymph gland.
– Samples may grow in the laboratory and indicate
plague within 48 hours and blood tests may also be
performed.
Treatment
– Treatment should not be delayed for confirmatory
testing. Victims of suspected plague will be isolated
for the first 48 hours after treatment begins. If
pneumonic plague is present, isolation may last for 4
more days. In 2021, the CDC significantly updated
their guidelines for the treatment of plague.
Ciprofloxacin is the recommended treatment now,
but other fluoroquinolone antibiotics (levofloxacin
and moxifloxacin) and gentamycin are also
acceptable alternatives. Streptomycin, while still an
approved treatment, is frequently not available.
Duration of treatment is 10-14 days, but treatment
can be extended for people with ongoing fever or
other concerning signs. The antibiotics may be given
either by mouth or intravenously, depending on
severity of illness and other clinical factors.
– If treated with antibiotics, buboes typically become
smaller in 10-14 days and do not require drainage.
Victims are unlikely to survive primary pneumonic
plague if antibiotic therapy is not begun within 18
hours of the beginning of symptoms. Without
treatment, 60% of people with bubonic plague die,
and 100% with pneumonic and septicemic forms die
Prevented
– Fleas always must be targeted for destruction
before the rodents, because killing rodents may
release into the environment massive amounts of
infected fleas, which will be hungry for a blood meal
and, in the absence of rodents, the fleas will seek out
any warm-blooded animal, including humans and
infect them. Pesticides have been successful in
getting rid of rats and other animal hosts. Public
education about how plague spreads is an important
part of prevention.
– People who have been exposed to pneumonic
plague and those who have been exposed to
organisms in the air may be treated with antibiotics.
Currently recommended antibiotics are streptomycin
or gentamycin IM for 10 days, or until 2 days after the
fever subsides. Alternative medications include
doxycycline, ciprofloxacin, and chloramphenicol.
– Contacts with victims who have bubonic plague do
not need preventive medication. But people who
were in the same environment as those who are
infected may need preventive antibiotics. A
previously FDA-approved plague vaccine is no longer
manufactured. It was useful against the bubonic form
of plague but not the more serious pneumonia (lung)
form of plague, which is the kind most often expected
in a terrorist incident. A new vaccine effective against
all varieties of plague is under development.
CHOLERA
– Cholera is an acute and potentially severe
gastrointestinal disease (stomach and intestines)
caused by the bacteria Vibrio cholera. This agent has
been investigated in the past as a biological weapon.
Cholera does not spread easily from human to
human, so it appears that major drinking water
supplies would have to be profusely contaminated for
this agent to be effective as a biological weapon.
– Cholera normally can infect water or food that
becomes contaminated by human bowel waste. The
organism can survive for up to 24 hours in sewage
and as long as 6 weeks in certain types of relatively
impure water containing organic matter. It can
withstand freezing for 3-4 days, but it is killed readily
by dry heat, steam, boiling, short-term exposure to
ordinary disinfectants, and chlorination of water.
– The toxin causes a person's intestines to create
massive amounts of fluid that then produces thin,
grayish-brown diarrhea.
Signs and Symptoms
– Depending on how many organisms a person
drinks or eats, the illness could begin within 12-72
hours. The symptoms start suddenly with intestinal
cramps and painless (rice-water appearing) diarrhea.
Vomiting, feeling ill, and headache often accompany
diarrhea, especially early in the illness.
– Fever is rare. If untreated, the disease generally
lasts 1-7 days. During the illness, the body loses great
amounts of fluid, so it is important during recovery to
replace fluids and balance electrolytes (such as
sodium and potassium).

– Children may experience seizures and
cardiovascular imbalances severe enough to cause
heart problems. The rapid loss of body fluids often
leads to more severe illness. If not treated, up to half
of the children with cholera may die.
DIagnosis
– Although cholera can be suspected in patients with
a large volume of watery diarrhea, physicians make a
definitive diagnosis through stool culture on
specialized culture media (thiosulfate citrate bile
sucrose (TCBS) agar or taurocholate tellurite gelatin
agar (TTGA).
– There are rapid tests that are also available for
diagnosis. However, the tests lack specificity and are
usually not recommended at this time
Treatment
– Fluids and electrolytes need to be replaced because
the body has lost large amounts of fluids through
vomiting and diarrhea. Doctors may encourage the
person to drink, but if someone continues to vomit or
has frequent stools, an IV may be used to replace the
fluid lost.
– Antibiotics are recommended if there is severe
dehydration or some dehydration with continued
stool loss during rehydration therapy. Antibiotics are
also recommended for pregnant women and
immunocompromised people (for example, severe
malnutrition or HIV).
– Antibiotics such as tetracycline or doxycycline
shorten the duration of diarrhea and reduce fluid
losses. The currently recommended treatment is a
single 300 mg oral dose of doxycycline for adults,
pregnant women, and children. The antibiotics
ciprofloxacin or erythromycin also may be used for a
few days but are not routinely recommended.
Prevention
The FDA recently approved a new single-dose live
oral cholera vaccine called Vaxchora (lyophilized CVD
103-HgR). The Advisory Committee on Immunization
Practices (ACIP) recommends the vaccine's use for
adults 18-64 years old who are traveling to an area of
active cholera transmission. It is not recommended
for routine travelers
TULAREMIA
– Tularemia is an infection that can strike humans
and animals. It is caused by the bacterium Francisella
tularensis. The disease causes fever, localized skin or
mucous membrane ulcerations, regional swelling of
lymph glands, and occasionally pneumonia.
– G.W. McCay discovered the disease in Tulare
County, Calif., in 1911. The first confirmed case of
human disease was reported in 1914. Edward
Francis, who described transmission by deer flies via
infected blood, coined the term tularemia in 1921. It
has been considered an important biological warfare
agent because it can infect many people if dispersed
by the aerosol route.
– Rabbits and ticks most commonly spread tularemia
in North America. In other areas of the world,
tularemia is transmitted by water rats and other
aquatic animals.
– The bacteria are usually introduced into the victim
through breaks in the skin or through the mucous
membranes of the eye, respiratory tract, or GI tract.
Ten virulent organisms injected under the skin from a
bite or 10-50 organisms breathed into the lungs can
cause infection in humans. Hunters may contract this
disease by trapping and skinning rabbits in some
parts of the country
Tularemia has six major forms:
● Ulceroglandular tularemia
● Glandular tularemia
● Oculoglandular tularemia
● Pharyngeal (oropharyngeal) tularemia
● Typhoidal tularemia
● Pneumonic tularemia
– Victims with the most common form,
ulceroglandular type, typically have a single
papule-ulcerative lesion with a central scar (often at
the site of a tick bite) and associated tender regional
lymphadenopathy (swollen lymph nodes).
– A sore up to 1 inch across may appear on the skin
in a majority of people and is the most common sign
of tularemia. If the bite associated with infection was
from an animal carrying the disease, the sore is
usually on the upper part of a person's body, such as
on the arm.
– If the infection came from an insect bite, the sore
might appear on the lower part of the body, such as
on the leg.
– Enlarged lymph nodes are seen in a majority of
victims and maybe the initial or the only sign of
infection. Although enlarged lymph nodes usually
occur as single lesions, they may appear in groups.
Enlarged lymph nodes may come and go and last for
as long as three years. When swollen, they may be
confused with buboes of bubonic plague.
– The glandular form of the disease has tender
regional lymphadenopathy but no identifiable skin
lesion.
– Oculoglandular tularemia presents as
conjunctivitis (white of the eyes are red and
inflamed), increased tearing, photophobia, and
tender enlarged lymph nodes in the head and neck
region. Pharyngeal tularemia presents with a sore
throat, fever, and swelling in the neck.
– The most serious forms of tularemia are typhoidal
and pneumonic diseases. Patients with typhoidal
disease can have fever, chills, anorexia, abdominal
pain, diarrhea, headache, myalgias, sore throat, and
cough. Patients with pneumonic tularemia have
mostly pulmonary findings. Many patients with
pulmonary findings have underlying typhoidal
tularemia.
Diagnosis
– Tularemia can be diagnosed by growing the
bacteria in the laboratory from samples taken of
blood, ulcers, sputum, and other body fluids.
Serological tests (done to detect antibodies against
tularemia), direct fluorescent antibody (DFA) staining
of clinical specimens, and polymerase chain reaction
(PCR) test on clinical specimens are available from
specialized labs.
Treatment
– Victims with tularemia who do not receive
appropriate antibiotics may have a prolonged illness
with weakness and weight loss.
– Treated properly, very few people with tularemia
die. If a patient has severe disease, it is recommended
to give them a 14-day course of streptomycin or
gentamicin.
– For patients with mild to moderate disease, oral
ciprofloxacin or doxycycline is recommended. In
children with mild to moderate disease, gentamycin
is often recommended. However, despite the
concerns over side effects in children, some clinicians
may recommend oral treatment with ciprofloxacin or
doxycycline.
– Although laboratory-related infections with this
organism are common, the human-to-human spread
is unusual. Victims do not need to be isolated from
others.
Prevention
– There is no recommendation for prophylactic
treatment of people going into areas where tularemia
is more common. In fact, in the case of low-risk
exposure, observation without antibiotics is
recommended.
– There no longer exists a vaccine against tularemia.
New vaccines are under development.
Post exposure Prophylaxis
– In the event of a biological attack using Francisella
tularensis, the recommendation is to treat exposed
people who are not yet ill with 14 days of oral
doxycycline or ciprofloxacin.
BRUCELLOSIS
– Brucellosis is an infection of domesticated and wild
animals that can be transmitted to humans. It is
caused by an organism of the genus Brucella. The
organism infects mainly cattle, sheep, goats, and
other similar animals, causing death of developing
fetuses and genital infection. Humans, who usually
are infected incidentally by contact with infected
animals, may develop numerous symptoms in
addition to the usual ones of fever, general illness,
and muscle pain.
– The disease often becomes long-term and may
return, even with appropriate treatment. The ease of
transmission through the air suggests that these
organisms may be useful in biological warfare.
– Each of six different strains of the bacteria infect
certain animal species. Four are known to cause
illness in humans. Animals may transmit organisms
during a miscarriage, at the time of slaughter, and in
their milk. Brucellosis is rarely, if ever, transmitted
from human to human.
– Certain species can enter animal hosts through skin
abrasions or cuts, the eye membranes, the
respiratory tract, and the GI tract. Organisms grow
rapidly and eventually go to the lymph nodes, liver,
spleen, joints, kidneys, and bone marrow.
Sign and symptoms
– Victims may have a fever or a long-term infection or
just a local inflammation. The disease may appear
suddenly or develop slowly anywhere from 3 days to
several weeks after exposure. Symptoms include
fever, sweats, fatigue, loss of appetite, and muscle or
joint aches. Depression, headache, and irritability
occur frequently. In addition, infection of bones,
joints, or the genitourinary tract may cause pain.
Cough and chest pain also may be present.
– Symptoms often last 3-6 months and occasionally
for longer than a year. Different species of the
organism can cause different symptoms from skin
sores to low back pain to liver disease
Diagnosis
– The doctor will want to know about any exposure
to animals, animal products, or environmental
exposures in making the diagnosis. Those who drink
unpasteurized milk are at higher risk of infection.
Military troops exposed to a biological attack and
who have fever are likely candidates for this illness.
Environmental samples may show the presence of
this organism in the attack area. Laboratory tests and
cultures of blood or body fluid samples including
bone marrow may be performed
Treatment
– Therapy with a single drug has resulted in a high
relapse rate, so a combination of antibiotics should
be prescribed. A 6-week course of doxycycline and
rifampin is effective in most adults with most forms
of brucellosis, but there are other alternative
antibiotic options.
Prevention
– Animal handlers should wear appropriate
protective clothing when working with infected
animals. Meat should be well cooked, and milk should
be pasteurized. Laboratory workers need to take
appropriate cautions in handling the organism.
Post Exposure Prophylaxis
– In the event of a biological attack, the standard gas
mask should protect adequately from airborne
species. No commercially available vaccine exists for
humans. If the exposure is considered high risk, the
CDC recommends treating with doxycycline and
rifampin for 3 weeks
Q FEVER
– Humans have been infected most commonly by
contact with domestic livestock, particularly goats,
cattle, and sheep. The risk of infection is increased
greatly if humans are exposed while these animals
are giving birth to young. Large numbers of the
germs may be released into the air as an animal gives
birth. Survival of the organism on surfaces, such as
straw, hay, or clothing, allows for transmission to
other people who are not in direct contact with
infected animals.
– People can become infected by breathing the
organisms.
Signs and Symptoms
– Humans are the only hosts that commonly develop
an illness as a result of the infection. The illness may
begin within 10-40 days. There is no typical pattern
of symptoms, and some people show none at all. Most
people appear mildly to moderately ill.
– Fever (can go up and down and last up to 13 days),
chills, and headache are the most common signs and
symptoms. Sweating, aches, fatigue, and loss of
appetite are also common. Cough often occurs later in
the illness. Chest pain occurs in a few people.
Sometimes there is a rash. Other symptoms such as
headache, facial pain, and hallucinations have been
reported.
– Sometimes problems in the lungs are seen on chest
X-rays. And some people may seem to have acute
hepatitis because of their liver involvement. Others
may develop a heart condition called endocarditis
Diagnosis
– Blood tests may help in making the diagnosis of Q
fever.
Treatment
– The drug of choice for treatment of Q fever is
doxycycline. There are several alternative antibiotic
options that may be preferred under different
circumstances. People with chronic Q fever who
develop endocarditis may die, even with appropriate
treatment.
 Prevention
– Although an effective vaccine (Q-Vax) is licensed in
Australia, all Q fever vaccines used in the United
States are under study. Q fever can be prevented by
immunization.
Post exposure Prophylaxis
– In the case of bioterror attack, post exposure
prophylaxis is recommended using oral doxycycline.
SMALLPOX
– Variola (the virus that causes smallpox) is the most
notorious of the poxviruses. Smallpox was an
important cause of illness and death in the
developing world until recent times. In 1980, the
World Health Organization (WHO) declared that
smallpox had been completely wiped out. The last
case was noted in Somalia in 1977.
– Variola represents a significant threat as a
biological warfare agent. Variola is highly infectious
and is associated with a high death rate and
secondary spread. Currently, the majority of the U.S.
population has no immunity, the vaccine is in short
supply, and no effective treatment exists for the
disease. Two WHOapproved and inspected
repositories remain: One is at the Centers for Disease
Control and Prevention in the United States and the
other at Vector Laboratories in Russia. It is widely
believed that clandestine stockpiles exist in other
countries such as Iraq and North Korea.
– Variola virus is highly infectious when released into
the air. It is environmentally stable and can retain its
ability to infect people for long periods. Infection
through contaminated objects such as clothing is
infrequent. After a person is exposed to the
aerosolized virus, the virus multiplies in the person's
respiratory tract. After a period of 7-17 days, variola
is spread through the bloodstream to lymph nodes
where it continues to multiply
– Variola then moves into smaller blood vessels near
the surface of the skin where the inflammatory
changes occur. The classic smallpox rash then begins.
Two types of smallpox generally are recognized.
Variola major, the most severe form, may cause death
in up to 30% of unvaccinated people who develop it
(3% of people vaccinated people may also develop
variola major). Variola minor, a milder form of
smallpox, produces death in 1% of unvaccinated
people.
Signs and Symptoms
– The symptoms of variola major occur after a seven-
to the 17-day incubation period. They begin acutely
with high fever, headache, chills, aches, vomiting,
abdominal pain, and back pain. During the initial
phase, some people develop delirium
(hallucinations), and a portion of light-skinned
people may develop a fleeting rash.
– After two to three days, the rash develops on the
face, hands, and forearms and extends gradually to
the trunk and lower part of the body. The sores
progress all at once into fluid-filled sacs. The
distribution of the rash is important in making the
diagnosis of smallpox. A greater number of lesions
will appear on the face arms and legs compared to
the trunk.
– With the milder form of smallpox, variola minor, the
skin sores are similar but smaller and fewer in
number. People are not as ill as those who have
variola majors.
Diagnosis
– Most doctors have never seen a case of smallpox
and may have difficulty diagnosing it. Other viral
illnesses with rash, such as chickenpox or allergic
contact dermatitis, can look similar. Smallpox is
different from chickenpox because of the distribution
of the lesions and because they are all at the same
stage of development everywhere on the body. With
chickenpox, sores may be forming while others are
scabbing over.
– The failure to recognize mild cases of smallpox in
people with partial immunity permits rapid
person-to-person transmission. Exposed people may
shed viruses through coughing without ever showing
the signs and symptoms of the disease.
– The doctor may look at scrapings of tissue under a
microscope but will be unable to tell the difference
between smallpox and monkeypox or cowpox.
Advanced PCR techniques have been developed and
may provide for a more accurate diagnosis shortly
Treatment
– People with smallpox are usually isolated from
people without smallpox for 17 days. Anyone
exposed to either weaponized variola or people
infected with smallpox must be vaccinated
immediately; this may lessen or prevent the illness if
done within four or five days of infection.
– The FDA has approved two antiviral medications
for the treatment of smallpox (tecovirimat and
brincidofovir). The antiviral agent cidofovir may be
effective, but it is not FDA approved. Tecovirimat and
cidofovir are both included in the Strategic National
Stockpile in case of a public health emergency or
terrorist attack.
Prevention
– The smallpox vaccine is used to prevent people
from getting smallpox. The vaccine is given as a type
of shot, but a two-pronged needle is used to place the
medication into the skin. This leaves a permanent
scar, which many adults may still have from smallpox
inoculations given to them when they were babies
– Once the shot is given, a small fluid-filled pimple
usually appears 5-7 days later. A scab forms over the
site during the next 1-2 weeks. Common side effects
include low-grade fever and swollen lymph glands.
People with weakened immune systems should not
have the smallpox vaccination. This includes people
with HIV, anyone with a history of eczema, and
pregnant women.
Post exposure Prophylaxis
– In the case of a bioterror attack, it is recommended
that all people who were exposed be immunized
using the vaccine as soon as possible, but at least
within 4 days. Again, the use of the vaccine is not
recommended in people with skin diseases like
eczema, immunocompromised individuals (like HIV),
or in pregnant women.
MONKEYPOX
– The monkeypox virus, which is found in Africa, is a
naturally occurring relative of variola. The first case
of human monkeypox was identified in 1970, but
fewer than 400 cases have been diagnosed since.
Some concern exists that monkeypox may be
weaponized, however, human monkeypox is not as
potent as smallpox. Pneumonia due to monkeypox
may cause death in about half of people who develop
it.
ARBOVIRAL ENCEPHALITIDES
– The arboviral encephalitides with high fatality
rates include the Venezuelan equine encephalitis
(VEE) virus, western equine encephalitis (WEE)
virus, and eastern equine encephalitis (EEE) virus.
They are members of the Alphavirus genus and are
regularly associated with encephalitis. These viruses
were recovered from horses during the 1930s. VEE
was isolated in the Guajira peninsula of Venezuela in
1930, WEE in the San Joaquin Valley of California in
1930, and EEE in Virginia and New Jersey in 1933. A
more common, but milder arboviral disease, is West
Nile, which is caused by a flavivirus.
– Although natural infections with these viruses
occur following bites from mosquitoes, the viruses
are also highly infectious when spread through the
air. If intentionally released as a small particle
aerosol, this virus may be expected to infect a high
percentage of people exposed within a few miles.
– VEE virus has the capacity to produce epidemics.
Outcomes are significantly worse for the very young
and the very old. Up to 35% of people infected may
die. WEE and EEE typically produce less severe and
widespread disease but are associated with death
rates as high as 50%-75% in those with severe illness
Signs and symptoms
– EE: After an incubation period of 2-6 days, people
with VEE develop fevers, chills, headaches, aches,
sore throat, and sensitivity to light (eyes). They may
become mildly confused, have seizures or paralysis,
or go into a coma. For those who survive, their
nervous system functions usually recover completely.
– EEE: The incubation period for EEE varies from
5-15 days. Adults may have certain early symptoms
up to 11 days before the onset of nervous system
problems such as mild confusion, seizures, and
paralysis. Signs and symptoms include fever, chills,
vomiting, muscle rigidity, lethargy, slight paralysis,
excess salivation, and difficulty breathing. Children
frequently develop swelling on their faces and near
their eyes. A significant percentage of survivors of
severe disease have permanent nervous system
problems such as seizures and various degrees of
confusion (dementia).
– WEE: The incubation period is 5-10 days. Most
people have no symptoms, or they might develop a
fever. Other symptoms include nausea, vomiting,
headache, a stiff neck, and drowsiness. Up to a
majority of victims, younger than 1 year of age have
seizures. Typically, adults recover completely.
Children, especially newborns, may have lasting
nervous system problems.
Diagnosis
– Laboratory tests, including nasal swab samples,
may show any of the three viruses.
Treatment
– No specific treatment is available. Doctors will help
control symptoms. For some people, that may include
medications to control fever and seizures or help to
breathe.
Prevention
– There are no commercially available vaccines
against any of the arboviral encephalitides. They are
experimental and only available for researchers who
work with the virus.
VIRAL HEMORRHAGIC FEVERS
– Viral hemorrhagic fevers are caused by four
families of viruses.
● Arenaviridae (Lassa, Lujo, Guanarito,
Machupo, Junin, Sabia, and Chapare viruses)
● Bunyaviridae (Rift Valley, Crimean-Congo,
Hantaan)
● Filoviridae (Marburg, Ebola)
● Flaviviridae (Yellow, Dengue, Kyasanur Forest,
Alkhurma, Omsk HFs)
– The best known of viral hemorrhagic fevers is the
Ebola virus. First recognized in Zaire in 1976, the
virus has been linked to at least 20 outbreaks in
Africa. Earlier outbreaks in central Africa, with the
Zaire species of the Ebola virus, had very high
mortality rates (80%- 90%). However, the most
recent outbreaks with the same virus in Western
Africa have had lower mortality rates (approximately
50%). The largest outbreak of the Ebola virus in
history began in 2014, located primarily in the
Western African countries of Sierra Leone, Guinea,
and Liberia. In June 2016, the WHO reported that
there were 28,616 confirmed or probable cases and
11,323 deaths in those three countries, including 500
healthcare workers. The World Health Organization
declared Sierra Leone Ebola-free in November 2015,
and in June 2016, the WHO declared Liberia and
Guinea Ebola-free. However, there could be more
cases identified, and there will be continued
surveillance. During the outbreak, there were four
cases diagnosed in the United States: One in a
Liberian man who was visiting in Texas, two nurses
who took care of that man, and one physician who
had just returned from treating Ebola patients in
Guinea
VIRAL HEMORRHAGIC FEVERS (VHFs)
– These viruses are each characterized by an acute
generalized illness that includes feeling quite ill
(flulike illness) with profound exhaustion and is
sometimes associated with internal bleeding. The
West African Ebola outbreak was characterized more
by severe gastrointestinal illness with vomiting and
large-volume diarrhea. This leads to severe volume
depletion, metabolic abnormalities, and hypovolemic
shock. Other symptoms include fever, body and joint
pain, profound and progressive weakness, loss of
appetite, sore throat, headache, and fatigue.
– Most agents are highly infectious via the aerosol
route, and most are stable as respiratory aerosols.
Thus, they possess characteristics that may make
them attractive for use by terrorists.
– However, the Ebola virus has not been
demonstrated to be contagious person-to-person
through an aerosol route. It is spread through direct
contact with the blood or other body fluids of an
infected person, including a corpse.
– The agents that produce viral hemorrhagic fever
are all simple RNA viruses. They are able to survive in
blood for long periods, which means they can infect
people who are around animals slaughtered
domestically. These viruses are linked to the rodents,
bats, or insects that help to spread them, which helps
in searching for a diagnosis.
– The specific viral hemorrhagic fever manifestations
that develop depend on many factors such as the
strength of the virus, its strain, and the route of
exposure.
Signs and Symptoms
– The incubation period (time from exposure to onset
of symptoms) ranges from 2-21 days. Although
initially, a classic symptom of all of the viral
hemorrhagic fevers is bleeding, it actually only
occurred in about 20% of Ebola patients in the most
recent outbreak. Humans are not infectious until
symptoms develop. The incubation period is the time
interval from infection with the virus to onset of
symptoms is 2-21 days. Humans are not infectious
until they develop symptoms. The first symptoms
seen are fever, muscle aches, headaches, and sore
throat. Patients then go on to develop vomiting and
large-volume diarrhea. This leads to severe
dehydration and results in impaired kidney and liver
function. Some patients develop internal and external
bleeding (blood in stools and oozing from the gums).
Diagnosis
– It is important for the doctor to know a person's
travel history in making a diagnosis of viral
hemorrhagic fever. These agents are linked tightly
with their natural geographic area and the ecology of
the species and vectors found in that specific locale.
Victims often recall exposures to rodents
(Arenavirus, Hantavirus), mosquitoes (Valley fever
virus, yellow and dengue fever viruses), or even
slaughtered horses (Rift Valley fever virus,
Crimean-Congo virus). Laboratory tests may be
helpful. Testing of whole blood or serum includes
antibody-capture enzyme-linked immunosorbent
assay (ELISA), antigen-capture detection tests, and
reverse transcriptase-polymerase chain reaction
(RT-PCR) assay. Testing can be conducted at the CDC
in Atlanta or the U.S. Army Medical Research Institute
of Infectious Disease (USAMRIID) at Fort Detrick in
Frederick, Md
Treatment
– Treatment for viral hemorrhagic fevers is largely
directed at easing the discomfort of the symptoms.
Victims benefit from being placed in a hospital
setting immediately. Air transport is not advised.
Sedative and pain-relieving medications are helpful,
but aspirin and similar drugs should not be given
because of their tendency to make bleeding worse.
– There has been a lot of controversy surrounding the
use of IV fluids for victims. At the beginning of the
outbreak, the medical community was divided on the
topic. However, both the CDC and WHO recommend
IV rehydration to treat patients with dehydration and
bleeding problems. The improved survival in the
recent outbreak was likely due to the extensive use of
IV hydration. The treatment for bleeding is
controversial. Generally, mild bleeding is not usually
treated, but severe bleeding requires appropriate
replacement therapy (blood transfusions through an
IV line).
– Specific treatment with ribavirin has been used and
is currently under investigation as a therapy for Lassa
fever, hantavirus, Crimean-Congo, and Rift Valley
fever. Treatment is most effective if begun within 7
days. Ribavirin has poor activity against the
filoviruses and flaviviruses.
Prevention
– The only established and licensed virus-specific
vaccine against any of these viruses is the yellow
fever vaccine. It is mandatory for those traveling into
areas of Africa and South America where the disease
is commonly found. Current trials are underway for
further vaccines and antibody therapies. There are
ongoing trials of at least two Ebola vaccines.
STAPHYLOCOCCAL ENTEROTOXIN B
– Staphylococcal enterotoxin B (SEB) is one of the
best-studied and, therefore, bestunderstood toxins.
– Staphylococcal enterotoxin is one of the most
common causes of food poisoning. Nausea, vomiting,
and diarrhea normally occur after someone eats or
drinks contaminated food.
– The toxin creates different symptoms when
exposure is through the air in a biological warfare
situation. Only a small, inhaled dose is necessary to
harm people within 24 hours of inhalation.
Signs and Symptoms
– After exposure, signs, and symptoms begin in two
to 12 hours. Mild-to-moderate exposure to SEB
produces fever, chills, headache, nausea, vomiting,
shortness of breath, chest pain, body aches, and a
nonproductive cough. Severe exposures can lead to a
toxic shock-type picture and even death. Depending
on the severity of exposure, the illness may last 3-10
days.
Diagnosis
– Diagnosis of SEB can be difficult. Laboratory tests
and a chest X-ray may be performed. Nasal swabs
may show the toxin for 12-24 hours after exposure.
Treatment
– Doctors provide care to relieve symptoms. Close
attention to oxygenation and hydration are
important. People with severe SEB may need help
breathing with a ventilator. Most victims are expected
to do well after the initial phase, but the time to full
recovery may belong.
Prevention
– No approved human vaccine exists for SEB,
although human trials are ongoing. Passive
immunotherapy agents have demonstrated some
promise when given within four hours of exposure,
but such therapy is still being tested.
RICIN
– Ricin, a plant protein toxin derived from the beans
of the castor plant, is one of the most toxic and easily
produced plant toxins. Although the lethal toxicity of
ricin is about 1,000-fold less than botulinum toxin,
the worldwide ready availability of castor beans and
the ease with which the toxin can be produced give it
significant potential as a biological weapon.
– Since ancient times, more than 750 cases of ricin
intoxication have been described. Ricin may have
been used in the highly published killing of Bulgarian
exile Georgi Markov in London in 1978. He was
attacked with a device in an umbrella that implanted
a ricin-containing pellet into his thigh.
Signs and Symptoms
– The toxicity of ricin varies greatly with the way it is
given. Ricin is extremely toxic to cells and acts by
inhibiting protein synthesis. Inhalation exposure
causes primarily breathing and lung problems. If
eaten, ricin causes symptoms in the GI tract. If
injected, the reaction takes place in that area.
– Following inhalation exposure of ricin, toxicity is
characterized by the sudden onset of nasal and throat
congestion, nausea and vomiting, itching of the eyes,
itching, and tightness in the chest. If exposure is
significant, after 12-24 hours severe breathing
problems may set in. In animal studies, death occurs
36-48 hours after severe exposure.
– Ingestion of ricin is generally less toxic because it is
not absorbed well and may degrade in the digestive
tract. Out of 751 ingestions recorded, only 14
resulted in a death.
– At low doses, injection exposures produce flu like
symptoms, body aches, nausea, vomiting, and
localized pain and swelling at the injection site.
Severe exposure results in tissue death and GI
bleeding, as well as widespread liver, spleen, and
kidney problems.
Diagnosis
– The diagnosis of ricin poisoning is made on the
basis of symptoms and whether exposure is possible.
In biological warfare, exposure is likely to occur by
inhalation of a toxin aerosol. Victims may have
certain signs on a chest X-ray. The diagnosis can be
confirmed by lab tests on samples from a nasal swab.
Ricin can be identified for up to 24 hours after
exposure.
Treatment
– Treatment is mainly to relieve symptoms. If
exposure was by inhalation, the person may need
help breathing. Those who ingested the poison may
need to have their stomachs pumped (gastric lavage),
or they might be given charcoal to soak up the
material.
Prevention
– Currently, no vaccine is available for ricin exposure.
Test vaccines have proven effective in animals. Other
drugs are being studied as well.
BOTULINUM TOXIN
– Botulinum toxins are the most deadly toxins
known. Because botulinum toxin is so lethal and easy
to manufacture and weaponize, it represents a
credible threat as a biological warfare agent. When
used in this manner, exposure is likely to occur
following inhalation of aerosolized toxin or ingestion
of food contaminated with the toxin or its microbial
spores. Iraq admitted to active research on the
offensive use of botulinum toxins and to weaponizing
and deploying more than 100 munitions with
botulinum toxins in 1995.
– All seven subtypes (A-G) of botulinum toxin act in
similar ways. The toxin produces similar effects
whether ingested, inhaled, or via a wound. The time
course and severity of illness vary with route of
exposure and dose received. Symptom onset is
slower after inhalation exposure.
Signs and Symptoms
– Symptoms may occur hours to several days after
exposure. Initial signs and symptoms include blurred
vision, dilated pupils, difficulty swallowing, difficulty
speaking, an altered voice, and muscle weakness.
After 24-48 hours, muscle weakness and paralysis
may cause the person to be unable to breathe.
Varying degrees of muscular weakness may occur.
Diagnosis
– Paralysis may indicate the presence of this
exposure. Typical laboratory tests generally are not
helpful, although special tests of nerve conduction
and muscle response may be useful. Infection by
inhalation can be diagnosed from nasal swabs up to
24 hours after exposure.
Treatment
– The most serious complication is respiratory
failure. With attention to symptoms and help
breathing, sometimes with a ventilator, death occurs
in fewer than 5% of cases. For confirmed exposures,
an antitoxin is available from the CDC. This antitoxin
has all of the disadvantages of horse serum products,
including the risks for shock and serum sickness.
Skin testing is performed first by injecting a small
amount of the antitoxin into the skin and then
monitoring the person for 20 minutes.
Prevention
– The only botulinum vaccine was discontinued by
the CDC in 2011.
MYCOTOXINS
– The trichothecene mycotoxins are highly toxic
compounds produced by certain species of fungi.
Because these mycotoxins can cause massive organ
damage, and because they are fairly easy to produce
and can be dispersed by various methods (dust,
droplets, aerosols, smoke, rockets, artillery mines,
portable sprays), mycotoxins have an excellent
potential for weaponization.
– Strong evidence suggests that trichothecenes
("yellow rain") have been used as a biological warfare
agent in Southwest Asia and Afghanistan. From 1974-
1981, numerous attacks resulted in a minimum of
6,310 deaths in Laos, 981 deaths in Cambodia, and
3,042 deaths in Afghanistan. When taken from fungal
cultures, the mycotoxins yield a yellow-brown liquid
that evaporates into a yellow crystalline product
(thus, the "yellow rain" appearance). These toxins
require certain solutions and high heat to be
completely inactivated.
Signs and Symptoms
– After exposure to the mycotoxins, early symptoms
begin within five minutes. Full effects take 60
minutes.
– If skin exposure occurs, the skin burns, becomes
tender, swollen, and blisters. In lethal cases, large
areas of skin die and slough (fall off).
– Respiratory exposure results in nasal itching, pain,
sneezing, a bloody nose, shortness of breath,
wheezing, cough, and blood-tinged saliva and
sputum.
– If ingested, the person feels nausea and vomits,
loses appetite, feels abdominal cramping, and has
watery and/or bloody diarrhea.
– Following the entry into the eyes, pain, tearing,
redness, and blurred vision occur.
– Systemic toxicity may occur and includes weakness,
exhaustion, dizziness, inability to coordinate muscles,
heart problems, low or high temperature, diffuse
bleeding, and low blood pressure. Death may occur
within minutes to days depending on the dose and
route of exposure.
Diagnosis
– Diagnosis of an attack of trichothecene mycotoxin
depends on the symptoms and identifying the toxin
from biological and environmental samples. Many
people with these symptoms may report being in a
yellow rain or smoke attack.
– Initial laboratory tests are not always helpful.
Currently, a rapid identification kit for any of the
trichothecene mycotoxins does not exist. Gas-liquid
chromatography has been used in the past with great
success. However, chromatographic methods lack
great sensitivity, and present alternative methods of
detection are under investigation.
Treatment
– Treatment is mainly to help with symptoms. The
immediate use of protective clothing and mask
during a mycotoxin aerosol attack should prevent
illness. If a soldier is unprotected during an attack,
the outer clothing should be removed within four to
six hours and decontaminated with 5% sodium
hydroxide for six to 10 hours. The skin should be
washed with copious amounts of soap and
uncontaminated water. The eyes, if exposed, should
be washed out with large amounts of normal saline
or sterile water. U.S. military personnel can use a skin
decontamination kit effectively against most chemical
warfare agents, including mycotoxins.
– No specific therapy exists for trichothecene
exposure. After appropriate skin decontamination,
victims of inhalation and oral exposures may be given
super activated charcoal orally. Activated charcoal
removes mycotoxins from the GI tract. Some victims
may need help breathing with a ventilator. Early use
of steroids increases survival time by decreasing the
primary injury and shock-like state that follows
significant poisoning.
Prevention
– No vaccine exists for trichothecene mycotoxin
exposure.

GLANDERS
– Glanders is a disease mainly in horses and is
caused by the bacterium Burkholderia mallei. It can
be transmitted to humans and other domestic
animals. However, it is only rarely seen in humans. It
has been intermittently used by governments in
World War I and II and by Russia in the 1980s. In
humans, it causes a flu-like illness. In 2000, there was
a case in a U.S. military microbiologist who recovered
completely with treatment.

TYPHUS
– Typhus is an acute febrile illness caused by
Rickettsia typhi and Rickettsia prowazkeii. This
should not be confused with typhoid fever, which is a
gastrointestinal illness caused by Salmonella typhi
bacteria. There are endemic and epidemic forms of
the disease. The epidemic form is caused by
Rickettsia prowazkeii. This is typically transmitted
via lice. Rats, mice, and flying squirrels, which are
asymptomatic carriers, carry the disease. The disease
is spread to the human population through ticks,
chiggers, fleas, and lice. There have been natural
outbreaks throughout history that were usually
associated with wars and famine. Poor living
conditions and squalor allow the spread of the
disease. The typhus spread by ticks causes Rocky
Mountain spotted fever. The Centers for Disease
Control and Prevention (CDC) has categorized typhus
as a category B biological weapons agent. While
Rickettsia prowazekii is highly infectious, it cannot be
passed from person to person. A number of
governments have experimented with weaponizing
typhus, but typhus does not appear to have ever been
successfully used in a military setting.

Anti-Crop Biological Agents

– There have been a number of agents developed
during the last century to cause destruction of crops.
These include wheat stem rust, rye stem rust, rice
blast, cereal rust, wheat smut, and potato blight. A
number of governments have experimented with
using these agents, but there does not appear to have
ever been a use of these agents in a military setting.

Good Luck & God Bless!